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Farm
<br />W-9
<br />Request for Taxpayer
<br />Give Form to the
<br />(Rev.December2014)
<br />identification Number and Certification
<br />requester, Do not
<br />Department
<br />of the Treasury
<br />Send to fire Itis.
<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 />2 Business name/dludliarded entity name, If different from above
<br />ci
<br />m
<br />a
<br />e
<br />3 Check appropriate box for federal lax classification; check only ono of the following seven bozos:
<br />4 Exemptions (codes apply only to
<br />certain entities, not individuals; see
<br />o
<br />❑ Individual/sole proprietor or ❑ C Corporation ❑ 5 Corporation ❑ PaHnerchl Trustlestale
<br />P
<br />Instructions an page 3):
<br />a o
<br />single -member LLC
<br />❑ Limited liability company. Enter the tax classification (C=C corporation, S -S corporation, P=partnamhlp) ►
<br />Exempt payee code (if any)
<br />`o
<br />Note. Fora 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 />the tax classification of the single -member owner.
<br />code (If any)
<br />C
<br />Q.
<br />❑ Other(.. lnstruatfahs) 0
<br />(Applresmvccaunte malnUlned d,mtle lM1e USJ
<br />w
<br />5 Addmss (number, street, and apt, or suite no.)
<br />Raquester's name and address (optional)
<br />U
<br />W
<br />a
<br />w
<br />9 City, state, and ZIP cad.
<br />v
<br />y
<br />7 List account number(s) here (optional)
<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 I Social security number
<br />backup wlien, sole
<br />For individuals, this Is generally your social I i stru number (page However, fora _ m
<br />resident alien, sale proprietor, or disregarded entity, sea the Part I instructions on page 3. FoY other
<br />entities, it Is your employer identification number (EIN). If you do not have a number, see How fa get a
<br />TIN on page 3. 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 Employer tdenUncation number
<br />guidelines on whose number to enter- F—F-1 F—I-7—F—FT-1-1
<br />Under penalties of perjury, I certlfy that:
<br />I. The number shown on this form Is my correct taxpayer identification number (or I am waiting for a number to be issued tome); and
<br />2. lam not subject to backup withholding because; (a) I am exempt from backup withholding, or (h) 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 (o) 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 />sign Signature of
<br />Here U.S.paraon► onto 10.
<br />General instructions
<br />Section references are to the Intimal Revenue Code unless otherwhe, noted.
<br />Future developments. Information about developments affecting Form W-9 (such
<br />as legislation enacted after we release it) Is at www.lm.9ov/M199.
<br />Purpose of Form
<br />An Indlodual 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 />• Farm 1099 -DIV (dividends, Including those from stacks or mutual funds)
<br />• Form 1099-MISC (various types of Income, prizes, awards, or gross proceeds)
<br />• Form 1099-5 (stock or mutual fund sales and certain other transactions by
<br />brokers)
<br />• Farm 1099-S (proceeds from real estate transactions)
<br />• Form 1099-K (merchant card and third party network transactions)
<br />• Form f 090 (home mortgage Interest), 1099-E (student loan Interest), 1090-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 />Hyde do not return Form W-9 to the requester with a TIN, you might be subject
<br />to backup withholding. Soo What /s 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 />wlthholeing tax on foreign partners' share of effectively connected Income, and
<br />4. Carilty that FATCA code(s) entered on this form (If any) indicating that you are
<br />exempt from the FATCA reporting, Is correct. See What Is FATCA reporting? on
<br />page 2 for further Informaffan.
<br />Cat. No, 1923'1%
<br />75M-55
<br />Form W-9 (Rev. 12-2014)
<br />
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