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Form W-9 (Rev. 12-2014)
<br />Part H. Certification
<br />To establish to the withholding agent that you are a U.S. person, or resident alien,
<br />sign Form W-9. You may be requested to sign by the withholding agent even if
<br />Items 1, 4, or 5 below Indicate otherwise.
<br />For a Joint account, only the person whose TIN is shown in Part I should sign
<br />(when required). In the case of a disregarded entity, the person identified on line 1
<br />must sign. Exempt payees, see Exempt payee code earlier.
<br />Signature requirements. Complete the certification as indicated in items 1
<br />through 5 below.
<br />1. Interest dividend, and barter exchange accounts opened before 1984
<br />and broker accounts considered active during 1981 You must give your
<br />comact TIN, but you do not have to sign the certification.
<br />2. Interest, dividend, broker, and barter exchange accounts opened after
<br />1883 and broker accounts considered inactive during 1983. You must sign the
<br />certification or backup withholding will apply. If you are subject to backup
<br />withholding and you are merely providing your comet TIN to the requester, you
<br />must cross out item 2 in the certification before signing the forth.
<br />3. Real estate transactions. You must sign the certification. You may cress out
<br />hem 2 of the certification.
<br />4. Other payments. You must give your correct TIN, but you do not have to sign
<br />the certification unless you have been notified that you have previously given an
<br />incorrect TIN. "Other payments' include payments made in the course of the
<br />requester's trade or business for rents, royalties, goods (other than bills for
<br />merchandise), medical and health care services (including payments to
<br />corporations), payments to a nonemployee for services, payments made in
<br />settlement of payment card and third parry network transactions, payments to
<br />certain fishing boat crew members and fishermen, and gross proceeds paid to
<br />attorneys (including payments to corporations).
<br />S. Mortgage Interest paid by you, acquisition or abandonment of secured
<br />property, cancellation of debt qualified tuition program payments (under
<br />section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or
<br />distributions, and pension distributions. You must give your correct TIN, but you
<br />do not have to sign the certification.
<br />What Name and Number To Give the Requester
<br />For this type of account-
<br />Give name and SSN of:
<br />1. Individual
<br />The Individual
<br />2. Two or more individuals (joint
<br />The actual owner of the account or,
<br />account)
<br />if combined funds, the first
<br />Individual on the account'
<br />3. Custodian account of a minor
<br />The minor=
<br />(Uniform Gift to Minors Act)
<br />4. a. The usual revocable savings
<br />The grantor -trustee
<br />trust (grantor Is also trustee)
<br />b. So-called trust account that is
<br />The actual owner
<br />not a legal or valid trust under
<br />state law
<br />5. Sole proprietorship or disregarded
<br />The owner'
<br />entity owned by an Individual
<br />6. Grantor trust filing under Optional
<br />The grantor'
<br />Form 1099 Filing Method 1 (see
<br />Regulations section 1.6714(b)(2)()
<br />(A))
<br />For this type of account:
<br />Give name and EIN of:
<br />7. Disregarded entity not owned by an
<br />The owner
<br />individual
<br />8. A valid trust, estate, or pension trust
<br />Legal entity'
<br />9. Corporation or LLC electing
<br />The corporation
<br />corporate status on Form 8832 or
<br />Form 2553
<br />10. Association, club, religious,
<br />The organization
<br />charitable, educational, or other tax-
<br />exempt organization
<br />11. Partnership or mufti -member LLC
<br />The partnership
<br />12. A broker or registered nominee
<br />The broker or nominee
<br />13. Account with the Department of
<br />The public entity
<br />Agriculture In the name of a public
<br />entity (such as a state or local
<br />government, school district, or
<br />prison) that receives agricultural
<br />program payments
<br />14. Grantor "at filing under the Form
<br />The twat
<br />1041 Filing Method or the Optional
<br />Forth 1099 Filing Method 2 (see
<br />Regulations section 1.6714(b)(2)()
<br />B))
<br />' Ust firstand cimle the name of the person whose number you lurrirsh. If only ort, person on a
<br />fount amaum has an SSN, that person's number must be fumished.
<br />r Circle are minors name and funJsh the minors SSN.
