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Form
<br />W -
<br />Request for Taxpayer
<br />Give Form to the
<br />(Rev. Decamber 2014)
<br />Identification Number and Certification
<br />entitles, 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 />TIN on page 3.
<br />Send to the IRS.
<br />Internal
<br />Revenue Service
<br />I Name (as shown on your Income tax return). Name is required on this line; do not leave this fine blank.
<br />ci
<br />2 Bueiness name/dlaregarded entity name, If different from above
<br />w
<br />3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
<br />4 Exemptions (codes apply only to
<br />°
<br />❑ Individual/sole proprietor or ❑ C Corporation
<br />p ❑SGerporation ❑ partnership ❑TrusVestate
<br />t indi
<br />certain entities, not individuals; see
<br />v
<br />single -member LLC
<br />insiructionson poge 31:
<br />❑ Limited liability company. Enter the tax classification (CmC corporation, 5=3 corporation, P=partnership) ✓
<br />Exempt payee code (If any)
<br />`o
<br />Nota. For a single -member LLC that Is disregarded, do not check LLC; check the appropriate box in the line above for
<br />Exemption from FATCA reporting
<br />r
<br />the tax classification of the single -member owner.
<br />code Of any)
<br />5
<br />p, G
<br />❑Other (see lnatYGG110ne)
<br />(,1ppAeamaerounm mafntamNauftlCa m. us.)
<br />K
<br />S Address (number, street, and apt. or suite no.)
<br />Raqueater's name and address (optionag
<br />G
<br />N
<br />d
<br />re
<br />B City, state, and ZIP code
<br />W
<br />on
<br />7 List account mannerist here(optionalt
<br />Miff
<br />Taxpayer Identification Number (TIN)
<br />Enter your TIN In the appropriate box. The TIN provided must match the name given online 1 to avoid
<br />Social security number
<br />For Individuals, this is generally your social security number (page However, for a
<br />backup wlien, sole
<br />resident alien, sole proprietor, or disregarded entity, see the par[ I Instructions on page 3. For other
<br />entitles, 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 an page 4 for I Employer identification number
<br />guidelines on whose number to enter. j—I— F—T-7—T—F
<br />Under penalties of perjury, I certify that:
<br />'I. The number shown on this form Is my correct taxpayer Idontlfft atlon 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 />Servlce (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 />S. I am a U.S. citizen or other U.S. person (defined below); and
<br />4. The FATCA codes) 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, acqulsltion 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 certhIcatlon, but you must provide your correct TIN. See the
<br />Instructions on page 3.
<br />zsignI Signature of
<br />Here U,S. person t Date
<br />General Instructions
<br />Section references are to the internal Revenue Cade unless otherwise noted.
<br />Future developments. Information about developments affecting Form W-9 (9acli
<br />as legislation enacted after we release It) Is at rvacwha,bov)/WD.
<br />Purpose of Form
<br />An Individual 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 (ATI N), or employer
<br />Wen Wron ing number (AN), to report on an Information return the amount paid to
<br />you, or other amount I'epohable 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 />• Farm 1099-5 (proceeds from real estate transactions)
<br />• Form I OWK (merchant card and third party network lmnaactlons)
<br />• Form 1098 (home mortgage Interest), 1098-E (student loan interest), 1098-T
<br />gulllon)
<br />• Form 1099-C (canceled debt)
<br />• Form 1099-A (acquisition or abandonment of secured property)
<br />Use Farm 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 Form W-9 to the requester with a TIN, you might be subject
<br />to backup withholding. See What /s backup withholding? on page 2,
<br />By signing the filled -out form, you:
<br />1. Codify guards, TIN you are giving Is correctleryou are waiting for a number
<br />to be Issued),
<br />2. Certify That you are not subjact to backup withholding, or
<br />3. Glalm exemption from backup withholding If you are a U.S. exempt payed If
<br />applicable, you are also codifying 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 come(s) entered on this form (if any) indicating that you aro
<br />exempt from the FATCA reporting, is correct. See Whatis FATCA reporting? on
<br />page 2 for further Information.
<br />Cat, No. 10231X
<br />75J-52
<br />Form W-9 (Rev. 12.2014)
<br />
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