According to the instructions, all four certifications below must be on the substitute form.
Substitute Form W-9You may develop and use your own Form W-9 (a substitute Form W-9) if its content is substantially similar to the official IRS Form W-9 and it satisfies certain certification requirements. You may incorporate a substitute Form W-9 into other business forms you customarily use, such as account signature cards. However, the certifications on the substitute Form W-9 must clearly state (as shown on the official Form W-9) that under penalties of perjury:
1. The payee's TIN is correct,
2. The payee is not subject to backup withholding due to
failure to report interest and dividend income,
3. The payee is a U.S. person, and
4. The payee is exempt from FATCA reporting.http://www.irs.gov/pub/irs-pdf/iw9.pdf