<br />Paged
<br />°You must show your Individual name and you may also enteryour business or DBAnams on
<br />Me 'Business nameldieregmded entity' name line. You may use either your SSN or BIN (if you
<br />have one), but the IRS encourages you to use your SSN.
<br />'List first and chole tha name of the trust, estate, or Parisian trust. (Do not furnish the TIN of the
<br />personal representative or trustee unless the legal entity itself is not designated inthe account
<br />title.) Also see Special rules forpaAmrshipson page 2.
<br />'Note. Grantor also must provide a Form W-9 to trustee of trust
<br />Note. If no name is circled when mom than one name is listed, the number will be
<br />considered to be that of the first name listed.
<br />Secure Your Tax Records from Identity Theft
<br />Identity theft occurs when someone uses your personal information such as your
<br />name. SSN, or other Identifying information, without your permission, to commit
<br />fraud or other crimes. An identity thief may use your SSN to get a job or may file a
<br />tax return using your SSN to receive a refund.
<br />To reduce your risk:
<br />• Protect your SSN,
<br />• Ensure your employer is protecting your SSN, and
<br />• Be careful when choosing a tax preparer.
<br />If your tax records are affected by Identity theft and you receive a notice from
<br />the IRS, respond right away to the name and phone number printed on the IRS
<br />notice or letter.
<br />If your tax records are not currently affected by Identity theft but you think you
<br />are at risk due to a lost or stolen purse or wallet, questionable credit card activity
<br />or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit
<br />Forth 14039.
<br />For more Information, see Publication 4535, Identity Theft Prevention and Victim
<br />Assistance.
<br />Victims of identity, theft who are experiencing economic harm or a system
<br />problem, or are seeking help in resolving tax problems that have not been resolved
<br />through normal channels, may be eligible for Taxpayer Advocate Service (TAS)
<br />assistance. You can reach TAS by calling the TAS toll-free case intake line at
<br />1-877-777-4778 or TTY/TDD 1-800-829-4059.
<br />Protect yourself from suspicious smalls or phishing schemes. Phishing is the
<br />creation and use of email and websites designed to mimic legitimate business
<br />emails and websites. The most common act is sending an email to a user falsely
<br />claiming to be an established legitimate enterprise In an attempt to scam the user
<br />Into surrendering private Information that will be used for Identity theft.
<br />The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does
<br />not request personal detailed information through email or ask taxpayers for the
<br />PIN numbers, passwords, or similar secret access information for their credit card,
<br />bank, or other financial accounts.
<br />If you receive an unsolicited email claiming to be from the IRS, forward this
<br />message to phishing@im.gov. You may also report misuse of the IRS name, logo,
<br />or other IRS property to the Treasury Inspector General for Tax Administration
<br />(TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal
<br />Trade Commission at: spam®uce.gov or contact them at www.ftc.gowridtheft or
<br />1-877-IDTHEFT (1-877-438-4338).
<br />Visft IRS.gov to learn more about Identity theft and how to reduce your risk.
<br />Privacy Act Notice
<br />Section 6109 of the Internal Revenue Code requires you to provide your correct
<br />TIN to persons (including federal agencies) who are required to file Information
<br />returns with the IRS to report Interest, dividends, or certain other Income paid to
<br />you; mortgage Interest you paid; the acquisition or abandonment of secured
<br />property; the cancellation of debt; or contributions you made to an IRA, Archer
<br />MSA or HSA. The person collecting this form uses the Information on the forth to
<br />file information returns with the IRS, reporting the above information. Routine uses
<br />of this information Include giving it to the Department of Justice for civil and
<br />criminal litigation and to cities, states, the District of Columbia, and U.S.
<br />commonwealths and possessions for use in administering their laws. The
<br />Information also may be disclosed to other countries under a treaty, to federal and
<br />state agencies to enforce civil and criminal laws, or to federal law enforcement and
<br />intelligence agencies to combat terrorism. You must provide your TIN whether or
<br />not you are required to file a tax return. Under section 3406, payers must generally
<br />withhold a percentage of taxable Interest, dividend, and certain other payments to
<br />a payee who does not give a TIN to the payer. Certain penalties may also apply for
<br />providing false or fraudulent information.
<br />25C-17
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