Form 4109
Instructions

Application for Texas Identification Number

06-2011

PURPOSE

Every individual, business or organization receiving payments from the Department of Aging and Disability Services (DADS) for goods, services provided, refunds, public assistance, etc., must have a Texas Identification Number (TIN). This application is necessary to add a payee to the DADS Health and Human Services Administrative System (HHSAS) and/or the Comptroller of Public Accounts' Texas Identification Number System (TINS) before payment can be made. This form is also used to set up additional payment names/addresses (mail codes) for payees who already have a TIN on file on HHSAS/TINS. An additional mail code may be necessary for entities having multiple DBA ("doing business as") names, mailing addresses, direct deposit accounts or assignment agreements.

PROCEDURE

When to Prepare

Prepare this form before or in conjunction with submitting payment requests to HHSAS if the correct TIN is not already registered on HHSAS (see Purpose). Note: If a TIN is registered on HHSAS for a payee, but the information is incorrect, a Form 4110, Payee Change Request, should generally be submitted instead of Form 4109. Payees should contact their local contract manager, case worker, or DADS representative to initiate corrections via Form 4110.

This form may be prepared either by DADS staff or by the payee. If the payee completes the form, DADS staff authorizing the application must review the prepared form for completeness before submittal to DADS Accounting, and provide their contact information in Section VIII.

If assistance is needed in completing the form, please telephone Accounting at (512) 438-4684 or (512) 438-4310.

Transmittal

After completion, review and authorization by a DADS representative, the form is forwarded to Accounting, E-411. Accounting will update HHSAS with the information provided on the form. Accounting will also update the Comptroller's TINS as needed.

Form Retention

Accounting maintains the application as long as the payee is a vendor of the agency.

DETAILED INSTRUCTIONS

The TIN is a 14-digit number composed of:

  • A one-digit prefix number (1, 2 or 3) that indicates whether the TIN is based on a Social Security Number (SSN), Employer Identification Number (EIN), or a Comptroller-assigned number.
  • A nine-digit SSN, EIN or Comptroller-assigned number.
  • A self-check digit, calculated from the preceding digits.
  • A three-digit mail code.

Note: Shaded areas are for Accounting use only.

Section I. Texas Identification Number

Indicate the type of number the payee is using as the base for their TIN by marking the appropriate box. Enter the number. The type of number that is required to be used for the TIN is directly related to the ownership type of the business. See Section II.

  • This number will be used to report payments to the IRS, if applicable.
  • Comptroller-assigned numbers are given to payees who have no Social Security Number (SSN) or Employer Identification Number (EIN), such as foreign individuals or entities. Comptroller-assigned numbers are also used for state agencies' TINs.
  • Is this a new DADS payee? — Answer "Yes" to the question if the TIN is not found on HHSAS. An answer of "Yes" requires completion of Sections I, II, III (if applicable), IV, VII, and VIII. An answer of "No" requires completion of Sections I, III (if applicable), IV, VII, and VIII.
  • Location/TIN Mail Code — The location/mail code (not to be confused with the agency routing mail code) is the last three digits of the 14-digit TIN. "Location" is HHSAS terminology, whereas "mail code" is Comptroller terminology. The location/mail code indicates which name/address combination will be printed on the Comptroller-issued warrant. Enter the number if you know the mail code for which you are applying. This is an optional field. Note: Mail codes are assigned by Accounting in accordance with Comptroller regulations, regardless of the mail code requested.
  • Are you currently reporting any Texas tax other than unemployment? — An answer of "Yes" requires that the 11-digit Texas Taxpayer Number assigned by the Comptroller of Public Accounts be entered.

Section II. Ownership Codes

If the payee is a new DADS payee (see Section I), check the appropriate ownership type of the payee and provide the additional information as indicated for the respective ownership code. Refer to the following chart to determine the correct ownership type, additional information required and number to use as the base of the TIN.

