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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 <br />