|
Form W-9 (Rev. 1-2005)
<br />Part II. Certification
<br />To establish to the withholding agent that you are a U.S.
<br />person, or resident alien, sign Form W-9. You may be
<br />requested to sign by the withholding agent even if items 1, 4,
<br />and 5 below indicate otherwise.
<br />For a joint account, only the person whose TIN is shown in
<br />Part I should sign (when required). Exempt recipients, see
<br />Exempt From Backup Withholding on page 2.
<br />Signature requirements. Complete the certification as
<br />indicated in 1 through 5 below.
<br />1. Interest, dividend, and barter exchange accounts
<br />opened before 1984 and broker accounts considered
<br />active during 1983. You must give your correct TIN, but you
<br />do not have to sign the certification.
<br />2. Interest, dividend, broker, and barter exchange
<br />accounts opened after 1983 and broker accounts
<br />considered inactive during 1983. You must sign the
<br />certification or backup withholding will apply. If you are
<br />subject to backup withholding and you are merely providing
<br />your correct TIN to the requester, you must cross out item 2
<br />in the certification before signing the form.
<br />3. Real estate transactions. You must sign the
<br />certification. You may cross out item 2 of the certification.
<br />4. Other payments. You must give your correct TIN, but
<br />you do not have to sign the certification unless you have
<br />been notified that you have previously given an incorrect TIN.
<br />"Other payments" include payments made in the course of
<br />the requester's trade or business for rents, royalties, goods
<br />(other than bills for merchandise), medical and health care
<br />services (including payments to corporations), payments to a
<br />nonemployee for services, payments to certain fishing boat
<br />crew members and fishermen, and gross proceeds paid to
<br />attorneys (including payments to corporations).
<br />5. Mortgage interest paid by you, acquisition or
<br />abandonment of secured property, cancellation of debt,
<br />qualified tuition program payments (under section 529),
<br />IRA, Coverdell ESA, Archer MSA or HSA contributions or
<br />distributions, and pension distributions. You must give
<br />your correct TIN, but you do not have to sign the
<br />certification.
<br />Privacy Act Notice
<br />Page 4
<br />What Name and Number To Give the
<br />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
<br />account)
<br />or, 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
<br />The grantor -trustee'
<br />savings trust (grantor is
<br />also trustee)
<br />b. So-called trust account
<br />The actual owner'
<br />that is not a legal or valid
<br />trust under state law
<br />5. Sole proprietorship or
<br />The owner'
<br />single -owner LLC
<br />For this typo of account:
<br />Give name and EIN of:
<br />6. Sole proprietorship or
<br />The owner 3
<br />single -owner LLC
<br />7. A valid trust, estate, or
<br />Legal entity "
<br />pension trust
<br />8. Corporate or LLC electing
<br />The corporation
<br />corporate status on Form
<br />8832
<br />9. Association, club, religious,
<br />The organization
<br />charitable, educational, or
<br />other tax-exempt organization
<br />10. Partnership or multi -member
<br />The partnership
<br />LLC
<br />11. A broker or registered
<br />The broker or nominee
<br />nominee
<br />12. Account with the Department
<br />The public entity
<br />of Agriculture in the name of
<br />a public entity (such as a
<br />state or local government,
<br />school district, or prison) that
<br />receives agricultural program
<br />payments
<br />'List first and circle the name of the person whose number you fumish. If
<br />only one person on a joint account has an SSN, that person's number must
<br />be fumished.
<br />Circle the minors name and furnish the minor's SSN.
<br />You must show your individual name and you may also enter your business
<br />or "DBA" name on the second name line. You may use either your SSN or
<br />EIN (if you have one). If you are a sole proprietor, IRS encourages you to
<br />use your SSN.
<br />' List first and circle the name of the legal trust, estate, or pension trust. (Do
<br />not furnish the TIN of the personal representative or trustee unless the legal
<br />entity itself is not designated in the account title.)
<br />Note. If no name is circled when more than one name is
<br />listed, the number. will be considered to be that of the first
<br />name listed.
<br />Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns
<br />with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or
<br />abandonment of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRS
<br />uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this
<br />information to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry
<br />out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to
<br />enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
<br />You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable
<br />interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
<br />
|