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Cat. No. 14231X Form W- (RSM. 12.2014)
<br />Form ■IRS
<br />Request for Taxpayer
<br />Give
<br />dtmtothe
<br />(Rai. DSoembar2014a ry
<br />Identification Number and .Certification
<br />u
<br />star. Do not
<br />IntamzimiaevegilfUee&ENICC
<br />send
<br />to the IRS,
<br />I Name (as Shown on your income tax ratum). Name is required on We line: do not feava this Iles blank
<br />li'e'f"lie%',itzc)LcFrrao,9Cttea�iss�rezrra�
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<br />2 Business nama/dare9ardad lily Hama; ft ditforent frgm Soave
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<br />3 Check appropriate box for federal taxcls IcialOn; Shack Only one of the fallowing seven boxes: 4 Exemptions (cnd
<br />sG "sin entities, not
<br />[ hdividusiJoole
<br />apply dnryto
<br />d ividuals;
<br />o
<br />proprietor or Corporation [J S Corporation 0 partnership Trustlesiete
<br />single-marrrUAr'LLC instructions on pa
<br />sae
<br />3):
<br />[]Limited liability company.. Enter the tar classification(t'aC corporation, S=5 corporation, P.partnership)► Exempt payee code
<br />(y my)
<br />Note. For a sinoWmember LLC that q disregarded, do not check LLC; check the appropriate box in the lin; sbova for Exemption from FA
<br />reporting
<br />the tax classification of the aingle-member owner.
<br />Ottode {ro.cear,a
<br />y
<br />(� Other ism lrretrugtbna)► 01 e) j
<br />"am,wdousi,
<br />$ Address (number, street, and apt. ar}suit;e rrq.) Requaatera name and address (options
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<br />T List account num s} hers (optional}
<br />Tax ver IdentHlcaiion Number IN
<br />Enter your TIN in the appropriate box. The TW provided must match the name given on tine 1 to avoid ,
<br />backup withholding. For Individuals, this Is generally your social Security number (SSN). Nowsvar, fora
<br />n!n_
<br />resident alien, sole Proprietor, or disregarded entity, seethe Fart I Instructions on page3. For other
<br />entities, it is your employer identification number (EIN). if you do not have a number, see How to gat a
<br />T1JJon peg; 3. or
<br />Note, If the account Is In more then One name, $ae the instructions for line f and the chart on page 4 for Employer Identdf0amon numb
<br />,
<br />guidelines on whose number to enter.
<br />4`'7
<br />//i
<br />Certification
<br />Under penalties of perjury, I certify that:
<br />1. The number shown on this form Is my correct taxpayer Identification number (or I am wafting for a number to be issued to me); and
<br />2, 1 elm not subject to backup withholding because. (a) I am exempt from backup withholding, or (b) I have not been notified by the Inlay
<br />tell Revenue
<br />Service (IRS) that I am subject to backup withholding as A result of a failure to report ail Interest or dividends, or (o) the IRS has ncififif
<br />d me that I am
<br />no longer subject to backup withholding; and
<br />3. f am a U,S. citizen or other U.S. person (defined below); and
<br />4. The FATCA code(s) entered on this form if any) Indicating that I am exempt from FATCA reporting is correct.
<br />Cerullo stion instructions, You must cross out item 2 above if you have been notified bylhe IRS that you ars currently subject W backu
<br />-'withholding
<br />because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. Form
<br />rtgage
<br />Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangemo
<br />t(IRA), and
<br />generally, payments other than Interest and dividend you are no u(red to sign the certification, but you must provide your correct T.
<br />Instructions on page 3.
<br />N. Sea the
<br />Sign
<br />Fiera
<br />Signatupere of
<br />U.S.U.s. parson r
<br />onl '//a2�
<br />� pate r 1101'1
<br />Generali Instructions = Form 1098 (home mortgage intereat},1098-E (student ban ante
<br />st), I098 -T
<br />(arttion)
<br />Bsotlan U#WAnceS are to the Internal Revenue Code unless otherwise noted. . Form 1089.0 (oaneeled debt)
<br />Future developments. Information about developments affecting form W-9 (such • Form 1499-A acqulsidw or abandonment of secured property)
<br />as legislation enacted after we release it) is at www.lr^,.gnvlice.
<br />Uae Form W-9 only ff you are a U.S. person 4ncluding a menden
<br />Purpose of Form provide your correct TIN,
<br />afion), to
<br />An individual or entity (Form W -e requester) who Is required to file an Information lfyou do not return r'onr, W8 to fhs rsquesWurith a TPN, you 0
<br />ghtbe subject
<br />return with the IRB must obtain your correct taxpayer identification number (CIN) to backup withholding. Sea What is backup wXhholding? on page
<br />.
<br />which may be your social security number (SSW), individual taxpayer Identification By aiming the filled -out farm, You:
<br />number (ITIN), adoption taxpayer identification number (ATIN), or employer
<br />t. Gert' that the TIN
<br />Identification number PN), to report on an information return the Amount paid to rfY You are giving is correct (o you are waif
<br />for a number
<br />you, or other amount reportable an an information return. Examples of information to be Issued),
<br />returns include, but are not limited tc, me following: 2. CamNy that you are not subject to backup withholding, or
<br />• Form 1496 -INT (Intoreat earned or pall) 3. Claim exemption from backup withholding H you aro a U.S. a
<br />ampt payee. if
<br />•• Form 1099 -DN (dividends, including those from stacks or mutual funds) applicable, you are also corfifying that as a U.S. person, your alisc
<br />sple share of
<br />• Form 1099-MIBC (various types of indOma, Wiz",, awards, loss any partnership income from a U.S, trade w business is not subject
<br />proceeds) or
<br />g P ) withholding tax on foreign paMsrs'share of effectively connected
<br />to the
<br />income, sad
<br />• Form 1099-B (stook or mutual fund setas and certain other transactions by 4. CSorth, that FATCA coda(A) entered on this form (f arty) Indica
<br />brokers)
<br />Ing that you ora
<br />exempt from the FATCA reporting, is correct. See What isFAMA
<br />'ng?on
<br />0 FOrm 1099.5 (proceeds from real estate Iramesfidns) page 2 for further information.
<br />• Form 1498-K (merchant card and Hard party network transactions)
<br />Cat. No. 14231X Form W- (RSM. 12.2014)
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