Application for Vendor Payment

Application for Vendor Payment
Prior to processing a payment for goods and/or services an Application for Vendor Payment form must be completed and submitted to the Business Office. Completed forms provide the necessary information for use internally by District personnel, as well as for federal and state reporting purposes.
Vendor Information
Type of Vendor:*

BusinessSmall BusinessGovernment AgencyOther Not-for-ProfitAthletic/Activities Official
Name:*
Phone Number:*
Please enter a valid phone number.
Email:*

Confirmation EmailPlease enter your email address again to confirm.
Business Classification (if applicable):*

Minority OwnedFemale OwnedOwned by Persons with DisabilitiesVeteran Owned
* In accordance with Illinois School Code (105 ILCS 5/10-17), schools are required to publish an annual report identifying the total number of contracts awarded to minority, female, veteran, small business, or disabled contractors/vendors, as certified by a certifying agency (e.g. Cook County, State of Illinois, U.S. Small Business Association) in accordance with the definitions provided in 30 ILCS 575/2.
1099 Address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is payment remittance address the same as above?*

YesNo
Remittance Mailing Address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tax Payer Identification
Tax Classification*

Individual/Sole Proprietor or single-member LLCC - CorporationS - CorporationP - PartnershipTrust/EstateLimited Liability Company (Insert Type)Other
Tax Number:*

Social Security NumberFederal Tax Id Number
Social Security Number:*
Federal Tax ID Number:*
Agreement
Under penalties of perjury, I certify that the information provided on this form is complete and accurate. I understand that this information will be utilized for local, federal and state reporting purposes. I further certify that I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.
Name of Individual Completing Form:*
Today's Date:*

MonthDayYear
Date
Signature:*

Clear
Should be Empty:

Application for Vendor Payment

Vendor Information

1099 Address

Remittance Mailing Address

Tax Payer Identification

Agreement