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<br />I @-:::;: ~;;':._, 332-1'" <br />.tEXAS APPLICATION FOR PAYEE IDENTIFICATION NUMBER <br /> <br />;;'0' Cotr\ClCltlli.n U$I CI'lfy <br /> <br />I <br /> <br />'oPLEASETYPEORPR'NTINB"'CK 101 I 12131ul51rl7181QI <br />lNK YOUR NU~BERS LIKE THIS T \:) ~ I <br /> <br />. Shaded areas for slste agency use only . S.... instructions on back <br /> <br /> 1. IS this a new account? DYES Mail COde 000 ONO Enter Mail Code [ID A.gency number UTI <br /> Complete Sections I . V Com~/ete Sections I. /I. & V <br /> 2. PAYEE IDENTIFICATION NUMBER (PIN) . Indicate the type of numbe; you are providing to be used for your PIN. <br /> - o 1 . Federai Employefs Identification Number (FEIN) o 2 . Social Security Number (SSN) o 3 . Comptroller's assigned number <br /> z <br /> 0 <br /> ;:: Enter number indicated I I I I <br /> u <br /> w 3. Are you currently reporting any Texas tax to the Comptroller's office other than unemployment (e.g.. sales tax. franchise tax)? <br /> Ul <br /> DYES ONO If .YES.. enter Texas Taxpayer Number) _ __ - - I I I I I I <br /> PAYEE INFORMATION Please O( nnt in all UPPER CASE ferretS s shOwn Oeiow. ECl'lar>>crer 'box. <br />I 4. Name of pa ae (individual or business to be paid) IA B CIDIE F GIHII J KI L 1M N 01 PIQ R SI '11 VI\NlXIYIZ <br />i I I <br />I <br /> (This;s a cantmuous line 01 U/J to 50 Characrers. Leave only J spaos 08tw'8en names.) <br /> 5. Mailing address where you want to be paid <br /> = S!rHf <br /> Z <br /> 0 <br /> ;:: <br /> U <br /> w <br /> Ul <br />I Zone <br /> ""'" <br /> :" I I I I I I I I I I I I I I I I II S..,. CD ~ ITIIIJ - DID <br /> 6. DID Payee telephone number mJ /ITTI DID <br /> SIC Code Security type code 0 (0.1.2) (Area code and number) - <br /> 7. OWNERSHIP COOES. Check only one code by the appronate ownership type that applies to you or your bUSiness. <br /> 0 5 - Sote ownershic (Individual oWOlng a buslness)/I checked. enter the owners name and Social Security Number (SSN). <br /> Owners <br /> ~ame <br /> SOCial Security Number <br /> 0 p. Partnerhsip. If checked, enter two partners names and Social Secunty Numbers (SSN). /I a partner IS a corporation, use the corporaffon's <br /> Federal Employer's Identification Number (FEIN). <br /> :<jame I <br /> o SSN o FEIN o Comptroller no. <br /> Name <br /> - <br /> Z o SSN o FEIN o Comptroller no. <br /> 0 <br /> ;:: 01. o L- limited Partnership - If checked. enter the TeXBS Ale Number. <br /> u Individual Recipient (not owning a busmess) <br /> w <br /> Ul I I I I I II I I <br /> DE. State Employee. If checked, enter emplOying agency Or- Texas Corporation - /I checked. enter the Texas Charter <br /> number. ---------------- ITTI <br /> Number. ----- I II I I II I I <br /> DO. Out-of-State Corporation OA- Professional AssocIation. /I checked. enter the Texas Charter <br /> OG- Governmental Entity Number. ----- I II I I I I I <br /> OU. Slale agency I University DC, Professional Corporatlon - If cheCked. enter the Texas Charter <br /> Number. ----- I I I I <br /> OJ. Joint Venture <br /> OF. FinanCial Institution ON. Other. If checked. explain. <br /> OR- Foreign (out of U.S.A.) <br /> ::: 8. Payment Assignment? DYES ONO NOTE: A copy 01 the assignment agreement between payees must". sNsched. <br /> ti ASSIQtl" PIN ASSlQnmenlda'. (1fIMdt1Y'/J <br /> W I rn::IIJ] <br /> Ul <br /> . Com".,l, <br /> > <br /> z sign. Autl'loru:IIOS9'\&IUI.(~M.U~.9fHI') i 0.1. <br /> 0 10 <br /> ;:: <br /> u here j <br /> w " A9'N'C1 name I prepatllO Oy : Pf'IoMIAtMcooe*'lJftI.IfICM) <br /> Ul i <br /> , <br /> <br />I <br /> <br />I <br />