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<br />Request for Taxpayer
<br />Give Form
<br />Form
<br />(Rev, November2017)
<br />Identification Number and Certification
<br />to the
<br />requester. Do not
<br />Department
<br />of the Treasury
<br />send to the IRS.
<br />Internal Revenue Service
<br />► Go to w ImJrs.gov/FormW9 for instructions and the latest information.
<br />1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
<br />AdminSure Inc.
<br />2 Business name/disregarded entity name, if different from above
<br />cn
<br />3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
<br />4 Exemptions (codes apply only to
<br />mfollowing
<br />seven boxes.
<br />certain entities, not individuals; see
<br />a
<br />p
<br />❑ Individual/sole proprietor or ❑x C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
<br />instructions on page 3):
<br />y
<br />a;c
<br />single -member LLC
<br />Exempt payee code (if any)
<br />a o
<br />4�
<br />❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ►
<br />`0 V
<br />Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check
<br />Exemption from FATCA reporting
<br />c y
<br />LLC if the LLC Is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is
<br />code an
<br />(
<br />It 5
<br />another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that
<br />y)
<br />a o
<br />u
<br />is disregarded from the owner should check the appropriate box for the tax classification of its owner.
<br />y
<br />❑Other (see instructions) 1-
<br />(appnesmzccounts maintained outeiae and us)
<br />a
<br />y
<br />5 Address (number, street, and apt. or suite no.) See instructions.
<br />Requester's name and address (optional)
<br />N
<br />3380 Shelby Street
<br />6 City, state, and ZIP code
<br />Ontario, CA 91764.5566
<br />7 List account number(s) here (optional)
<br />Number I7
<br />Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
<br />S,
<br />backup withholdina. For individuals, this is generally ,your snr_.ial security number (.SSN). However, for a
<br />r
<br />resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
<br />L
<br />entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
<br />TIN, later.
<br />or
<br />Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
<br />[_Ei
<br />Number To Give the Requester for guidelines on whose number to enter.
<br />F
<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 waiting for a number to be issued to me); and
<br />2. 1 am not subject to backup withholding because; (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
<br />Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
<br />no longer subject to backup withholding; and
<br />3. 1 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 />Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
<br />you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
<br />acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
<br />other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later.
<br />vJwnl Signature of
<br />Here I U.S. person ►
<br />General Instructions V
<br />Section references are to the Internal Revenue Code unless otherwise
<br />noted.
<br />Future developments. For the latest information about developments
<br />related to Form W-9 and its instructions, such as legislation enacted
<br />after they were published, go to www.irs.gov/FormW9.
<br />Purpose of Form
<br />An individual or entity (Form W-9 requester) who is required to file an
<br />information return with the IRS must obtain your correct taxpayer
<br />identification number (TIN) which may be your social security number
<br />(SSN), individual taxpayer identification number (]TIN), adoption
<br />taxpayer identification number (ATIN), or employer identification number
<br />(EIN), to report on an information return the amount paid to you, or other
<br />amount reportable on an information return. Examples of information
<br />returns include, but are not limited to, the following.
<br />• Form 1099-INT (interest earned or paid)
<br />Date► 6/8/18
<br />• Form 1099-DIV (dividends, including those from stocks or mutual
<br />funds)
<br />• Form 1099-MISC (various types of income, prizes, awards, or gross
<br />proceeds)
<br />• Form 1099-B (stock or mutual fund sales and certain other
<br />transactions by brokers)
<br />• Form 1099-S (proceeds from real estate transactions)
<br />• Form 1099-K (merchant card and third party network transactions)
<br />• Form 1098 (home mortgage interest), 1098-E (student loan interest),
<br />1098-T (tuition)
<br />• Form 1099-C (canceled debt)
<br />• Form 1099-A (acquisition or abandonment of secured property)
<br />Use Form W-9 only if you are a U.S. person (including a resident
<br />alien), to provide your correct TIN.
<br />If you do not return Form W-9 to the requester with is TIN, you might
<br />be subject to backup withholding. See What is backup withholding,
<br />later.
<br />Cat. No. 10231X Form W-V (Rev. 11-2017)
<br />
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