GUEST SPEAKER PAYMENT REQUEST FORM NEVADA SYSTEM OF HIGHER EDUCATION

ON BEHALF OF THE UNIVERSITY OF NEVADA, RENO

I. Guest Speaker Information – All information is required throughout the whole form.

Guest Speaker*____________________________________________________________________________________ Last First MI

Speaking Date(s) __________________________________________________________________________________

Guest speaker must complete Form W-9 as Page 2 of this form. Department must include a flyer, announcement, brochure, offer letter, or acceptance letter as page 5 of this form.

Please direct any questions to icgs@unr.edu.

YES NO 1. Is this a one-time, nonrecurring speaking engagement?

If NO, do NOT proceed with this form. Contact icgs@unr.edu or (775) 784-1404 with completeinformation for further instructions.

2. Is the recommended guest speaker a current or former (during the past twelve months) employee ofNSHE (which includes College of Southern Nevada, Desert Research Institute, Great BasinCollege, Nevada State College, Truckee Meadows Community College, UNLV, UNR, WesternNevada College, or any NSHE System Administration Offices) or the State of Nevada?

If YES, do NOT proceed with this form. Process the payment on an employment document. Forcurrent or former state employees, contact Controller’s for instructions.

3. Is the recommended guest speaker related to an NSHE employee?

If YES, do NOT proceed with this form. Under the Board of Regents Conflict of Interest Policy(BOR Title 4 Chapter 10) payment is not allowed.

4. Is the recommended guest speaker a U.S. citizen or lawful permanent resident (green card holder)?

If NO, contact the Nonresident Alien Tax Specialist at nra@unr.edu or 784-1404 for additionaldocumentation requirements and approval of Section III.

II. Determination/Approval

This contract is not fully executed until it is reviewed and approved by the NSHE Independent Contractor Review Authority.

Approval of NSHE Independent Contractor Review Authority Date

* Guest Speakers are independent contractors/independent service providers from the IRS perspectives.

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III. Foreign Nationals

Foreign nationals may not be contracted, paid, or reimbursed without documentation substantiating the individual’s immigration status PRIOR TO the commencement of services. Contact the Nonresident Alien Tax Specialist for information and approval. Payments to foreign national contractors are subject to 30% federal income tax withholding. All payments will be reported on Form 1042-S.

Approval of NSHE Nonresident Alien Tax Specialist Date

IV. Insurance Requirements – All information is required.

Any insurance related questions can be forwarded to BCN Risk Management, (775) 682-6107.

1. I UNDERSTAND THAT PAYMENT(S) WILL NOT BE PROCESSED UNLESS THE AFFIDAVIT AND/OROTHER INSURANCE REQUIREMENTS listed below ARE FULLY MET, if applicable.

Initial – Guest Speaker Date Initial - Department Date

2. Workers’ Compensation and Employer’s Liability Insurance

(a) Workers’ Compensation Insurance is not required if the Guest Speaker is:

To receive only travel reimbursements, and/or travel expenses are to be paid to vendor(s) directly on behalf of the contractor using a PCard or request for payment, i.e., no fee or honorarium is to be paid to the contractor. Corresponding receipts must be attached. A faculty member of another U.S. institution and covered under his/her home institution’s workers’ compensation policy. An individual and NOT a sole proprietor. NRS 616A.310 defines a “SOLE PROPRIETOR” as a self-employed owner of an unincorporated business and includes: working partners and members of working associations.

If any of the above applies, then skip to item 3 below.

(b) Nevada law allows the following to reject workers’ compensation coverage if they do not use employees or subcontractors in the performance of work under the contract. Indicate the appropriate category below:

Sole proprietors (NRS 616B.627 and NRS 617.210). Unpaid officers of quasi-public, private, or nonprofit corporations (NRS 616B.624 and NRS 617.207). Unpaid managers of limited liability companies (NRS 616B.624 and NRS 617.207). An officer or manager of a corporation or limited liability company who owns the corporation or company (NRS 616B.624 and NRS617.207).

If the Contractor has rejected workers’ compensation coverage under applicable Nevada law, the Contractor must indicate the basis for the rejection of coverage above; and complete, sign, and have notarized an Affidavit of Rejection of Coverage. The Affidavit of Rejection forms can be found at: http://www.bcn-nshe.org/downloads/?deptID=Workers%20Compensation.

3. High Risk speaking engagements should be referred to BCN Risk Management, (775) 682-6107, for review. SpecialEvent liability insurance may be required for events including: debates, demonstrations, controversial topics, largecrowds (over 500) and high media profile speakers.

