W-9 Attestation for Organizations

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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 employer identification number (EIN) is the correct taxpayer identification number for the applicant and not subject to backup withholding as a result of a failure to report all interest or dividends, and 2) I am a U.S. citizen or other U.S. person as allowed by the IRS.