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Form
<br />W'9
<br />Request for Taxpayer
<br />Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line
<br />Give Form to the
<br />(Rev. August 2013)
<br />Identification Number and Certification
<br />entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
<br />requester. Do not
<br />Department
<br />of the Treasury
<br />Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
<br />Employer identification number
<br />send to the IRS.
<br />Internal Revenue Service
<br />Name (as shown on your Income tax return)
<br />Kimle -Horn and Associates, Inc.
<br />N
<br />Business name/disregarded entity name, if different from above
<br />m
<br />m
<br />ro
<br />°-
<br />Check appropriate box for federal tax classification:
<br />Exemptions (see instructions):
<br />0
<br />ElIndividual/sole proprietor ❑✓ C Corporation El Corporation ElPartnership E]Trust/estate
<br />N
<br />C
<br />Exempt payee code (if any) 5
<br />2
<br />E] Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ►
<br />Exemption from FATCA reporting
<br />code (if any)
<br />p�, U
<br />❑ Other (see Instructions)►
<br />;�
<br />Address (number, street, and apt. or suite no.)
<br />name and address (optional)
<br />P.O. Box 33068
<br />y
<br />m
<br />City, state, and ZIP code
<br />m
<br />u,
<br />Raleigh, North Carolina 27636-3068
<br />List account numbers) here (optional)
<br />Mijig
<br />IM Taxpayer Identification Number (TIN)
<br />Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line
<br />I Social security number
<br />to avoid backup withholding. For individuals, this is your social security number However, fora
<br />resident alien, sole proprietor, or disregarded entity, see the Pan I instructions onn page 3. For other
<br />_ m
<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 />Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
<br />Employer identification number
<br />number to enter.
<br />IT1
<br />�oen000ca��
<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 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 />`919n Signature of
<br />Here U.S.parson► Date► October 13, 2014
<br />General Instructions
<br />Section references are to the Internal Revenue Code unless otherwise noted.
<br />Future developments. The IRS has created a page on IRS.gov for information
<br />about Form W-9, at www.im.gov/w9. Information about any future developments
<br />affecting Form W-9 (such as legislation enacted after we release it) will be posted
<br />on that page.
<br />Purpose of Form
<br />A person 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 settlement of payment card and third party network
<br />transactions, real estate transactions, mortgage Interest you paid, acquisition or
<br />abandonment of secured property, cancellation of debt, or contributions you made
<br />to an IRA.
<br />Use Form W-9 only if you are a U.S. person (including a resident alien), to
<br />provide your correct TIN to the person requesting it (the requester) and, when
<br />applicable, to:
<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 (if any) Indicating that you are
<br />exempt from the FATCA reporting, is correct.
<br />Note. If you are a U.S. person and a requester gives you a form other than Form
<br />W-9 to request your TIN, you must use the requester's form if it is substantially
<br />similar to this Form W-9.
<br />Definition of a U.S. person. For federal tax purposes, you are considered a U.S.
<br />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 organized in the
<br />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 361.7701-7).
<br />Special rules for partnerships. 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 foreign partners' share of effectively connected taxable income from
<br />such business. Further, in certain cases where a Form W-9 has not been received,
<br />the rules under section 1446 require a partnership to presume that a partner is a
<br />foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
<br />U.S. person that is a partner In a partnership conducting a trade or business in the
<br />United States, provide Form W-9 to the partnership to establish your U.S. status
<br />and avoid section 1446 withholding on your share of partnership income.
<br />Cat. No. 10231X
<br />Form VV -`J (Rev. 8-2013)
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