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Primary Contact

Trust/estate (SSN or EIN) LLC tax classification

Disregarded Entity Partnership Corporation

EIN

Substitute W-9 form

Controller’s Office Mail Stop 0124

Ross Hall, Room 103 Reno, Nevada 89557-1124

(775) 784-4168 Fax: (775) 784-6229

1. NAME For proprietorship, provide proprietor’s name in first box and DBA in second box.

Legal Business Name, Proprietor’s Name or Individual’s Name Doing Business as (DBA)

2. ADDRESS/CONTACT INFORMATIONPhysical address of

Company Headquarters Remittance Address

Address Address

Address Address

City State Zip Code City State Zip Code

Web Address

Fax Number Phone Number E-mail Address

3. ORGANIZATION TYPE AND TAX IDENTIFICATION NUMBER (TIN)Check only one organization type and supply the applicable Social Security Number (SSN) or Employee Identification Number (EIN).For proprietorship, provide SSN or EIN, not both.

OTHER INFORMATION Check all that apply. Doctor or Medical Facility Attorney or Legal Facility

Nevada Business License Number:

4. ELECTRONIC FUNDS TRANSFER (Optional)Complete the following information AND provide a copy of a voided imprinted check (not a deposit slip) or bank verification of your checking /savings account. Bank Name Bank Account Type

Checking Savings Provide an e-mail address for receiving Direct Deposit Remittance Advices

Transit Routing Number Bank Account Number

5. DISADVANTAGED BUSINESS ENTERPRISE DESIGNATION

Small business enterprise

Women owned business Historically underutilized business zone

Disabled/veteran disabled owned business

Yes

6. IS BUSINESS OWNED / OPERATED BY

A member of the Board of Regents of the Nevada System of Higher Education: Yes No A Nevada System of Higher Education employee: Yes No A member of a NSHE regent or employee’s household: No

Individual’s Residence

Minority owned business

Yes

Individual (SSN) Sole Proprietorship (SSN or EIN) Partnership (EIN) Corporation (EIN) Government (EIN) Tax Exempt/Nonprofit (EIN)

No If you checked any of the above, have you been certified? If yes, by which agency:

Please specify ethnicity:

Name associated with SSN:

SSN

7. IRS FORM W-9 CERTIFICATION AND SIGNATUREUnder penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that

I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and3. I am a U.S. citizen or other U.S. person (as defined by IRS Form W-9 rev December 2014), and

Cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Signature Print Name & Title of Person Signing Form Date

Certificate Number:

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Exemptions (See instructions): Exempt payee code (if any) Exemption form FATCA reporting code (if any)

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Registration Instructions General Instructions:

1. The substitute IRS Form W-9 is for the use of United States entities only. Detailed instructions can be found at www.irs.gov/pub/irs-pdf/fw9.pdfNon-US entities must submit an IRS Form W-8.

2. Type or legibly print all information except for signature.3. All sections are mandatory and require completion except section 4.Specific Information:

1. NAMEa. Partnership, Corporation, Government or Nonprofit – Enter legal business name as registered with the Internal Revenue Service (IRS) in first

box. If the company operates under another name, provide it in the second box.b. Proprietorship – Enter the proprietor’s name in the first box and the business name (DBA) in the second box.c. Individual – Name must be as registered with the Social Security Administration (SSA) for the Social Security number (SSN) listed in Section 3.

2. ADDRESS/CONTACT INFORMATIONa. Physical address – If the address is non-deliverable by the United States Postal Service, complete both Physical Address and Remittance address

Company – Provide physical location of company headquarters.Individual – Provide physical location of residence.

b. Remittance address – Provide address and related information when appropriate.c. Primary Contact – Person (and phone number or extension) to be contacted for payment-related questions or issues.

Telephone Number – Include area code.Fax Number – Include area code.E-mail – Provide complete e-mail address when available.

