rayant  
 
Find a Dentist    About Rayant    Site Map    Contact Us   
 
 
 
 
 

Help and Resources

W-9 Tax Form

Request for
TAXPAYER IDENTIFICATION NUMBER

(Substitute W-9 Form)

IRS ALERT FOR PAYEES

For a Blank, Printable W-9 Form, click here.


Use this form only if you are a U.S. person (including a resident alien). If you are a foreign person, use the appropriate Form W-8.

Please complete the following information. We are required by law to obtain this information from you when making a reportable payment to you. If you do not provide us with this information, your payments may be subject to federal income tax backup withholding at the current rate. Also, if you do not provide us with this information, you may be subject to a penalty imposed by the Internal Revenue Service under IRC Section 6723.
spacer image
* = Required fields

* TAX STATUS
 (Check only one)		 Individual Sole Proprietor Partnership Corporation
Qualifying Exemptions – If you are exempt from Form 1099 Reporting, please select one of the following:
Tax Exempt Charity under 501(a) (includes 501(c)(3)), or IRA
The United States or any of its agencies or instrumentalities
A state, the District of Columbia, a possession of the U.S., or any of their political subdivisions
A foreign government or any of its political subdivisions
Corporation EXCEPT there is NO EXEMPTION for medical and healthcare payments or payments for legal services.
LEGAL NAME (As it appears on your tax return) Help
* Legal Name:
Doing Business As Name:

* Street Address
Street Address 2

* City:
* State:

 
* Zip Code:
 
-
* TAXPAYER IDENTIFICATION NUMBER (List only one)
Social Security Number:
Employer ID Number:
- -            -OR-
-
* Date Taxpayer Identification Number Was Issued:
/ /
 
Please Read and Sign Below:

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 notified me that I am no longer subject to backup withholding, and
  3. I am a U.S. person (including a U.S. resident alien).

Certification Instructions. Do not check 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.


Electronic Signature:
* First Name: Middle Initial: * Last Name:
* Phone Number:
- -

Today’s Date: 2/5/2012

Comments:

 

Person completing this form:

Name:  
 

I would like to receive a confirmation email with a .pdf copy of this completed form as a receipt of this submission.
Enter email here:


If you have any questions, please contact Monique Wesley at (973) 466-7467 or email her at Monique_Wesley@Rayant.com.
Electronic Claims Submission

A simple and easy way to file your claims.

Learn why you should submit claims electronically.

Dental Consultant Corner

Read our quick guide to submitting your claims and preauthorizations.
SITE MAP    TERMS OF USE    PRIVACY POLICY     

In New York, products are underwritten by Rayant Insurance Company of New York. In Pennsylvania, products are underwritten by Rayant Insurance Company of Pennsylvania.
© 2007