Affiliate Signup Form

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This Affiliate Agreement ("Agreement"), is entered into this 24th day of September, 2017 by and between Paygrip, LLC, a Maine Corporation with an address of 75 Market Street, Suite 503, Portland, Maine 04101 ("Paygrip"), and the Referral Partner listed below ("Referrer") (or collectively, the "Parties"), whose name, contact, and other information is as follows:

Affiliate Recital Instructions

IN WITNESS WHEREOF,
the parties hereto execute this Agreement as of the day and year written below;

Signature of Referrer:

Draw your signature

Date: September 24, 2017

Form W-9

(Rev. December 2014) Department of the Treasury, Internal Revenue Service


Part I : Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter

Part II : Certification

Under 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), and
  2. 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, and
  3. I am a U.S. citizen or other U.S. person (defined below), and
  4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must 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. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Signature of U.S. Person:



Draw your signature

Date: September 24, 2017

  • By checking this box you agree that you have read, understand, and accept the W9 General Instructions as outlined here W9 General Instructions

(By clicking the submit button you are submitting both the Affiliate application and the W9 form)

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