Financial Forms for U.S. Based Institutions

Transcription

1 ALEXION INVESTIGATOR-SPONSORED RESEARCH PROGRAM FINANCIAL FORMS FOR U.S. BASED INSTITUTIONS 1 Financial Forms for U.S. Based Institutions Your institution must submit completed financial forms in order to receive funding support for Investigator-Sponsored Research (ISR) from Alexion. These financial forms are required to set up your institution as a payee (i.e., recipient of payment) from Alexion. Information provided in this guide is only meant to assist the study initiation process and should not be construed as tax advice. For U.S. based institutions, the following completed documents must be submitted: 1. Internal Revenue Service (IRS) Form W-9: Request for Taxpayer Identification Number and Certification 2. Alexion Vendor Authorization Form 1 Receive the Financial Forms All required Financial Forms will be forwarded to you once your study is approved by Alexion. If you did not receive the forms or cannot locate them, please contact Alexion ISR Operations at ISR@alxn.com. 2 Complete IRS Form W-9 (For U.S. Based Institutions) Alexion must obtain your institution s correct Taxpayer Identification Number (TIN) in order to file required tax documents and report funding support for your ISR study. Consequently, a qualified financial officer from your institution must complete and provide IRS Form W-9, Request for Taxpayer Identification Number, to Alexion. For additional information and instructions about IRS Form W-9, please see: IRS Form W-9 is organized in three (3) sections: 1. Taxpayer Information 2. Part I: Taxpayer Identification Number 3. Part II: Certification Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service Print or type See Specific Instructions on page 2. Request for Taxpayer Identification Number and Certification 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. 2 Business name/disregarded entity name, if different from above Give Form to the requester. Do not send to the IRS. 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to Individual/sole proprietor or C Corporation S Corporation Partnership Trust/estate certain entities, not individuals; see instructions on page 3): single-member LLC Exempt payee code (if any) Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner. Exemption from FATCA reporting code (if any) Other (see instructions) (Applies to accounts maintained outside the U.S.) 5 Address (number, street, and apt. or suite no.) Requester s name and address (optional) 6 City, state, and ZIP code 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally 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 instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. Social security number or Employer identification number 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 In the on Taxpayer page 3. Information section: Sign Signature of Here 1. Enter your Institution s legal name in Business Name U.S. person 2. Check the appropriate box for Federal Date General Instructions Tax Classification (tuition) Section references are to the for Internal your Revenue institution: Code unless otherwise noted. Form 1099-C (canceled debt) Future developments. Information about developments affecting Form W-9 (such Form 1099-A (acquisition or abandonment of secured property) as legislation enacted after we release it) is at C Corporation Use Form W-9 only if you are a U.S. person (including a resident alien), to Purpose of Form provide your correct TIN. S Corporation An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), Partnership individual taxpayer identification By signing the filled-out form, you: number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information Trust return. / Examples Estate of information returns include, but are not limited to, the following: 2. Certify that you are not subject to backup withholding, or Form 1099-INT (interest earned or paid) Limited Liability Company (if selected, enter the tax Form 1099-DIV (dividends, including those from stocks or mutual funds) any partnership income from a U.S. trade or business is not subject to the Form 1099-MISC (various types of income, classification prizes, awards, or gross proceeds) in the space on the right) Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) Other (if selected, enter the specific tax Form 1099-S (proceeds from real estate transactions) page 2 for further information. Form 1099-K (merchant card and third party classification network transactions) in the space on the right) 3. Enter your institution s street address in Address 4. Enter City, State, and Zip Code Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on Cat. No X Form W-9 (Rev )

