Expression, Vendor Information/Certification

• Legal Form Number: AO 213
• Court: United States Federal Court
• Section: United States Federal Court

AO 213 (Rev.11/23)

REQUEST FOR VENDOR INFORMATION ANDTIN CERTIFICATION

Refer to theinstructions page for further information oncompleting this form.

Note: Typed forms and forms that include a populated Type of Vendor may result in more efficient andprecise processing. **For handwritten forms, please see the

General Instructions for the list of options for the Type of Vendor, Part 5 - U.S. Tax Classification, and Part 8 - Account Type drop down menus.

Part 1Payee Information

Line 1.Payee Name:

Line 2.Additional payee information: (if applicable)

Part 2Business Name (if different from above)

Part 3

Part 4SAM UEI # (if applicable)

Part 5**SelecttheappropriateU.S. tax classificationforpersonorentity listedinPart1, Line1.

Part 6Mailing Address (where payments, orders, and IRS 1099 forms, as applicable, will be sent)

State:Zip code:

State:Zip code:

Name:

Email Address:

1. The number shown on this formis mycorrect taxpayer identification number; and

2. I amnot subjectto backup withholding because: (a) I amexempt frombackup withholding,or (b) I have notbeennotified

bythe IRS that I amsubject to backup withholdingas a result of a failure to report all interest anddividends, or (c) the IRS

has notifiedmethat I amno longer subject to backup withholding; and

3. I ama U.S. citizen or other U.S. person(defined inthe instructions).

The IRS does not require your consent to anyprovision of thisdocument other than the certifications required toavoidbackup

withholding.

Signature: Date:

Sensitive information must be securely maintained and only visible to designated staff.

**Type of Vendor

Part 7Additional Address Information (if different from above)

Street address:

City:

Part 8 Electronic Funds Transfer (EFT) Information

Owner(s) name as it appears on bank account:

Bank Name:

**Select anAccount Type: Routing # (9 digits):

Account Number:(do not includechecknumber)

Part 9 Certification

Under penalties of perjury, I certifythat:

Intern vendors only (effective end date):

Street address:

City:

Point of Contact(if different from Part 1, Line1 above)

Phone #:(no dashes)Email address:

Page 1 of 3

Enter only one TIN in the appropriate box. The TIN must match the name givenin Part 1,Line 1.

EIN:or--

- SSN:

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