Individual Vendor / Payee Request Form - Complete

Individual Vendor / Payee Request Form

Instructions: To submit an application to become a Vendor / Payee to the University when doing business or being paid as an individual using your SSN number, complete the fields below and attach the appropriate completed IRS W8 / W9 form.

Note, to digitally sign aW8 / W9 document, it must be saved to your device, and opened using Adobe. Otherwise, the signature feature will not work properly.

If you are processing this on a Smart Phone or Tablet, and would like assistance on how to digitally sign a W8 / W9 on your device, please see our Instructions for New Supplier Request via Smartphone page for informationon how to download PDF writer in order to prepare and sign a PDF document.

Fields with asterisks (*) are required.

Vendor / Payee Application – Individuals Only

Legal First Name: (Name that is used on your Federal Tax Return) *

Legal Last Name: (Name that is used on your Federal Tax Return) *

Former Name(s): (If none, type N/A)

Please indicate the Wayne State person that invited you to conduct business with the University. *

Please provide the above person's e-mail address so we may notify them *

Mailing Address:

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Phone *

Your Email Address *

Date of birth (Optional - this will help us prevent duplicate records)

IRS W9 Form (signed)

You must provide a valid Social Security Number (SSN) in order for the University to process payment(s). The University is required by Federal law where applicable to report payments, along with the SSN to Federal and State agencies. Failure to provide a correct name and Taxpayer Identification Number may subject your payments to a 28% federal income tax withholding. Additional withholding may apply for foreign individuals. Payment Terms are Net 30, unless otherwise stated and agreed to by the University.

Attach your W8 or W9 Here *

Enter your Social Security Number *

Prior University Affiliation

Are you a Current Employee? *

Are you a Current or Former Student? *

Are you a Former Employee? *

If so, Approximate Employment End Date (mm/yyyy)

AccessID / Supplier ID / Payee Number, if known (If you’ve been paid by WSU before, this number can be located on your check or payment remittance stub)

Conflict of Interest:

Are you, or if this a business, are any Officer, Owner or Partner in this company an employee of Wayne State University, or have you been an employee within the past 24 month? *

Yes

Are any immediate family members or extended family members (e.g. spouse, child, sibling, parent, niece, nephew, or in-law) of any Officer, Owner or Partner employees of Wayne State University? *

Yes

Are there any other potential conflicts of interest in doing business with the University that we should be aware of? *

Yes

If yes to either above, please state who and explain and their University position or the family relationship (father, mother, sister, brother, child, etc.)

ACH Enrollment Form

If you would also like to Enroll in our Direct Deposit / ACH program, please complete the information below.

All fields in this section are required to successfully be entered in the Direct Deposit program, but are not required if you prefer to be paid by check.

Declaration:

I (we) hereby authorize Wayne State University (hereafter WSU) to initiate ACH automatic deposits (credits) to my account at the financial institution named below. Additionally, I authorize WSU to make necessary debit adjustments in the event a credit entry is made in error.

Further, I agree not to hold WSU responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or my institution or due to an error on the part of my financial institution in depositing funds into my (our) account. I will notify WSU immediately of any changes made to my checking account.

This agreement will remain in effect until WSU receives written notification of cancellation from me or my financial institution. Upon receipt of notice, I understand WSU will need 72 hours to comply with the request and interim deposits may occur.

ACH Payment Agreement Form Type

New Enrollment

Modify / Update Existing Enrollment

Vendor / Payee Banking Information:

Name of Financial Institution

Branch/State

Routing Number *

Checking Account Number

ACH Remittance Advice Email

Vendor / Payee Authorization:

By checking this box and typing my name below, I acknowledge that the information provided is accurate and complete to the best of my knowledge. *

I Agree

Typed Name: *

Date *