|
Docusign Envelope ID:ABAOF1AB-1 F56-41 F1-8C93-C2D999BB641A
<br /> Request for Taxpayer Give Form to the
<br /> Form YY 1Ar�9 Identification Number and Certification requester.Do not
<br /> (Rev.October 2018) send to the IRS.
<br /> Department of the Treasury
<br /> y
<br /> Internal Revenue Seervice ► Go to www.lrs.8 ov/FormIN9 for instructions and the latest Information.
<br /> 1 Name(as shown on your Income tax return).Name is required on this Iln%do not leave this line blank.
<br /> 2 Business nameidisregarded entity name,it different from above
<br /> cn 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of th-7 4 Exemptions(codes apply only to
<br /> (D following seven boxes. certain entitles,not Individuals;see
<br /> ar instructions on page 3):
<br /> c.
<br /> o ❑ Individual/solo proprietor or El Corporation El Corporation El Partnership Trustlestate
<br /> 0 single-member LLC Exempt payee code(If any)
<br /> ❑ Limited ltablllty company.Enter the tax classifcatlon(C=C corporation,S=S corporation, P=Partnershlp)►
<br /> o Note:Check the appropriate box In the line above for the tax classification of the single-member owner. Do not check Exemption From FATCA reporting
<br /> LLC if the LLG is classified as a single-member LLC that Is disregarded from the owner unless the owner of the LLC Is code(If any)
<br /> another LLC that is not disregarded from the owner for U.S.Federal tax purposes.Otherwise,a single-member LLC that
<br /> IL Is disregarded from the owner should check the appropriate box for the tax classification of its owner.
<br /> �] (apaua5roacwunf.marntnrnedouladsrhBus.)
<br /> Other(see instrucklons).►
<br /> c
<br /> N 5 Address(number,street,and apt or suite no.)See instructions. Requester's name and address(optional)
<br /> w
<br /> m
<br /> 0 City,state,and ZIP code
<br /> 7 List account numbers)here(optional)
<br /> Taxpayer Identification Number(TIN)
<br /> EnteryourTlN In the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number
<br /> backup withholding. For individuals,this is generally your social security number(SSN).However,for a
<br /> reSldent alien,sale proprietor, or disregarded entity, see the instructions for Part I,later.For other
<br /> entities, it is your employer Identification number(EIN).If you do not have a number,see How to get a
<br /> TIN,later, or
<br /> Note: If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number
<br /> Number To Give the Requester for guidelines on whose number to enter.
<br /> JiM 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 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 yourtax 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 /> otherthan Interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions for Part ll,later.
<br /> Sign Signature of
<br /> Here U.S.person► Dale►
<br /> Form 1099-D1V(dividends,Including those from stocks or mutual
<br /> General instructions
<br /> funds)
<br /> Section references are to the Internal Revenue Code unless otherwise •Form 1099-MISC(varioustypes of income, prizes,awards,or gross
<br /> noted. proceeds)
<br /> Future developments.Forthe latest information about developments •Form 1099-B(stock or mutual fund sales and certain other
<br /> related to Form W-9 and its instructions, such as legislation enacted transactions by brokers)
<br /> after they were published, go to www.ks.gov/FormW9. •Form 1099-S(proceeds from real estate transactions)
<br /> Purpose of Form •Form 1099-K(merchant card and third party network transactions)
<br /> An Individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(student loan interest),
<br /> information return with the IRS must obtaln your correct taxpayer 1098-T(tuition)
<br /> Identification number(TIN)which may be your social security number •Form 1099-C(canceled debt)
<br /> (SSN),Individual taxpayer identification number(ITIN),adoption •Form 1099-A(acquisition or abandonmentof secured property)
<br /> taxpayer identification number(ATIN),or employer identification number
<br /> (EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S,person(Including a resident
<br /> amount reportable on an information return.Examples of Information alien),to provide your correct TIN.
<br /> returns Include,but are not limited to,the following, If you do not return Form W-9 to the requester with a TIN,you might
<br /> j •Form 1099-tNT(interest earned or paid) be subject to backup withholding. 5oe What is backup withholding,
<br /> later.
<br /> Cat,No.10231X Form W-9(Rev,10-2018)
<br />
|