Instructions for Vendor Survey for Individuals

Section 1

Vendor Name – Formal name as filed with the Internal Revenue Service

Address, City, State, Zip – List all addresses to which payments could be remitted

Section 2

Electronic ACH Payments -  May the University send electronic payments directly to your bank account?  This would not be applicable for one-time payments.

Section 3

Type of Payment to be received from the University  – Please check one (1) category.

Section 4

You or family members employed by the University of Louisville or any of its affiliates -  The following is a list of University of Louisville affiliates:

• University of Louisville Research Foundation, Inc.
• University of Louisville Athletic Association
• University of Louisville Medical School Fund, Inc.
• University of Louisville Foundation, Inc. and Affiliates
• ULH, Inc.
• University of Louisville and Jewish Hospital Cardiovascular Innovation Institute, Inc.
• OMHS/UofL Cancer Research Center, Inc.

Section 5 (This question not applicable to study participants)

Excluded, debarred or otherwise ineligible to participate – Federal and state governments maintain multiple lists of individuals or entities that have been excluded, disbarred, suspended, or otherwise deemed ineligible from participation in and/or receiving funds from government-funded programs.  Two such lists maintained by the Federal government include the DHHS OIG LEIE  and the GSA EPLS .  If you have been excluded, disbarred, suspended, or otherwise deemed ineligible, please provide an explanation in the space provided on the form so that your eligibility to provide services to the University can be assessed.

Section 6

Please certify the accuracy of the information provided in the survey, and sign & date the form.

Please return the survey, along with a W-9 form to the University department that requested the forms.

Last Update: September 2009