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Form
<br />W'9
<br />Request for Taxpayer
<br />Give Form to the
<br />(Rev. December2o,4)
<br />Identification Number and Certification
<br />requester. Do not
<br />Depa d'
<br />ant of the Treasury
<br />Send to the IRS.
<br />Internal
<br />Revenue Service
<br />I Name (as shown or your income tax return). Name Is required on this line; do not leave this line blank.
<br />6� �� nc
<br />of
<br />2 Business nameldisregarded entity name, if different from above
<br />p
<br />a
<br />4 Exemptions to
<br />c
<br />3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
<br />(codes apply only
<br />certain entities, not individuals; see
<br />o
<br />Q Individuat'sole proprietor or ❑ C Corporation Lyt S Corporation ❑ Partnership ❑ Tmstiestate
<br />istrad lens on page 3):
<br />p CQ
<br />t °
<br />single - member LLC
<br />Uni liability company. Enter the tax classification (C =C corporation, 5 =6 corporation, P = partnership)►
<br />Exempt payee code lit any)_
<br />%
<br />u U
<br />p 0
<br />Note. For asingle- member LLC that is disregarded, , do not check LLC; check the appropriate pox in the line above for
<br />Exemption from FATCA reporting
<br />� y
<br />be
<br />the tax classification of the single - member owner,
<br />code (if any)
<br />pC,E
<br />U
<br />❑ Other (see Instructions)►
<br />I/wn� me�amn•man,u,.aa wn�ee ire u. &r
<br />5
<br />5 Address (number, street and apt, or suite no.) Requesters name and address (optionap
<br />AW�?
<br />5 City, slate, and'2,1,P
<br />Acodfe/',(,
<br />Llot he, ti to
<br />account number(a) 2 (
<br />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 (Sag). However, fora
<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
<br />
<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 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 ant 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 papa 1 _
<br />algn Signature of /f %
<br />Here Us.person► Y-11
<br />General Instructions
<br />Section refarenaes are Co the Internal R enueI ode unless otherwise noted.
<br />Future developments. Information about dev oprnents affecting Form W -9 (such
<br />as legl=lation enacted after we release it) is at www.irs.gov /6vg.
<br />Purpose of Form
<br />An individual or entity (Form W -9 requester) who is required to file an Information
<br />retain with the IRS must obtain your correct taxpayer identification number (TIN)
<br />which may be year social security number (SSN), individual taxpayer identification
<br />number (III N), adoption taxpayer Identification number (ATIN), or employer
<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
<br />returns Include, but are not limited to, me following:
<br />• Form 1099 -INT (Interest earned or paid)
<br />• Form 1099 -DIV (dividends, including those from stocks or mutual hinds)
<br />• Form 1099 -MISC (various types of income, prizes, awards, or gross proceeds)
<br />• Farm 1099 -B (stock or mutual turd sales and certain other transactions by
<br />brokers)
<br />• Farm 1099 -5 (pmcoeds from real estate transactions)
<br />• Form 1009 -K (merchant card and third party network transactions)
<br />Date► 2 -1 -16
<br />• Form 1098 (home mortgage interest), 1098 -E (student loan interest), 1098 -T
<br />(tuition)
<br />• Form 1099 -0 (canceled debt)
<br />• Form 1099 -A (acquisition or abandonment of secured property)
<br />Use Form W4 only if you are a U.S, person (including a resident alien), to
<br />provide your correct TIN.
<br />If you de not return Form 1,1114 to the requester with a TIN, you might be subject
<br />to backup withholding. See What is backup withholding? on page 2,
<br />By signing the filled -out form, you:
<br />1, Certify that the TIN you are giving is correct (or you are waiting for a number
<br />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 payee. If
<br />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 />withholding tax on foreign partnere' sham of effectively connected income, and
<br />4. Certify that FATCA decals) entered on this form (if any) indicating that you as
<br />exempt from the FATCA reporting, is correct, See What is FATCA reporting? on
<br />page 2 for further information.
<br />Cat. No. 10231X Form tiff -9 (Rev. 12.2014)
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