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Form ■1 se9 (Request
<br />(Rev. November 2017) I Identification Nun
<br />Department of the Treasury
<br />IntemN 11 .. vis Service I * Qo to www.lrs.govfFormM for
<br />1 Name (as shown on your Income tax return). Name la required on this un
<br />Benefit Administrative Services International Corporate
<br />dba BASIC
<br />3 Check appropriate box for federal tax da"iffCation of the person whose n
<br />following seven boxes.
<br />c ❑ Indlvldual(sole proprietor or ❑ C Corporation ✓❑ S Corpomill
<br />ai a single -member LLC
<br />❑ Un ite t liability Company. Enter the tax classif artlon (0-0 eorporetlon,
<br />o Note: Check the appropriate box in the line above for the tax classifies'
<br />LLC'd the LLC is classified as a single-mambar LLC that is disregarded
<br />C — another LLC that Is not disregarded from the owner for U,6. federal tax
<br />a' Is disregarded from the owner should check the appropriate box for the
<br />g$? Other (ass Instructions)►
<br />Na Address (number, street, and apt. or suite no.) See Instructions.
<br />8 PO Box 775339
<br />IL 60677.5339
<br />)r Taxpayer
<br />tier and Certification
<br />QIve Form to the
<br />requester. Do not
<br />"ructions and the latest information.
<br />to the IRS.ctiona '
<br />Jo not leave this line blank.
<br />1
<br />resident ellen, sole proprietor, or disregarded entity, see the instructions for Part I, later. For ether
<br />entities, it is your employer Identification number (EIN). If you do not have a number, see How togef a
<br />me is entered on line 1. Check only one of the
<br />4 Exemptions (codes apply on to
<br />TIN, later.
<br />certain entitles, not Individuals; see
<br />it ❑ Partnership ❑ Tmst/estats
<br />instructions on page 3):
<br />Number To Give the Requester for guidelines on whose number to enter.
<br />Exempt payee Code (harry)
<br />54 corporation, P-Parmership) )-
<br />on of the single -member owner. Do not check
<br />from the owner unless the owner of the LLC is
<br />purposes. Otherwise, a single -member LLC that
<br />Exemption from FATCA reporting
<br />code (if any)
<br />tax classification of its owner.
<br />(Tpgl»roxrnxxe meM4%epm,2ye e»U.aJ '
<br />Requesters name and
<br />address (optlona9 _
<br />Enter your TIN in the appropriate box. The TIN provided must match the n'me given on line 1 to avoid
<br />backup withholding. For individuals, this is generally your social security number (SSN). However, for a
<br />Soctal
<br />security
<br />resident ellen, sole proprietor, or disregarded entity, see the instructions for Part I, later. For ether
<br />entities, it is your employer Identification number (EIN). If you do not have a number, see How togef 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 (Khat Name and
<br />Empmyer identi
<br />Number To Give the Requester for guidelines on whose number to enter.
<br />t-1-1 F—
<br />1. The number shown on this form is my correct taxpayer Identification nur
<br />2.1 am not subject to backup withholding because: (a) I am exempt from b
<br />Service (IRS) that I am subject to backup withholding as a result of a fall
<br />no longer subject to backup withholding; and
<br />S. I am a U.S. citizen or other U.S. person (defined below); and
<br />4. The FATCA codo(s) entered on this form (if any) indicating that I am exer
<br />Certification Instructions. You must cross out (torn 2 above If you have been
<br />you have failed to report all interest and dividends on your tax return. For real e
<br />acquisition or abandonment of secured property, cancellation of debt, contdbu
<br />otherthan interest and dividends, you are not required to sign the certification,
<br />i1ve©nn©©oo
<br />r (or I am waiting for a number to be issued to me); and
<br />up withholding, or (b) I have not been notified by the Internal Revenue
<br />to report all interest or dividends, or (c) the IRS has notified me that I am
<br />om FATCA reporting Is correct.
<br />4 by the IRS that you are currently subject to backup withholding because
<br />transactions, Item 2 does not apply. For mortgage interest paid,
<br />to an individual retirement arrangement (IRA), and generally, payments
<br />ou must Provide your correct TIN. See the instructions for Part II, later.
<br />yn 81 nature of ---
<br />Here uS.Pewaa► Done ►
<br />General InstrLfc ions
<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.1rs.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(rlN) 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 />Cat. No. 10231x
<br />• Form 1099 -DIV (dividends, Including those from stocks or mutual
<br />funds)
<br />• Form 1099-MISO (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 parry 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 />ellen), to provide your correct TIN.
<br />If you do not return Form w-9 to the requester with a TIN, you might
<br />be subject to backup withholding. See What is backup withholding,
<br />later.
<br />Form ver- (Rev. 11-2017)
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