Taxpayer Certification Form - Instructions

If you filed a claim in the Baxter Securities Class Action, or a claim was submitted on your behalf, you may be considered a Class Action Authorized Claimant for the Baxter Fair Fund established in the related Securities and Exchange actions described in the Plan Notice. To have your claim from the Class Action considered for payment from the Baxter Fair Fund, you must complete a Taxpayer Certification Form.

Please note if the claim you submitted in connection with the Class Action was denied for not having valid documentation supporting the purchases/acquisitions of Baxter International common stock claimed, or because the Claim Form was missing (i) a valid signature; or (ii) the authority and/or the capacity of the person to sign on behalf of the beneficial owner, a Claim Deficiency Notice has been included with your Plan Notice. The Claim Deficiency Notice specifies the defects associated with your Class Action claim that must be cured for your claim to be considered for payment from the Baxter Fair Fund. The Taxpayer Certification Form, as well as the information required to cure the deficiencies associated with your claim, must be submitted so that they are postmarked or received by the Fund Administrator on or before March 8, 2024.

If you want to modify the claim that you submitted in connection with the Class Action, you should file a new claim in connection with the Baxter Fair Fund. You may obtain a copy of the Claim Form from this website, here, by calling toll-free 844-787-6813, emailing info@BaxterFairFundDistribution.com, or writing to Baxter Fair Fund, P.O. Box 6700, Portland, OR 97228-6700. The completed claim form must be submitted so that it is postmarked or received by the Fund Administrator on or before March 8, 2024.

The Baxter Fair Fund is a “Qualified Settlement Fund” (“QSF”) as defined in Section 468B(g) of the Internal Revenue Code, 26 U.S.C. Section 468B(g), as amended, and the Treasury regulations promulgated thereunder, 26 C.F.R. 1.468B-1 et seq.

To ensure that the QSF can comply with its reporting and/or withholding obligations, please complete and provide one (1) of the following forms, as applicable:

  • IRS Form W-9 or Substitute IRS Form W-9 (below); OR
  • IRS Form W-8BEN, W-8BEN-E, or other W-8 series form

If you are a U.S. person, as that term is defined below, then you should complete the Substitute IRS Form W-9 below.

If you are not a U.S. person, then you should not complete the Substitute IRS Form W-9 below. Instead, you should complete IRS Form W-8BEN, W-8BEN-E, or other W-8 series form, which can be found by visiting the following IRS website: https://www.irs.gov/forms-instructions.

The term “U.S. person” means:

  • A citizen or resident of the United States;
  • A partnership created or organized in the United States or under the law of the United States or of any State, or the District of Columbia;
  • A corporation created or organized in the United States or under the law of the United States or of any State, or the District of Columbia;
  • Any estate or trust other than a foreign estate or foreign trust (see Internal Revenue Code § 7701(a)(31) for the definition of a foreign estate and a foreign trust); or
  • Any other person that is not a foreign person.

If the QSF does not receive a valid and complete Form W-9 or W-8 from you, the QSF may be required under the Internal Revenue Code to make certain presumptions about you for purposes of tax reporting and, as applicable, withholding. The QSF may be required to presume the interest is being paid to: (1) a payee subject to 30% withholding under the Foreign Account Tax Compliance Act (“FATCA”) and reporting on Form 1042-S; (2) a nonresident alien of the U.S. (“NRA”) subject to reporting and 30% NRA withholding and reporting on Form 1042-S; or (3) a U.S. person subject to 24% backup withholding and reporting on Form 1099-INT.

All claims, documents submitted in response to a Deficiency Notice, and tax documents must be submitted so that they are postmarked or received by the Fund Administrator by March 8, 2024.

Click here to download a copy of the Taxpayer Certification Form.


You may submit the Taxpayer Certification Form:

  1. By mail to the Fund Administrator at the following address:

    Baxter Fair Fund
    Fund Administrator
    P.O. Box 6700
    Portland, OR 97228-6700


    OR

  2. By using the online Taxpayer Certification filing option here.