Payment Verification Form Instructions

1.	Federal ID No./Social Security No. for Individuals (9 digits): Please check to make sure this information is correct. If it is incorrect, please write in the correct information.
2.	Name of Firm or Individual: Please check to make sure this information is correct. If it is incorrect, please write in the correct information.
3.	If Sole Proprietorship, owner's name: If the business is a sole proprietorship, please print the owner's name.
4.	Address for Ordering Goods and/or Services: If applicable, please verify or print the correct mailing address for state agencies to use to send purchase orders when ordering goods or services. If you have registered using EProcurement @ your service this section will not need to be completed.
5.	County Name: The county where the address for ordering goods and/or services is located.
6.	Fax Number, Toll-Free Phone number, Area Code & Phone Number, Email Address, and Contact Name: Please complete with the appropriate information.
7.	Remittance Address: Please verify or print the correct mailing address where state agencies are to send payments.
8.	County Name: The county where the remittance address is located.
9.	Fax Number, Toll-Free Phone number, Area Code & Phone Number, Email Address, and Contact Name: Please complete with the appropriate information.
10.	Individual and Business Characteristics - Part I: Please check each characteristic that applies to you or your business.
11.	Individual and Business Characteristics - Part II: Please check each characteristic that applies to you or your business.
12.	Does your business provide: Please check the option that most closely represents your business. Individuals do not need to answer this question.
13.	Does your business provide medical services?: Please check yes or no. Individuals do not need to answer this question.
14.	Form Completed By: Please sign and date the form at the bottom and mail it to the address listed at the top of the form or fax it to (919) 981-5561.