Illinois Lottery Retailer Application Packet

Form W-9(Rev. December 2011)Department of the TreasuryInternal Revenue ServicesName (as shown on your income tax return)Request for TaxpayerIdentification Number and CertificationGive form to therequester. Do notsend to the IRS.Print or typeSee Specific Instructions provided.Business name/disregarded entity name, if different from aboveCheck appropriate box for federal tax classification:Individual/sole proprietor C Corporation S Corporation Partnership Trust/estateLimited liability company. Enter the tax classification (C=corporation, S=corporation, P=partnership) ..............................Other (see instructions)Address (number, street, and apt. or suite no.)Requesters name and address (optional)City, state, and ZIP codeList account number(s) here (optional)ExemptpayeePart 1Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name”line to avoid backup withholding. For individuals, this is your social security number (SSN).However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions onpage 3. For other entities, it is your employer identification number (EIN). If you do not have a number,see How to get a TIN on page 3.Note. If the account is in more than one name, se the chart on page 4 for guidelines on whosenumber to enter.Social Security Number– –orEmployer identification number–Part 2SignHereSignature ofU.S. personCertificationUnder 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), and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the InternalRevenue 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 hasnotified me that I am no longer subject to backup withholding, and3. I am a U.S. citizen or other U.S. person (defined below).Certification instructions. you must cross out item 2 above if you have been notified by the IRS that you are currently subject to backupwithholding 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 retirementarrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you mustprovide your correct TIN. See the instructions on page 4.Answer the FollowingA background investigation is conducted for the applicant and each owner/officer/partner/member (a “principal”) of the applicant business,if an entity, as part of the Retailer Licensing/Approval process. If you or, if the applicant is an entity, the applicant or any other principal of thebusiness/applicant have been convicted of any offense defined in or under the Illinois Criminal Code or the criminal code of any other State,or of a criminal offense under any federal law, you must submit a separate statement setting forth the name of the offender, the nature of theoffense, the state and county or federal court in which the criminal conviction occurred, the date of the conviction, the sentence, and any otherinformation you may wish to add. Further, you must submit a statement if anyone listed on the Retailer licensing application has ever been foundguilty of fraud or misrepresentation, has been a gambling promoter or professional gambler, or has been engaged in bookmaking or other formsof illegal gambling. A criminal conviction does not automatically mean this application will be denied. However, concealment of a criminal recordmay result in denial of the application or in a subsequent license suspension or revocation. The Lottery will compare the information you givewith criminal records maintained by federal and state law enforcement agencies.Please check theappropriate box.A separate statement describing anycriminal conviction is attached.DateNo separate statement is attached. Neither theapplicant business nor a principal of the businesshas ever been convicted of a criminal offense.a. Have the applicants, individually or as part of another business,ever been licensed by the Department of Lottery or the Departmentof Revenue for the purpose of selling Lottery Tickets?Yesb. If yes, write the previous Illinois Lottery Retailer Number(s)