W-9 Request for Taxpayer Identification Number and Certification 400-28-105-50

(Revised 4/1/14 ML #3401)

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The "W-9,” Request for Taxpayer Identification Number and Certification" must be submitted by the Provider when the following occurs:

• A provider who is going to provide services to a family who is receiving Child Care Assistance
• Lapse between qualified provider period (such as renewal)
• Change in name
• Change in provider type (family to group, group to center, et cetera)
• Change in address
• Change in either Social Security Number (SSN) or Employee Identification Number (EIN) when either is being used as the Taxpayer Identification (TIN)

The W-9’s should be completed and mailed to:

Child Care Assistance Program

ND Department of Human Services – Dept 325

600 E Boulevard Ave

Bismarck, ND 58505-0250