Own. Code Ownership Type Definition Additional Info Required Number to Use for TIN
I Individual Recipient Person not owning a business. Individual who receives entitlements from the State of Texas; such as kidney patients, welfare recipients, pensions, crime victims, etc. N/A SSN
E State Employee Any employee of a State of Texas agency. Employing agency number. SSN
S Sole Owner Person with exclusive title or right to a business. Owner name and owner SSN Option to use owner's SSN or business EIN
P Partnership Legal relationship existing between two or more persons or other legal entities contractually associated as joint principals in a business. Names and numbers of two partners. If partner is a person, SSN is required. If partner is a corporation, EIN is required. EIN
Note: EIN must represent the partnership, not one of the partners.
J Joint Venture A legal entity in the nature of a partnership engaged in the joint prosecution of a particular transaction for mutual profit. A one-time grouping of 2 or more persons in a business undertaking. N/A EIN
L Limited Partnership Type of partnership comprised of one or more general partners who are personally liable for debts, contribute capital and share in profits, but who take no part in running the business. File number as listed with the Texas Secretary of State EIN
T Texas Corporation For-profit or non-profit corporation chartered with the Texas Secretary of State. Charter number and Profit Status as listed with the Texas Secretary of State EIN
A Professional Association Entity chartered with the Texas Secretary of State, such as medical doctors and professional organizations. Charter number as listed with the Texas Secretary of State EIN
C Professional Corporation Corporation chartered with the Texas Secretary of State as a professional corporation. Charter number as listed with the Texas Secretary of State EIN
O Out-of-State Corporation Corporation legally chartered by a governmental entity outside the State of Texas. Profit Status (may be listed with the Texas Secretary of State) EIN
G Governmental Entity Any legal government agency, such as a county, city, or federal agency not created by the State of Texas Legislature. Does not include Texas state agencies or universities. N/A EIN
U State Agency/University Any agency or university created by the Texas State Legislature. Does not include agencies of other states. N/A Comptroller-assigned in most cases, with a format of: 3 + agency number repeated 3 times + check digit + mail code
F Financial Institution Any state bank, federal bank, savings and loan, or credit union. N/A EIN
R Foreign (out of USA) Entity outside of the United States that does not have either an SSN or an EIN. Profit Status Comptroller-assigned
N Other Organizations not defined within one of the other types. Examples: estates, informal organizations not chartered by the Secretary of State of Texas. Indicate short description of the organization type -

Section III. Facility/Provider/Contract/Vendor/Lease Number(s)

If the payee will be assigned another internal agency identification number, such as a facility number, contract number, etc., please indicate the number here, if known. You may enter more than one number if applicable.

Section IV. Payee Information

Enter a maximum of 50 characters per line.

  • Name of Payee (Individual or legal entity to be paid) — Enter the payee name here. If the payee is a business, enter the legal entity name. Do not include titles for individual names. (Examples: Dr., Mr., Ms., etc.)
  • DBA-Doing Business As (if applicable) – mailing address where you want to receive payments — Enter the "DBA" name on this line, if applicable. If there is no DBA name, enter the mailing address.
  • 2nd line of address (if needed) — If a DBA name was entered on the preceding line, enter the mailing address on this line. This line may also be used for any additional lines of address as a continuation from the preceding line, as needed.
  • 3rd line of address (if needed) — This line may be used for any additional lines of address as a continuation from the preceding line, as needed.
  • 4th line of address (if needed) — This line may be used for any additional lines of address as a continuation from the preceding line, as needed.
  • City, State, ZIP, Business or Daytime Telephone No. — Self-explanatory.
  • Sic Code, Security Type, Zone — Fiscal use only

Note: The U.S. Postal Service requires that the street address be on the line immediately preceding the city, state and ZIP address line. Suite numbers and apartments numbers should be on the same line as the street address, provided that the total line length does not exceed 50 characters. Use standard postal abbreviations. (Examples: St, Ave, Ln, Ste, etc.)

Example:

Name of Payee: The XYZ Healthcare Company, Inc.
DBA Name: DBA Restful Care Home
2nd line of address: Administration Office
3rd line of address: 2901 Shady Ln Ste 301
City, State, ZIP: Austin, TX 78751

Section V. Payee Assignment Information

An assignment is a legal transfer of a right or property. For the purposes of this form, it is the transfer of the right to payment.

  • Do not complete this section unless you are setting up a mail code for an assignment agreement.
  • A copy of the assignment agreement between payees must be attached to this form. The agreement must have the date and signatures of the two parties.
  • The assignor is the party transferring their right to payment. The assignor is typically the entity with which the agency is in contractual agreement.
  • You must enter the EIN/SSN of the assignor in Section I as the number to be used for the TIN.
  • Assignee Name — The assignee is the party receiving the right to payment.
  • Assignee SSN/EIN — Enter the EIN/SSN of the assignee. This is for reference information; the number will not be used as the base of the TIN.
  • Assignment Date — Date of the agreement. Note: This date may be used to determine right to payment in the event that either party incurs a debt to the state.

Section VI. Comments

Enter any additional comments or explanations that may be helpful in processing the form.

Section VII. Applicant Information

  • Name of Applicant or Authorized Contact — Print or type the name of the applicant or person authorized as a contact of the payee. This person may be contacted if there are questions about information provided on the form.
  • Telephone No., Date — Self-explanatory.

Section VIII. DADS Representative Information (Required)

  • DADS Representative and Division/Facility — Print or type the name of the DADS representative and division or facility of the person who is serving as contract manager, caseworker or other business point of contact for the payee.
  • Telephone No., Date — Self-explanatory.
  • Check box to be notified of assigned TIN by mail at the DADS Mail Code entered — A notification memo verifying the resulting TIN will be sent to the DADS representative at the mail code indicated in this section if the box is checked. If the box is not checked, notification will not be sent, and Accounting assumes that the DADS representative has determined the correct TIN by inquiring on HHSAS.