City of Edina Form Center

Vendor Information and Certification

2. About This Form
   The City of Edina's Finance Department requires those receiving payment from the City to provide a W9 and up-to-date financial contact/Remit To information. For more information about why the City of Edina is collecting this information or to ask questions, contact Accounting Clerk Lonnia Jefferson at 952-826-0411 or ljefferson@EdinaMN.gov.
4. Use This Form To:

   1. Submit a copy of your W9
   2. Update contact information for those authorized to provide banking information and change the Remit To address
   3. Update your Remit To information
   4. Provide any other contact information such as sales, accounts receivable, etc.
   5. Provide proof of certifications

   DO NOT INCLUDE bank routing or financial account numbers with this form
6. Please use ALL CAPS
   Please use ALL CAPITAL LETTERS when filling out the form fields.
10. Provide W9 Information
    Please have your W9 in front of you and input the information EXACTLY as it appears on your W9. (Remember to use ALL CAPS)
12. W9 Name*
13. W9 DBA
15. W9 Street Address*
17. W9 City*
18. W9 State*
19. W9 Zip Code*
21. W9 Taxpayer Identification Number*
    No dashes
23. Upload W9 (for verification)*
    Most common file types accepted including JPG, PDF, DOC, DOCX, TIF, etc.
25. Letter from Finance Department?
    If you received a letter from the City of Edina's Finance Department requesting you fill out this online form, please input the company name that the letter and/or envelope was addressed to (Example: Lunds & Byerlys). This will help us match up records already in our system.
29. Financial Contact
    We will contact you separately for banking information. Please list the proper contact for banking/payment receipt information who has the authority to change the remit address.
31. Financial Contact Name*
32. Email Address*
34. Address*
36. City*
37. State*
38. Zip Code*
40. Phone Number*
    Please format with dashes as above
42. Electronic Payments*

    Are you interested in payments being made to your business electronically? (Yes or No)

    1. Y
    2. N
46. Remit To Information*

    Is the Remit To the same information as listed on your W9?

    1. Yes
    2. No
48. Remit To Name*
49. Email Address*
51. Address*
53. City*
54. State*
55. Zip Code*
57. Phone Number*
    Please format with dashes as above
61. Other Contacts
63. Accounts Receivable Contact*

    Is there an A/R contact other than the person(s) already listed on this form?

    1. Yes
    2. No
65. Name*
66. Email Address*
68. Address*
70. City*
71. State*
72. Zip Code*
74. Phone Number*
    Please format with dashes as above
76. Other Contact*

    Is there another contact you would like to provide, such as in sales or customer service, that would be a contact for financial information?

    1. Yes
    2. No
78. Name*
79. Email Address*
81. Address*
83. City*
84. State*
85. Zip Code*
87. Phone Number*
    Please format with dashes as above
91. Certifications
    Please check any applicable certifications, supply last certification date and upload a copy of your certifications obtained through the Minnesota United Certification Program, the Office of State Procurement (OSP) or the Central Certification Program (CERT).
93. Certification Type

    Check all that apply

    1. Minority-Owned Business
    2. Women-Owned Business
    3. Veteran-Owned Business

    1. Substantial Physical Disability
    2. Economically Disadvantaged Area
    3. Other
95. Explain Other*
    If you marked "Other" certification type, please provide a brief explanation and upload proof in the upload section below.
97. Last Certification Date
    Please list last certification date for any of the certifications you checked.
99. Upload Certificate
100. Upload Certificate
     Use if you have more than one
102. Questions?
     For questions regarding this form or the vendor payment process, contact Accounting Clerk Lonnia Jefferson at 952-826-0411 or ljefferson@EdinaMN.gov.
104. Public Records Notice*

     Some information you provide on this form, such as your business' certification type, is considered public record and would be released upon request. W9s and financial information are not public records and would not be released.

     1. I have read and understand the public records notice.
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106. Submit

* indicates a required field