Laserfiche WebLink
Form <br />W-9 <br />Request for Taxpayer <br />Give Form to the <br />(Rev. December 2014) <br />identification Number and Certification <br />entitles, it is your employer Identification number (EIN). If you do not have a number, see Has, to gets <br />requester. Do not <br />Department <br />offlpTo,.surV <br />TIN on page 3. <br />send to the IRS. <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/disregarded entity name, if different from above <br />of <br />m <br />o' <br />e <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 />certain entities mar Individuate; sea <br />o <br />❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate <br />, <br />Instructions on page 3): <br />v <br />(° <br />aingle-member LLC <br />❑ Limited liability company. Enter the tax classification (C=C corporation, 5=5 corporation, P=padnershlp)1• <br />Exempt payee code Of any) <br />`o <br />Note. For a aingle-member =that Is disregarded, do not check LLC; check the appropriate box in the line above for <br />Exemption from FATCA reporting <br />b <br />c <br />the tax classification of the single -member owner. <br />code (if any) <br />5 p, <br />❑Other (sea lnsimcllons)i <br />(Applies to a«oems ale l„ramaew,..:-lerna U.S.) <br />IE <br />5 Address (number, street, and apt, or suite no.) <br />Requester'n name and address (optional) <br />�i <br />So m <br />6 City, state, and ZIP code <br />m <br />m <br />7 Her account numbers) here (optional) <br />Taxpaor Identification Number (TIN) <br />Enter your TIN In the appropriate box. The TIN provided must match the name givan online Ito avoid <br />social security numuer <br />backup Withholding. For Individuals, this is generally your social security number e ( However, for a <br />resident plan, sale proprietor, or disregarded entity, see the Part I instructions on page 3 For other <br />entitles, it is your employer Identification number (EIN). If you do not have a number, see Has, to gets <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 on page 4 for I Employer Identification number <br />guidelines on whose number to enter. F -F-1 F-F-F7-Ir <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 QRS) 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 tle 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. Seo the <br />instructions on page 3. <br />sign Signature of <br />Here I U.S. person 0- Dale b <br />General Instructions <br />Station references are to the Internal Revenue Cade pulses otherwise noted. <br />Future developments. Information about developments affecting Form W-9 (such <br />as legislation enacted after we release It) Is at navetips.gov/09. <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 (TIM <br />which maybe your social security number (SSN), individual taxpayer Identification <br />number(ITIN), adoption taxpayer identification number (ATIN), or employer <br />idenililcetion 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 10994NT (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 />• Form 1099-5 (proceeds from real estate transactions) <br />• Form 1099-K(merchant card and third parry network transactions) <br />• Form 1099 (home mortgage Interest), 1098-E (student loan interest), 1099-T <br />(tuition) <br />• Form 1099-C (canceled debt) <br />• Form 1099-A (acquisition or abandonment of secured preparty) <br />Use Form W-9 only If you are a U.S. person (Including a resident alien), to <br />provide your correct TIN. <br />II you do not return Form W-9 to the requasfer with a TIN, you might be subject <br />to backup 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. Coulty 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 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 code(s) entered on this form Of any) Indicating that you are <br />exempt from the FATCA reporting, is correct, See What Is FATCA reporting? on <br />page 2 for further Information. <br />Cat, No, 10231X <br />750-49 <br />Farm VV -9 (Rev. 12-2014) <br />