| C.C. Silver & Gold Inc. 2028 W Camelback Rd Phoenix, AZ 85015-3441 phone: 602.242.6310 |
web: www.ccsilver.com e-mail: info@ccsilver.com fax: 602.433.9522 Back to Sell Page |
1099B AUTHORIZATION | |||||||||
| C.C. Silver & Gold Inc. (C.C.S.G. Inc.) is required by law to report certain payments made to vendors/individuals to the Internal Revenue Service (IRS). In order to comply with federal law regarding Form 1099-B (Broker or Barter Exchange Transactions), we are requesting the following information. Failure to provide us with a correct taxpayer ID number/social security number may subject you to backup withholding on all payments we make to you, and may subject you to a penalty. | |||||||||
| Name: | __________________________________________________ | ||||||||
| Company: | __________________________________________________ | ||||||||
| Address: | __________________________________________________ | ||||||||
| __________________________________________________ | |||||||||
| __________________________________________________ | |||||||||
| Phone: | __________________________________________________ | ||||||||
| Type of Entity: | |||||||||
| _____ | Individual | _____ | Government Agency | ||||||
| _____ | Sole Proprietorship | _____ | Tax Exempt Organization | ||||||
| _____ | Partnership | _____ | Other (Please Explain) | ||||||
| _____ | Corporation | _____ | ______________________________ | ||||||
| Taxpayer Identification Number: (Please list whichever applies to above entity) | |||||||||
| Employer ID Number: | __________---____________________________ | ||||||||
| or | |||||||||
| Social Security Number: | ____________---____________---____________ | ||||||||
| CERTIFICATION: Under penalties of perjury, I certify that the number and information shown on this form is correct to the best of my knowledge. | |||||||||
| Signed: | __________________________________________________ | ||||||||
| Print Name: | __________________________________________________ | ||||||||
| Title: | __________________________________________________ | ||||||||
| Date: | __________________________________________________ | ||||||||
| Thank you for your cooperation in this matter. | |||||||||