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Form W-9 (Rev. 12-2014)
<br />Part 11. Certification
<br />To establish to the withholding agent that you are a U.S. person, or resident alien,
<br />sign Form W-9. You may be requested to sign by the withholding agent even If
<br />Items 1, 4, or 5 below Indicate otherwise.
<br />For a joint account, only the person whose TIN Is shown In Part I should sign
<br />(when required). In the case of a disregarded entity, the person Identified on Ilne 1
<br />must sign. Exempt payees, see Examptpayee code earlier.
<br />Signature requirements. Complete the certification as Indicated In Items 1
<br />through 5 below.
<br />1. Interest, dividend, and barter exchange accounts opened before 1984
<br />and broker accounts considered active during 1963, You must give your
<br />correct TIN, but you de not have to sign the certification.
<br />2. Interest, dividend, broker, and barter exchange accounts opened after
<br />1983 and broker accounts considered inactive during 1083. You must sign the
<br />certification or backup withholding will apply. If you are subject to backup
<br />withholding and you are merely providing your cot rest TIN to the requester, you
<br />must cross out Item 2 In the certlficallan before signing the form.
<br />3. Real estate transactions. You must sign the codification. You may crass out
<br />Item 2 of the certification,
<br />4. Other payments. You must give your correct TIN, but you do not have to sign
<br />the certification unless you have been notified that you have previously given an
<br />Incorrect 7119. "Other payments" Include payments made In the course of the
<br />requester's trade or business for rents, royalties, goods (other than bills for
<br />merchandise), medical and health care services (Including payments to
<br />corporations), payments to a nonemployee for services, payments made in
<br />settlement of payment card and third party network transactions, payments to
<br />certain fishing boat crew members and fishermen, and gross proceeds paid to
<br />attorneys (Including payments to corporations),
<br />5. Mortgage Interest paid by you, acquisition or abandonment of secured
<br />property, cancellation of debt, qualified tuition program payments (under
<br />section 524 IRA, Covert ell ESA, Archer MSA or HSA contributions or
<br />distributions, and pension distributions. You must give your correct TIN, bulyou
<br />do not have to sign the certification.
<br />What Name and Number To Give the Requester
<br />Forthis type of readable
<br />Give name and SSN of:
<br />1. Individual
<br />The individual
<br />2. Two or more Individuals Qeint
<br />The actual owner of the account or,
<br />account
<br />It combined funds, the first
<br />Individual on the account'
<br />3. Custodian account of a minor
<br />The minor'
<br />(Uniform Gift to Minors Act)
<br />4. a. The usual revocable savings
<br />The grantor -trustee'
<br />trust (granter Is also trustee)
<br />b. So-called trust account that is
<br />The actual owner'
<br />not a legal or valid trust under
<br />state law
<br />5. Sole proprletorship or disregarded
<br />The owns r'
<br />entity owned by an individual
<br />6. Grantor trust filing under Optional
<br />The grantor'
<br />Form 1999 Filing Method 1 (sea
<br />Regulations section 1.571-4(b)(2)(q
<br />(A))
<br />For this type ort account:
<br />Give game and EIN of.,
<br />7. Disregarded entity not owned by an
<br />The owner
<br />Individual
<br />8. A valid bust, estate, or pension trust
<br />Legal entity°
<br />9. Corporation or LLC electing
<br />The corporation
<br />corporate status on Form BB32 or
<br />Form 2553
<br />10. Association, club, rotigicua,
<br />The organization
<br />charitable, educational, or other tax-
<br />exempt organization
<br />11. Partnership or multi -member LLC
<br />The partnership
<br />12. A broker or registered nominee
<br />The broker or nominee
<br />13. Account with the Department of
<br />The public entity
<br />Agriculture in the name of a public
<br />entity (such as a state or local
<br />government, school district, or
<br />prison) that receives agricultural
<br />program payments
<br />14. Grantor trust filing undarthe Form
<br />The trust
<br />1041 Filing Method or the Optional
<br />Farm 1099 Filing Method 2 (see
<br />Regulations section 1.071-4(6)(2)0)
<br />(S))
<br />' List first and circle the mom of the person whose number you furnish. If only one Primerica a
<br />joint account has an SSN, that pemon's number must be marched.
