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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)
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