3. ORGANIZATION TYPE AND TAX IDENTIFICATION NUMBER (TIN)a. Individual – A person that has no association with a business.b. Proprietorship – A business owned by one person.c. Partnership – A business with more than one owner and not a corporation.d. Corporation – A business that may have many owners with each owner liable only for the amount of his investment in the business.e. LLC – Limited Liability Company. Must mark appropriate classification – disregarded entity, partnership or corporation.f. Government – The federal government, a state or local government, or instrumentality, agency, or subdivision thereof.g. Tax Exempt/Nonprofit – Organization exempt from federal income tax under section 501(a) or 501(c)(3) of the Internal Revenue Code.h. Doctor or Medical Facility – Person or facility related to practice of medicine.i. Attorney or Legal Facility – Person or facility related to practice of law.j. Nevada Business License number – Current NV business license number which was issued by the NV Secretary of State.k. The Taxpayer Identification Number (TIN) is always a 9-digit number. It will be a Social Security Number (SSN) assigned to an individual

by the SSA or an Employer Identification Number (EIN) assigned to a business or other entity by the IRS. The IRS preferes a socialsecurity number for a proprietorship.

4. ELECTRONIC FUNDS TRANSFERProvide a copy of a voided imprinted check or bank verification. A deposit slip will not be accepted.Information on this form and the support documentation must match.

a. Direct Deposit Remittance Advice – Direct Deposit Remittance Advices are sent via e-mail when possible. Companies should provide anaddress that will not change, i.e. accounting@business.com.

5. DISADVANTAGED BUSINESS ENTERPRISE DESIGNATIONa. MINORITY OWNED BUSINESS: An independent business which performs a commercially useful function and is at least 51% owned and

controlled by one or more minority persons of African American, Hispanic American, Asian Pacific American or Native American Ethnicity.b. WOMEN OWNED BUSINESS: An independent business which performs a commercially useful function and is at least 51% owned and

controlled by one or more women.c. DISABLED/VETERAN DISABLED OWNED BUSINESS: An independent business which performs a commercially useful function and is

at least 51% owned and controlled by one or more disabled and or veteran disabled individuals pursuant to the American with DisabilitiesAct or who have served in the active military and discharged under conditions other than dishonorable.

d. SMALL BUSINESS ENTERPRISE: An independent business which performs a commercially useful function is not owned and controlledby individuals designated as minority, woman, veteran or physically challenged and where gross sales do not exceed $2,000,000.

e. HISTORICALLY UNDERUTILIZED BUSINESS ZONE: An independent business which qualifies for the HUB Zone EmpowermentContracting Program provides federal contracting opportunities for qualified small businesses located in distressed areas

6. IS BUSINESS OWNED / OPERATED BYa. NSHE institutions are: NSHE System Office, CSN, DRI, GBC, NSC, SCS, TMCC, UNLV, UNR, WNC

7. IRS FORM W-9 CERTIFICATION AND SIGNATUREa. The Certification is copied from IRS Form W-9 (rev. December 2014). See IRS Form W-9 for further information.b. The Signature should be provided by the individual, owner, officer, legal representative or other authorized person of the entity listed on the form.c. Print the name and title, when applicable, of the person signing the form.d. Enter the date the form was signed. Forms over three years old will not be processed.

l. Exemptions - Provide exemptions codes. Detailed instructions can be found at www.irs.gov/pub/irs-pdf/fw9.pdf

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V. Payment Source

FUND AGCY ORGN OBJT SOBJ BACC DESCRIPTION Include last four digits of PCard, if applicable

AMOUNT Due to Speaker

AMOUNT Prepaid by Dept

Disposition of Check Mail as addressed Pick up at Cashier’s Estimated amounts – Invoice to be submitted

Total Due to Speaker:

Total Prepaid by Department:

Total Expenses:

Department must include a flyer, announcement, brochure, offer letter, or acceptance letter as page 5 of this form.

VI. Signatures

The total amount paid to the guest speaker will be subject to IRS 1099 or 1042-S (if nonresident alien) reporting guidelines, except when receipts are submitted for travel expenses or the university per diem rates are applied for meals.

CERTIFICATION: Based on the above, it is my determination that the contractor meets the guidelines of one-time, nonrecurring guest speaker payments.

Authorized Hiring and Account Signature Date

Printed Name of Authorized Signer

Department Mail Stop

Department Contact Name and E-mail Address

Telephone No. Fax No.

AGREEMENT: I have read and agree to the above representations and assert that they are true and correct. Workers’ Compensation: I acknowledge that the University of Nevada, Reno will not be considered to be my employer and is not liable as a principal contractor to me for any compensation or other damages as a result of an industrial injury or occupational disease incurred in the performance of these services. THIS CONTRACT IS NOT FULLY EXECUTED UNTIL SECTION II IS COMPLETED [in addition to section III for foreign nationals].

Speaker’s Signature Date

Mailing Address

City State Zip

E-mail Address

Telephone No. Fax No.

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