<br />z Clrcle the mlmr'a name and tarnish the miner's SSN,
<br />Page 4
<br />°You must show your Individual name and you may arca anter your business or DRAnamo an
<br />the"eusiness mama/disregarded entity" name line, You may use either yourSSN or EIN (i(Wu
<br />have ane), but the IFS encourager you to use your SSN.
<br />' Rsd first and drde the name of the lost, estate, or pension treat. (Do not furnish the TIN of the
<br />personal res eaentathre or leader, unless the legal enthy Itself is not denigrated In the account
<br />titiaJ Also see Special Nile IarparfdarePips on page 2.
<br />'Note. Grantor also most pradde a Farm W-9 to trustee of trust.
<br />Not.. If no name Is ckcled when more than one name is listed, the number will be
<br />considered to be that of the first name listed.
<br />Secure Your Tax Records from Identity Theft
<br />Identity theft occurs when someone uses your personal Information such as your
<br />name, Si or other identifying Information, without your permission, to commit
<br />fraud or other cdmes. An Identity thief may use your SSN to get a job or may file a
<br />tax return using your SSN 10 receive a refund.
<br />To reduce your risk:
<br />• Protect your SSN,
<br />• Ensure your employer is protecting your SSN, and
<br />• Be careful when choosing a tax preparer,
<br />If your tax records are affected by Identity theft and you receive a notice from
<br />the IRS, respond right away to the name and phone number printed on the IRS
<br />notice or letter.
<br />If your tax records are not currently affected by Identity theft but you think you
<br />are at risk due to a lost or stolen purse or waiter, questionable credit card activity
<br />or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit
<br />Form 14039.
<br />For more Information, see Publication 4535, Identity Theft Prevention and Victim
<br />Assistance.
<br />Victims of Identity theft who are experiencing economic home or a system
<br />problem, or are seeking help In reaolving tax problems that have not been resolved
<br />through normal channels, may be eligible for Taxpayer Advocate Service (IFAS)
<br />assistance. You an reach TAS by calling the TAS tall -free case Intake line at
<br />1-677-777-4778 or TTY/TDD 1-800-829-4059.
<br />Protect yourself from suspicious smalls or phishing schemes. Patching is the
<br />creation and use of email and websites designed to mimic legitimate business
<br />smalls and websites. The most common act is sanding an email to a user falsely
<br />claiming to he an established legitimate enterprise in an attempt to scam fire user'
<br />into sort boosting private information that will be used for identity theft.
<br />The IRS does not initiate contacts with taxpayers via smalls. Also, the IRS does
<br />not request personal detailed Information through small or ask taxpayers for the
<br />PIN numbers, passwords, or similar secret access information for their credit used,
<br />bank, or other financial accounts.
<br />It you receive an unsolicited email claiming to be from the IRS, forward this
<br />message to phishing@lm.gov. You may also report misuse of the IRS name, loge,
<br />or other IRS property, to the Treasury Inspector General for Tax Administration
<br />(NGTA) at 1-800-366-4484. You can forward auspicious smalls to the Federal
<br />Trade Commission at: spa miluce.gov or contact (hem at www.fte.govlidlhog or
<br />1-877-1 DTH EFT (I.877 -43B-4338).
<br />Visit IRS.gov to learn more about Identity theft and how to educe your risk.
<br />Privacy Act Notice
<br />Section 6199 of the Internal Revenue Code requires you to or sales your correct
<br />TIN to persons md"ding federal agencies) who are required to file information
<br />returns with the IRS to report interest, dividends, or certain other Income paid to
<br />you; mortgage In latest you paid; the acquisition or abandonment of secured
<br />property; the cancellation of debt; or contributions you made to an IRA, Archer
<br />MSA, or HSA. The person collecting this form uses the information on the form to
<br />If. Information returns with the IRS, reporting the above information. Routine uses
<br />of this Information include giving It to the Department of,Iurtho for civil and
<br />criminal litigation and to cities, states, the District of Columbia, and U.S.
<br />commonwealths and possessions for use in administering their laws. The
<br />information also may be dlsmlosed to other countries under atreaty, to federal and
<br />state agencies to enforce civil and criminal laws, or to federal law enforcement and
<br />Intelligence agencies to combat terrorism. You must provide your TIN whether or
<br />not you are required to file a tax return. Under section 34(1 payers must generally
<br />withhold a percentage of taxable times I, dividend, and certain other payments to
<br />a payee who does not give a TIN to the payer. Certain penalties may also apply for
<br />providing false or fraudulent Information.
<br />750-52
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