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Form
<br />W=
<br />Request for Taxpayer
<br />Give Form to the
<br />(Rev, December 2011
<br />Identification Number and Certification
<br />requester. Do not
<br />Ce rtral R t of the Treasury
<br />real
<br />Intemel Revenue Service
<br />send to the IRS.
<br />Name (as shown on your Income tax return)
<br />Western Dental Services, Inc.
<br />N
<br />Business name /disregarded entity name, If different from above
<br />d
<br />m
<br />m
<br />ca
<br />Check appropriate box for federal tax classification:
<br />0
<br />m
<br />❑ Individual /sole proprietor ❑✓ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
<br />n�
<br />0
<br />0
<br />❑ Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= padnership) ►
<br />F-1 Exempt payee
<br />c.
<br />❑ Other (see instructions)►
<br />iE
<br />Address (number, street, and apt, or suite no.)
<br />Requester's name and address (optlona)
<br />W
<br />530 S. Main St. 6th Floor
<br />on
<br />City, state, and ZIP coda
<br />m
<br />N
<br />Orange, CA 92866
<br />List account number(s) here (optional)
<br />Enter your TIN In the appropriate box. The TIN provided must match the name given on the "Name" line
<br />to avoid backup withholding. For Individuals, this Is your social security number (SSN). However, for a
<br />resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page S. For other
<br />entities, it is your employer Identification number (EN). If you do not have a number, see How to get a
<br />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
<br />number to enter.
<br />
<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 tome), 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).
<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
<br />because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
<br />Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
<br />generally, payments other than Interest and tlivXends, you are not required to sign the certification, but you must provide your correct TIN. Seethe
<br />'J" I Signature of
<br />Here I U.S. person►
<br />General Instructions /I/
<br />Section references are to the Internal Revenue Code unless otherwise
<br />noted.
<br />Purpose of Form
<br />A person who is required to file an Information return with the IRS must
<br />obtain your correct taxpayer Identification number (TIN) to report, for
<br />example, income paid to you, reel estate transactions, mortgage interest
<br />you paid, acquisition or abandonment of secured property, cancellation
<br />of debt, or contributions you made to an IRA.
<br />Use Form W -9 only if you are a U.S. person (including a resident
<br />open), to provide your correct TIN to the person requesting It (the
<br />requester) and, when applicable, to:
<br />1. Certify that the TIN you are giving Is correct (or you are waiting for a
<br />number to be Issued),
<br />2. Certify that you are not subject to backup withholding, or
<br />3. Claim exemption from backup withholding If you are a U.S. exempt
<br />payee, If applicable, you are also certifying that as a U.S. person, your
<br />allocable share of any partnership Income from a U.S. trade or business
<br />is not subject to the withholding tax on foreign partners' share of
<br />effectively connected Income.
<br />Date ► -/ ffo
<br />Note. If a requester gives you a form other than Form W -9 to request
<br />your TIN, you must use the requester's form If it Is substantially similar
<br />to this Form W -9.
<br />Definition of a U.S, person. For federal tax purposes, you are
<br />considered a U.S, person if you are:
<br />• An individual who is a U.S. citizen or U.S. resident alien,
<br />• A partnership, corporation, company, or association created or
<br />organized in the United States or under the laws of the United States,
<br />• An estate (other than a foreign estate), or
<br />• A domestic trust (as defined In Regulations section 301.7701 -7).
<br />Speolai rules for partnerships. Partnerships that conduct a trade or
<br />business in the United States are generally required to pay a withholding
<br />tax on any foreign partners' share of income from such business.
<br />Further, in certain cases where a Form W -9 has not been received, a
<br />partnership is required to presume that a partner is a foreign person,
<br />and pay the withholding tax. Therefore, If you are a U.S. person that Is a
<br />partner In a partnership conducting a trade or business In the United
<br />States, provide Form W -9 to the partnership to establish your U.S.
<br />status and avoid withholding on your share of partnership income.
<br />Cat. No. 10231X Form W-9 (Rev. 12 -2011)
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