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Farm W-9 (Rev. 12-2014) Page 4
<br />Part H. 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 line 1
<br />must sign. Exempt payees, see Exempt payea code earlier.
<br />Signature requirements. Complete the certification as Indicated In Items i
<br />through 5 below.
<br />1. Interest, dividend, and barter exchange accounts opened before 1984
<br />and broker accounts considered active during 1983. You must give your
<br />correct TIN, but you do 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 1983. 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 correct TIN to the requester, you
<br />must crass out Item 21n the certification before signing the form.
<br />S. Real estate transactions. You must sign the cartificallon. You may cross out
<br />Item 2 of the certification.
<br />4, Other payments. You must give your correct Tl N, but you do not have to sign
<br />the c ntificatlon unless you have been notified that you have previously given an
<br />Incorrect TIN. "Other payments" include payments made In the course of the
<br />requester's trade or business for rants, royalties, goods (other than bilis 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, can collation of dubt, cru allfied tuition program payments (under
<br />section 529), IRA, Covardell ESA, Archer MSA or HSA contributions or
<br />distributions, and pension distributions. You must give your correct TIN, but you
<br />de not have to sign the certification.
<br />What Name and Number To Give the Requester
<br />For this type of account:
<br />Give name and SEN of:
<br />1. Individual
<br />The Individual
<br />2, Two or more Individuals dolor
<br />The actual owner of the account or,
<br />account)
<br />if combined funds, the first
<br />individual on the account'
<br />S. Custodian account of a minor
<br />Tho mint'
<br />(Uniform Gift to Minam Aot)
<br />4. a, The usual revocable savings
<br />The grantor -trustee'
<br />trust (grantor Is also trustee)
<br />b. So-called trust account that Is
<br />The actual owner'
<br />hat a legal or valid trust under
<br />state law
<br />5. Sale proprietorship or disregarded
<br />The owner'
<br />entity owned by an individual
<br />6. Grantor trust filing under Optional
<br />The grantor"'
<br />Form 1099 Filing Method 1 (see
<br />Regulations section 1.671-4(b)(2)(i)
<br />(A))
<br />Far this type of acca unt:
<br />Give name and FIN of:
<br />7. Disregarded entity not owned by an
<br />The owner
<br />Individual
<br />3. A valid frust, estate, or pension trust
<br />Legal entliv
<br />9. Corporation or LLC electing
<br />The corporation
<br />corporate status on Farm 8032 or
<br />Form 2553
<br />10. Association, club, religious,
<br />The organization
<br />charitable, educational, or other tax-
<br />exempt organa ation
<br />11. Partnership or multi -member LLC
<br />The partnership
<br />12. A brokeror registered nominee
<br />i' he 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 reserves agricultural
<br />program payments
<br />14. Grantor trust flung under the Form
<br />The fru at
<br />1041 Filing Method or the Optional
<br />Farm 1099 Filing Method 2 (see
<br />Regulations section 1.871-4(6)(2)(1)
<br />(B))
<br />' L181 fist and circle the nem. of the porion whose number you furnish, if only one person on a
<br />joint account has an SSN, that person's number must be fumerhed.
<br />'Circle the rnlnor's name and furnish the miner's SSN.
<br />o You must show your individual name and you may also enter your business or DBA mama on
<br />the "Busloona gameldroucadrded entity" memoirs. You may use either your SSW or FIN (lives
<br />have one), but the IRS encourages you to use your SEN.
<br />' List Iloet and chole the name of the trust, estate, or pension trust (Do not furnish the TIN of the
<br />personal representative or trustee unless the legal amity Itself Is not designated Inthe account
<br />title.) Also one Special miss for pad arthips on page 2.
<br />*Note. Grantor also must provide a Form W -g to uustea of trust.
<br />Note. If no name Is elected when more than one name Is listed, the number will be
<br />considered to he 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, SSN, or other identifying Information, without your permission, to commit
<br />fraud or other crimes. An Identity thief may use your SSN to get a job or may (Ile a
<br />tax return using your SSN to receive a refund.
<br />To reduce your risk;
<br />• Protect your SSN,
<br />• Ensure your employer Is protecting your SSN, and
<br />• Be carefut when ohousing a tax preperec
<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 wallet, questionable credit card activity
<br />or credit second, contact the IRS Identity Theft Hotline at 1-800-988-4490 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 berm or a system
<br />problem, or are seeking help In resolving tax problems that have not been resolved
<br />through normal channels, may be eligible for Taxpayer Advocate Service (YAS)
<br />assistance. You can reach TAS by calling the TAS tell -free case Intake line a1
<br />1-877-777-4778 or 7TY77DD 1400-829-4059.
<br />Protect yourself from suspicious emails or phishing schemes. Phiching is the
<br />creation and use of email and websites designed to mimic legitimate business
<br />amatls and wobstios. The most common act is sending an email to a user falsely
<br />assuming to bean established legitimate enterprise In an attempt to scam the user
<br />into surrendering private Information that will be used for Identity theft.
<br />The IRS does not Initiate contacts with taxpayers via emells. Also, the IRS does
<br />not request personal detailed information through email or ask taxpayers for the
<br />PIN numbers, passwords, or similar secret access information for their credit card,
<br />bank, or other financial accounts.
<br />If you receive an unsolicited email claiming to be from the IRS, forward this
<br />message to plashlogrifougov. You may also report misuse of the IRS name, logo,
<br />or other IRS property to the Treasury Inspector General for Tau Administration
<br />(TIGTA) at 1-800-366-4484. You can forward suspicious amatls to the Federal
<br />Trade Commission at: spam®uce.gov or contact them at www.1lc,gov1idthaR or
<br />1-877-IDTHEFr (1-877-438-4338).
<br />Visit IRS.gov to learn more about Identity theft and how to reduce your risk.
<br />Privacy Act Notice
<br />Section 6109 of the Internal Revenue Code requires you to provide your correct
<br />TIN to parsons (Including taboret agencies) who are required to file Information
<br />returns with the IRS to report interest, dividends, or certain other Income paid 10
<br />you; mortgage Interest 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 />Ole Information returns with the IRS, reporting the above infohnetion. Routine uses
<br />of this Information Include giving It to the Department of Justice 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 />In€ormallon also may be disclosed to other countries under a treaty, to federal and
<br />state ageneles 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 life a tax return. Under section 3408, payers must generally
<br />wlItihold a percentage of taxable interest, dividend, and certain other payments to
<br />a payee who does not give aTIN to the payer. Certain penalties may also apply for
<br />providing false or fraudulent Information.
<br />75Q-53
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