Department of Medicine

The Internal Revenue Service requires a form 1099 information return with a valid taxpayer identification number to be filed for payments totaling more than $600 in a calendar year to certain providers of services.

We are required to withhold 31% of payments subject to form 1099 reporting requirements if the payee has not provided us with his/her taxpayer identification number.

To enable us to comply with the law and avoid imposition of the 31% backup withhold tax on you, please supply the information requested below.  Sign, date and fax this letter to Dr. Elizabeth Tam (808) 586-7670.

Type of Payee (check your classification and provide required number)
(Social Security No.)
_____ Individual               Employer identification # _____________________________

_____ Proprietorship       Employer identification # _____________________________

_____ Partnership           Employer identification # _____________________________

_____ Corporation           Employer identification # _____________________________

_____ Other (Please explain)  ______________________________________________


Activity (check one)

_____ Consultant/Professional                       _____ Services Only

_____ Merchandise (goods) only                   _____ Rents

_____ Merchandise (goods) & Services        _____ Other (please explain) _________________


I CERTIFY, UNDER THE PENALTIES OF PERJURY, THAT THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE.

NAME (please print)         __________________________________________________

ADDRESS (please print) __________________________________________________

__________________________________________________


_____________________________        ________________________            ___________
Signature                                                      Title                                                  Date