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At least one Certification Statement must accompany the ETIN Application Form. CERTIFICATION STATEMENT INSTRUCTIONS​​ You will be asked to update your Certification Statement on an annual basis.Complete the form as appropriate, using the information provided below. This form must be printed out, completed, and submitted with the provider enrollment application form. Instructions: Please complete all sections of this application. Form W-7 is used to apply for an ITIN, or to renew an existing ITIN. The fiscal agent cannot accept Certification Statements that are not notarized. Provider ID(s) is not linked to the ETIN – a Certification Statement for. Provider Billing Medicaid must be completed, notarized, and mailed to CSC. These publications are available on the FTA State Exchange System (SES).