2 ALEXION INVESTIGATOR-SPONSORED RESEARCH PROGRAM FINANCIAL FORMS FOR U.S. BASED INSTITUTIONS 2 Payments related to ISR are not made directly to an individual. In Part I: Taxpayer Identification Number section, enter your institution s federal tax identification number in Employer Identification Number (EIN). In the Type of Request section, Select New Request if you are submitting the form for the first time, or Select Change Request if you are submitting changes to payment information related to your ISR study In Part II: Certification section, review the certification statement and instructions and Sign and Date the form to complete the certification. Please ensure that the appropriate financial officer of your institution is completing this form, as well as certifying the information provided (via signature and date). The completed form should be uploaded as an attachment in Visiontracker. Please refer to Section of this guide for detailed instructions. 4 In the Main Address section: Enter Institution Name and corresponding Address, Phone, , and Web Address for your institution in Main Address sub-section 3 Alexion Vendor Authorization Form (For All Institutions) A vendor is defined as an organization who will receive payments from Alexion. Such organizations first need to be certified within Alexion s financial system before any payments can be processed. A qualified financial officer from your institution must complete Alexion s Vendor Authorization Form in order to begin the vendor certification process. Alexion s Vendor Authorization Form is organized in nine (9) Sections: 1. Type of Request 2. Main Address 3. Customer Service Address 4. Remittance Address 5. Method of Payment 6. Industry 7. Business Type Classification 8. Patient Protection Affordable Care Act 9. Terms Payments related to investigator-sponsored research are not made directly to an individual. Please enter the name of your institution in Company Name\Individual Name. Address information must be identical to address information provided on IRS W-9 Tax Forms. In the Customer Service Address section: Enter Institution Name and corresponding contact information in Customer Service Address section where the Purchase Order needs to be issued, or, select Same as Main Address.

3 ALEXION INVESTIGATOR-SPONSORED RESEARCH PROGRAM FINANCIAL FORMS FOR U.S. BASED INSTITUTIONS 3 A Purchase Order is the final, official authorization from Alexion regarding funds appropriated for your study. Indicate the address of the department responsible for financial accounting related to your study. The purchase order, when issued, will be sent to this contact. In the Remittance Address section: Enter Institution Name and corresponding contact information in Remittance Address section where payments needs to be sent for the ISR study, or, select Same as Main Address. Payments related to Investigator-Sponsored Research are not made directly to an individual. Under Wire method of payment, provide: 1. Bank Name 2. Bank Address 3. Bank Code Swift code or Other 4. Account Name 5. Account Number or IBAN 6. Other Required Information If the institution has previously received payments for goods or services from Alexion, it is very important to list all previous remittance contacts, departments, and addresses in this section. In the Method of Payment section: Under Automated Clearing House (ACH) method of payment, available only for U.S. Based Institutions, provide: 1. Bank Name 2. Bank Account Name 3. Bank Address 4. Bank ACH Routing Number 5. Bank Account Number 6. for sending remittance detail

4 ALEXION INVESTIGATOR-SPONSORED RESEARCH PROGRAM FINANCIAL FORMS FOR U.S. BASED INSTITUTIONS 4 On the Industry Section, be sure to select the Industry Sector and enter the Sub-Sector which apply to your institution. for most ISR studies, the Industry Sector is Healthcare and Social Assistance and the Sub-Sector is Hospital or University For all U.S.-based institutions, on the Patient Protection Affordable Act section, provide the information needed for U.S. Aggregate Spend Reporting. For institutions, select NO on Question 1 and complete Questions 5 8. On the Business Type Classification section, be sure to select all classifications that are applicable to your institution. Review the terms and conditions noted in the Terms section, Sign and Date the form. Please ensure that the appropriate financial officer of your institution is completing this form, as well as certifying the information provided (via signature and date). Completed form should be uploaded as an attachment in Visiontracker. Please refer to Section 4 of this guide for detailed instructions.

5 ALEXION INVESTIGATOR-SPONSORED RESEARCH PROGRAM FINANCIAL FORMS FOR U.S. BASED INSTITUTIONS 5 4 Submit completed IRS Form and Alexion Vendor Authorization Form Once completed, the forms can be uploaded as an Attachment in Visiontracker. Log-in to Visiontracker and locate the approved ISR proposal for which you need to submit the Financial Forms. Select the proposal to display the Study Details screen. From the Study Detail screen: Click tab Click or next to Additional Attachments On the resulting Document Selection screen, click to select the appropriate file to upload On Type, select Financial Forms from the available list: Enter Description as appropriate (i.e., IRS W-9 Form, Vendor Authorization Form) and click The entry will be displayed on the list of Additional Attachments and can be edited, if needed, by clicking next to the entry. To Request the Financial Forms please contact Alexion ISR Operations at ISR@alxn.com When all Financial Forms that you want to submit are completed, you can click to send the Financial Forms to Alexion. VISIONTRACKER is a trademark of Envision Pharma, Inc.