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<br />7�Ilt740'
<br />Request for Taxpayer
<br />Give Form to the
<br />(Rey.,a,,a)Identification
<br />Treasury
<br />Number and Certification
<br />I
<br />requester. Re notlm
<br />Internal Revenue Service
<br />send to: the IRS.
<br />Name (as shown on your Income tax return)
<br />Ultras stems Environmental, Inc.
<br />ni
<br />Business aameldigregarded entity name, if different from above
<br />o
<br />Cheek appropriate box for federal lax classification:
<br />Exemptions (too Instructions):
<br />0
<br />❑ Individual7sde proprietor ❑ Ccorporation 0a Corporation ❑ Partnership ❑Tmst/osete
<br />G
<br />N
<br />❑ Limitedliablfty company,Enter(lie tax classification(C=a corporation. Corporation, P=parinershp)0_
<br />Exempt payee code (if any)
<br />�n
<br />Exemption from FATGA reporting
<br />IC
<br />IVti
<br />El Other (see Instructions) '
<br />Cddelitany)¢na)r�`
<br />P
<br />Address (number. street, and apt. or suite no.)
<br />Requomer'6 name end addross (optional)
<br />h
<br />16431 Scientific Way
<br />City,: state; and ZIP code
<br />w
<br />Irvine, CA 92618
<br />List account numbor(s) here (optional)
<br />Note. If the account Is in more than one name, see the chart on page 4 for guidelines on whose
<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 l am waiting for anumber to be, issued to me), and
<br />2. lam 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 Asaresult of a fallureto 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 Of any) Indicating that I am exempt: from FATGA reporting Is correct.
<br />Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are c
<br />because you have failed torecon all interest and diiridands nh vmrr tau rat„rn c„r mmi name r -.,—o,,.... u—
<br />, an
<br />....,
<br />General Instructions 1
<br />section references are to the Internal Revenue Code unless Onim4se acted.
<br />Future developments. The Ins has created a page onlRS.gov for information
<br />about Form W-91, at wonrarsgavywg. Information about anypAure developments
<br />affecting Form W-0 (such as legislation enacted after we release h) wig be posted
<br />on that page.
<br />Purpose of Form
<br />Aperson who Is required to file an information return with the IRS must obtain your
<br />correct taxpayer Identification number (TIN) to report, for example, income paid to
<br />YOU, payments made to you In schoo nl of payment card and third party network
<br />transactions, real estate transactions, mortgage Interest you paid, aaqulsltlon or
<br />abandonment of secured property, Cancellation of debt, or Contributions you made
<br />to an INA,
<br />Use form W0 only if you are a U.S. person imoluding a resident alien), to
<br />provide your correct TIN to the person requesting It (the requester) and, when
<br />applicable, lo:
<br />I. Codify that the TIN you aro giving Is correct for you are waiting for a number
<br />to be Issued),
<br />2, Codify that you are not subject to backup withholding. or
<br />3. Claim exemption from backup withholding if you aro a U.S. exempt payee,. It
<br />applicable, you are also certifying that as a US, person,. your allocable short of
<br />any partnership Income from:a U.S. trade or business Isnot subject to the
<br />,an fnravlouat retirement arrangement (IM); and
<br />but you must provide your correct TIN. See the
<br />4. Certify that FATGA code(6) entered on this form if any) indicating that you are
<br />exempt from the FATGA reporting, is Correct.
<br />Note. If you are a U.S person and a requester gives you a form other than Form
<br />W-0 to request your TIN, you must use the tequester's form if it Is substantially
<br />sioiliar to this Form W -g,
<br />Definition of a U.S. person. For federal tax purposes, you are Considered 0 U.S,
<br />person if you are:
<br />.:An individual who is U.S. citizen or U.6, resident alien,
<br />• A partnership, corporation, Company, or asspclanoa created ororganized in the
<br />Ursted 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 />Sgeclal rules for 00rt"mrshlies. Partnerships that conduct a trade or business in
<br />the United States are generally required to pay a withholding tax under section
<br />1446 on any foroign partners' share of effectively connected taxable Income from
<br />such business. Further, In certain cases whore a Form MID has not boon received,
<br />the rules under section 1446 requires partnership to presume that a partner Is a
<br />foreign person, and pay the section 1446 withholding' tax. Therefore, if area
<br />U.S: parson that is a partner in a partnership conducting a trade or business in the.
<br />United States, provide Form W -g to the partnership to establish your VS. status
<br />and avoid section 1446 VAthholding on yourshare of partnership income,
<br />Cat; No. 10231X Form
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