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Fort'
<br />Request for Taxpayer
<br />Give Form to the
<br />(Rev. D!,8tMfer 20'14)
<br />Idenfilficafiien Number and Certification
<br />requester. bo not
<br />DepartmIhaTraaaury
<br />send to the IRS.
<br />Internal Revenue Service
<br />1 Name (as shown on your income tax return). Name is required on this line: do hot leave this line blank,
<br />2 Business name/disregarded entity name, if different from above
<br />at
<br />m
<br />m
<br />0
<br />9 Check appropriate box for federal tax classlficetlon; check only one of the following seven boxes:
<br />4 EJimn ties (cod In apply only sea
<br />certain os, individuals; sea
<br />o
<br />❑Individual/axle proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
<br />ion. eri
<br />lOshuctions an page 3):
<br />m c
<br />y� o
<br />v
<br />single -member LLC
<br />LJ Limited liability company. Enter the tax classification (C=C corporation, S=S eorperation, P=partnership) i
<br />Exempt payee coda (if any)
<br />is
<br />0 5
<br />Note, For a single -member LLC that is disregarded, do not chock LLC; check the appropriate box in the line shove for
<br />Fram FATGA reporting
<br />i„
<br />the tax classification of the single -member owner.
<br />code (if any)
<br />p`,
<br />❑ other (so. instructions)
<br />Epprro• to aacwm:m.,mmmcdourna•ra usi
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<br />5 Address (number, street, and apt. or suite noJ
<br />Requester's name and address (optional)
<br />v
<br />a
<br />6 City, state, and ZIP coda
<br />N
<br />m
<br />7 List account numbor(s)here (optional)
<br />Taxpayer Identification Number (TIN)
<br />Enter your TIN in the appropriate box. The TIN provided must match the name given on line t to avoid I Social...urityraul
<br />hookup withholding. ole For individuals, this Is dgenerallyentity, your social security number (page However, for a
<br />Yesident alien, sole proprietor, or disregarded entity, sea the Part I instructions on page S. For other
<br />e flu— it Ic,mur mmninvpr idpntifiantinn m rmhar fEINI. If von do not have a number. gee How to oeta
<br />TIN on page 3.
<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 />guidelines on whose number to enter.
<br />der penalties of perjury, I certify that:
<br />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 notifled 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 FATGA coda(s) entered on this form (If 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 out rattly 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 most provide your correct TIN- Sae the
<br />instructions on page S.
<br />,Sign I structure of
<br />Bare U.S. persons Date
<br />General Instructions
<br />Section references are to the Internal Revenue Code mile.. atherwlse noted.
<br />Future developments, information about developments affecting Form W-9 (such
<br />as legislation enacted after we release Iti Is at wanvile gov/iw9.
<br />Purpose of Form
<br />An Individual or entity (Form W-9 requester) who la 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 (SSM, 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 />• Farm 1099 -INT (interest earned or call
<br />• Form 1099 -DIV (dividends, including those from stacks or mutual funds)
<br />• Form 1099-MISC (various types of Income, prizes, awal'de, or gross proceeds)
<br />• Form 1099-13 (stack or mutual fund sales and canaln other transactions by
<br />brokers)
<br />• Farm 1099-S (proceeds from real estate transactions)
<br />• Farm 1099-K (merchant card and third party network "i nsa itlons)
<br />• Form 1098 (home mortgage Interest), 1098-E (student loan interest), 10984
<br />(tuition)
<br />• Farm 1099-0 (canceled debt)
<br />• Form 1099-A (acquleltlon or abandonment of secured property)
<br />Ran Form W-9 only If you are a U.S. person (Including a resident ellen), to
<br />pl'ovlde your correct TIN.
<br />Nyou do not return Form W-9 to the requester with a TIN, you might be subject
<br />to bil 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 />withhokting tax on foreign partners' share of effectively connected income, and
<br />4. Certify that FATGA cartels) entered on this form Of any) Indicating that you are
<br />exempt from the FATCA reporting, Is correct, See What Is FATGA reporting? on
<br />page 2 for full Information.
<br />Cat. No. 10231X
<br />75H-43
<br />Form W-9 (Rev. 12-2014)
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