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Form W"9 Request for Taxpayer Give Form to the
<br /> (Rev.December 2014) Identification Number and Certification requester. Do not
<br /> Department Rwmf the
<br /> Treasury send to the IRS.
<br /> Intioe
<br /> 1 Name(as shown on your Income tax return).Name Is required on this line;do not leave this line blank.
<br /> Cooperative Personnel Services
<br /> of 2 Business name/disregarded entity name,If different from above
<br /> g, CPS HR Consulting
<br /> a 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to
<br /> ncertain entities,not Individuals;see
<br /> m ❑
<br /> Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership 0 Trust/estate instructions on page 3):
<br /> $ single-member LLC Exempt payee code(if any) 3
<br /> ,F'• 0Limited(lability company,Enter the tax classification(0=0 corporation,5=8 corporation,P=partnershlp)►
<br /> `o 3 Note.For a single-member LLC that Is disregarded,do not check LLC;check the appropriate box In the line above for Exemption from FATCA reporting
<br /> the tax classification of the single-member owner. code(if any) C
<br /> E 4 ❑✓ Other(see instructions)► California Joint Powers Authority !Applies to accounts maintained outside the aa)
<br /> it 6 Address(number,street,and apt.or suite no.) Requester's name and address(optional)
<br /> a 2450 Del Paso Road,Suite 220
<br /> 6 City,state,and ZIP code
<br /> tj Sacramento,CA 95834
<br /> 7 List account number(s)here(optional)
<br /> Part I Taxpayer Identification Number(TIN)
<br /> Enter your TIN In the appropriate box.The TIN provided must match the name given on line 1 to avoid I Social security number
<br /> backup withholding.For individuals,this is generally your social security number(SSW).However,for a
<br /> resident alien,sole proprietor,or disregarded entity,see the Part I Instructions on page 3.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 on page 3. or
<br /> Note.If the account Is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identification number
<br /> guidelines on whose number to enter.
<br /> 6 8 - 0 0 6 7 2 0 9
<br /> Part Ii 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. I 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. I 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
<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 dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
<br /> Instructions on page 3.
<br /> Sign
<br /> Signature of +r (y
<br /> Flare U S.parson yi f f l 1, Wof`I1'� Date Iv J
<br /> General Ins#rut tions •Form 1098(home mortgage interest),1008-E(student loan Interest),1098-T
<br /> (tuition)
<br /> Section references are to the Internal Revenue Code unless otherwise noted, •Form 1099-C(canceled debt)
<br /> Future developments.Information about developments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property)
<br /> as legislation enacted after we release it)Is at www.Irs.gov/fw9.
<br /> Use Form W-9 only If you are a U.S.person(Including a resident alien),to
<br /> Purpose of Form provide your correct TIN.
<br /> An Individual or entity(Form W-9 requester)who is required to file an Information if you do not return Form W-9 to the requester with a TIN,you might be subject
<br /> return with the IRS must obtain your correct taxpayer Identification number(TIN) to backup withholding.See What Is backup withholding?on page 2.
<br /> which may be your social security number(SSN),Individual taxpayer Identification By signing the filled-out form,you:
<br /> number((TIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving Is correct(or you are waiting for a number
<br /> identification number(EIN),to report on an Information return the amount paid to
<br /> you,or other amount reportable on an information return,Examples of Information to be Issued),
<br /> retums include,but aro not limited to,the following; 2.Certify that you are not subject to backup withholding,or
<br /> •Form 1099-INT(Interest earned or paid) 3.Claim exemption tram backup withholding If you are a U.S.exempt payee.If
<br /> •Form 1099-DIV(dividends,including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your allocable share of
<br /> any partnership income from a U.S.trade or business is not subject to the
<br /> •Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and
<br /> •Form 1099-5(stook or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(If any)Indicating that you are
<br /> brokers) exempt from the FATCA reporting,Is correct.See Whet Is FATCA reporting?on
<br /> •Form 1099-S(proceeds from real estate transactions) page 2 for further information.
<br /> •Form 1099-K(merchant card and third party network transactions)
<br /> Cat.No.10231k Form W-9(Rev.12-2014)
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