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:erm W-9
<br />Rev. January 2003)
<br />)eparur.m a the Treasury
<br />Request for Taxpayer
<br />Identification Number and Certification
<br />Give form to the
<br />requester. Do not
<br />send to the IRS.
<br />ntemal
<br />Revenue Service I
<br />Name NNe TN .4Z)� A
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<br />Business e, namt Ifferent from abov^V
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<br />�/( Individual/ ❑ ❑ Other
<br />box: ICI Sole ❑ corporation partnership---------
<br />Exempt from backup
<br />❑ withholding
<br />o �
<br />check appropriate proprietor
<br />Requester's
<br />suite no.)
<br />name and address (optional)
<br />Address (number, sVeet,ayyd apt. or
<br />c
<br />City, sla e, and ZIP code
<br />za-
<br />d
<br />List account number(s) here (Optional)
<br />u
<br />N
<br />•
<br />Tax a er Identification Number (FIN)
<br />Enter your TIN in the appropriate box. For individuals, this is your social security number (
<br />...:e.a. ar dKranamed entity. see the Part I insWtrUct ctions on
<br />Social
<br />
<br /> fur a rea,aa.n a ----r..----• -- — - -•,
<br />page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, or
<br />see How to get a TIN on page 3.
<br />Note: If the account is in more than one name, see the chart on page 4 for guidelines on whose number Eml i"Yw Idi t cat
<br />to enter. _ t
<br />number
<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
<br />Revenue 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
<br />notified me that I am no longer subject to backup withholding, and
<br />3. 1 am a U.S. person (including a U.S. resident alien).
<br />Certification instructions. You must cross out hem 2 above if you have been notified by the IRS that you are currently subject to backup
<br />withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
<br />For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
<br />arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
<br />provide your correct TIN. (See the instructions on page 4.)
<br />Sign Signature of
<br />Here I U.S. Person
<br />Purpose of Form
<br />A person who is required to file an information return with
<br />the IRS, must obtain your correct taxpayer identification
<br />number (TIN) to report, for example, income paid to you, real
<br />estate transactions, mortgage interest you paid, acquisition
<br />or abandonment of secured property, cancellation of debt, or
<br />contributions you made to an IRA.
<br />U.S. person. Use Form W-9 only if you are a U.S. person
<br />(including a resident alien), to provide your correct TIN to the
<br />person requesting it (the. requester) and, when applicable, to:
<br />1. Certify that the TIN you are giving is correct (or you are
<br />waiting for a number to be issued),
<br />2. Certify that you are not subject to backup withholding,
<br />or
<br />3. Claim exemption from backup withholding if you are a
<br />U.S. exempt payee.
<br />Note: If a requester gives you a form other than Form W-9
<br />to request your TIN, you must use the requester's form if it is
<br />substantially similar to this Form W-9.
<br />Foreign person. If you are a foreign person, use the
<br />appropriate Form W-8 (see Pub. 515, Withholding of Tax on
<br />Nonresident Aliens and Foreign Entities).
<br />Date ►
<br />Nonresident alien who becomes a resident alien.
<br />Generally, only a nonresident alien individual may use the
<br />terms of a tax treaty to reduce or eliminate U.S. tax on
<br />certain types of income. However, most tax treaties contain a
<br />provision known as a "saving clause." Exceptions specified
<br />in the saving clause may permit an exemption from tax to
<br />continue for certain types of income even after the recipient
<br />has otherwise become a U.S. resident alien for tax purposes.
<br />If you are a U.S, resident alien who is relying on an
<br />exception contained in the saving clause of a tax treaty to
<br />claim an exemption from U.S. tax on certain types of income,
<br />you must attach a statement that specifies the following five
<br />items:
<br />1. The treaty country. Generally, this must be the same
<br />treaty under which you claimed exemption from tax as a
<br />nonresident alien.
<br />2. The treaty article addressing the income.
<br />3. The article number (or location) in the tax treaty that
<br />contains the saving clause and its exceptions.
<br />4. The type and amount of income that qualifies for the
<br />exemption from tax.
<br />5. Sufficient facts to justify the exemption from tax under
<br />the terms of the treaty article.
<br />Cat. No. 10231X Form W-9 (Rev. 1-2003)
<br />
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