BPA F 4220.05e Beneficiary Request for Taxpayer Identification Number a

CUI
BPA F 4220.05e
(09-2023)
Substitute IRS
Form W9e
Page 1 of 3

U.S. DEPARTMENT OF ENERGY - BONNEVILLE POWER ADMINISTRATION (BPA)

OMB Control Number
1910-5190

REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATE
Beneficiary Version

Expires: XX/XX/XXXX

INSTRUCTIONS: Request for Taxpayer Identification Number and Certificate, and the New Profile Request must be completed to
create a profile to allow for contract and/or payment. See page 2 for Privacy Act Statement.
Due to the sensitive nature of information contained in this form please encrypt (see the end of the form for options) the form
for submittal. Route the encrypted form via email to [email protected]. Please send password in a separate email
to the same address.
Contact Phone Number: (360) 418-2800
1. Name (Required, as shown on your income tax return)
2. Decedent Name
3. Federal Tax Classification (Select the appropriate federal tax classification of the person in Question 1)
Other
(Specify)

Select One

4. Exemptions (codes apply only to certain entities, not individuals). See instructions on page 4 of Form W-9 (Rev. October 2018).
Exempt Payee Code
(If any)

Exemption from FATCA reporting code (Applies
to accounts maintained outside the U.S.)

5. Address:
City

State

6. Social Security Number

Zip Code
or

7. Employer Identification
Number

Certification: Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to
me); and
2. 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; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to
backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions,
item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt,
contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are
not required to sign the certification, but you must provide your correct TIN. See the certification instructions below.
Signature of U.S. Person

Filled in by BPA →

Date

CONTROLLED DISTRIBUTION
Access is restricted to those with a Lawful Government Purpose and must be protected and
marked when printed or distributed.
Controlled by:
Name/Agency/Org/Contact Info:
CUI Category: PRVCY Date:

File Code: PB – 1205; Retention: Destroy 6 years after final payment or cancellation, but longer retention is authorized if required
for business use.

CUI
BPA F 4220.05e
(09-2023)
Page 2 of 3

U.S. DEPARTMENT OF ENERGY - BONNEVILLE POWER ADMINISTRATION (BPA)

NEW VENDOR PROFILE REQUEST
Beneficiary Version

OMB Control Number
1910-5190
Expires: XX/XX/XXXX

Financial Institution Information (All fields required for ACH/EFT payment)
Bank Name
Payee Contact Person Name
Nine Digit Transit Number

Bank Phone Number
Payee Contact Phone Number
Depositor Account Number

Privacy Act Statement:
Authority: BPA must file information returns with the IRS, reporting interest, dividends and other income paid to
individuals. Under 26 U.S.C. § 6109 and 16 U.S.C. § 832a(f), 839f(a), individuals who receive such payments from BPA are
required to provide BPA with a Social Security number or Employer Identification Number.
Purpose: BPA will use this information to report and process payments (or debits) to the IRS, as required by law.
Routine Uses: A record from this system may be disclosed to the Internal Revenue Service to comply with applicable tax
laws. A record in this system may be disclosed to BPA/DOE employees and contractors who need the information to
complete job functions. A record in this system may be disclosed to the appropriate local, state, or federal agency when
the records alone, or in conjunction with other information, indicate a violation or potential violation of law, whether
civil, criminal, or regulatory in nature. Other routine uses of this information may be found in Privacy Act System of
Records DOE-18, Financial Accounting System.
Disclosure: Individuals who refuse to provide this information may be denied the ability to contract with BPA.
Paperwork Reduction Act Burden Statement:
This data is being collected to provide to the IRS, regarding processing and reporting payments or debits. The information you
supply will be used for reporting and processing payments. Public reporting burden for this collection of information is estimated
to average 15 minutes (.25 hours) per response, including the time for reviewing instructions, searching existing data sources,
gathering, and maintaining that data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to Office of the Chief Information Officer, Enterprise Policy Development & Implementation Office, IM-22,
Paperwork Reduction Project (OMB control number 1910-5190), U.S. Department of Energy, 1000 Independence Ave SW,
Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (OMB
control number 1910-5190), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty
for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that
collection of information displays a currently valid OMB control number.
The Paperwork Reduction Act (PRA) of 1995 requires each Federal agency to seek and obtain approval from the Office of
Management and Budget (OMB) before undertaking a collection of information directed to 10 or more persons of the general
public, including persons involved in or supporting the operations of Government-owned, contractor-operated facilities.
Submission of this data is voluntary.
File Code: PB – 1205; Retention: Destroy 6 years after final payment or cancellation, but longer retention is authorized if required
for business use.

CUI
BPA F 4220.05e
(09-2023)
Page 3 of 3

U.S. DEPARTMENT OF ENERGY - BONNEVILLE POWER ADMINISTRATION (BPA)

NEW VENDOR PROFILE REQUEST
Beneficiary Version

OMB Control Number
1910-5190
Expires: XX/XX/XXXX

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien;
• A partnership, corporation, company, or association created or organized in the United States or under the laws of the
United States;
• An estate (other than a foreign estate); or
•
A domestic trust (as defined in Regulations section 301.7701-7).
Options for Encryption
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File Code: PB – 1205; Retention: Destroy 6 years after final payment or cancellation, but longer retention is authorized if required
for business use.