W-9 Attestation for Individuals


All DHHS providers will electronically sign the W-9 Attestation as part of the Provider Enrollment Online Application.

Under penalties of perjury, I certify: 1) the supplied social security number or employer identification number (EIN) is the correct taxpayer identification number for the applicant 2) the applicant is not subject to backup withholding as a result of a failure to report all interest or dividends, and 3) the applicant is a U.S. citizen or other U.S. person as allowed by the IRS.