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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 <br />