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Form
<br />w-9
<br />Request for Taxpayer
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<br />Give Form to the
<br />(Rev. December 2014)
<br />Identification Number and Certification
<br />requester. Do not
<br />Department
<br />of the Treasury
<br />send to the IRS.
<br />Internal
<br />Revenue Service
<br />1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
<br />N
<br />2 Business name /disregarded entity name, if different from above
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<br />3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
<br />4 Exemptions (codes apply only to
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<br />❑ Individual /sole proprietor or ❑ C Corporation 718 Corporation ❑ Partnership ❑ Trust /estate
<br />certain entities, not individuals; see
<br />instructions pagefa
<br />m c
<br />°
<br />o
<br />single-member LLC
<br />Limited liability company. Enter the tax classification C =C corporation, S =S corporation, P= artnershi Ii.
<br />❑ y p y ( p p P)
<br />a
<br />Exempt payee code (if any)
<br />0 2
<br />Note. For a single- member LLC that Is disregarded, do not check LLC; check the appropriate box in the line she for
<br />Exemption from FATCA reporting
<br />c
<br />the tax classification of the single- member owner.
<br />code (if any)
<br />d5
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<br />E] Other (see instructions) ►
<br />lappres roaccounrs memrarncd oanree the U.S,)
<br />5 Address (number, street, and apt. or suite no.)
<br />Requester's name and address (optional)
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<br />a
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<br />8 City, state, and ZIP code
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<br />rn
<br />7 List account numbers) here (optional)
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<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
<br />Social security number
<br />backup withholding. For individuals, this is generally your social security number ( However, for a
<br />resident alien, sole proprietor, or disregarded entity, see the Pan page I instructions on page 3. For other
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<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.
<br />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 I Employer Identification number
<br />guidelines on whose number to enter. F7_1 F—F-77F
<br />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 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 />Jlgn Signature of
<br />Here I U.S. person 0- Date Iii
<br />General Instructions
<br />Section references are to the Internal Revenue Code unless otherwise noted.
<br />Future developments. Information about developments affecting Form W -9 (such
<br />as legislation enacted after we release it) is at www.Irs.gov /fw9.
<br />Purpose of Form
<br />An Indlvldual or entity (Form W -9 requester) who is required to file an information
<br />return with the IRS must obtain your correct taxpayer identification number (TIN)
<br />which may be your social security number (SSN), Individual taxpayer Identification
<br />number (ITIN), 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, the following:
<br />• Form 1099 -INT (interest earned or paid)
<br />• Form 1099 -DIV (dividends, including those from stocks or mutual funds)
<br />• Form 1099 -MISC (various types of income, prizes, awards, or gross proceeds)
<br />• Form 1099 -B (stock or mutual fund sales and certain other transactions by
<br />brokers)
<br />• Form 1099 -5 (proceeds from real estate transactions)
<br />• Form 1099 -K (merchant card and third party network transactions)
<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 W -9 only if you are a U.S. person (including a resident alien), to
<br />provide your correct TIN.
<br />If you do not return Farm W -9 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 partners' share of effectively connected income, and
<br />4. Certify that FATCA code(s) entered on this form (ii any) indicating that you are
<br />exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
<br />page 2 for further information.
<br />Cat. No. 10231X
<br />22A -14
<br />Form W-9 (Rev. 12 -2014)
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