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Form W-9 (Raw. 12-2014) Page 4
<br />Part II. 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 Othelwise
<br />For a joint account, only Ilia parson 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 91111. Exempt payees, see Exempt payee code earlier.
<br />Stimulate requfrements. Complete the cerllflcedon as Indicated In Items 1
<br />through 5 below.
<br />1. Interest, dividend, and barter exchange accounts opened before 1984
<br />and bra her accounts considered active durin9 1983. You must give Yonne
<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 can.1dered 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 T114 to the requester, you
<br />must cross out item 2 In the certification before signing the farm.
<br />3. Real estate transactions. You must sign the cart]traitor. You may cross 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 carthirailon unless you have been nolllied that you have previously given an
<br />In t.om.t TIN. "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 nonampioy to 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 529), IRA, Covenant ESA, Archer MSA or HSA contributions or
<br />distributions, and pension distributions. You must give your correct TIN, but you
<br />do not have to elgn the certification.
<br />What Name and Number To Give the Requester
<br />For this type of account:
<br />Give name and SSN of:
<br />1. Individual
<br />The Individual
<br />2. Two or more individuals Uoint
<br />The actual owner of the account or,
<br />account)
<br />If combined funds, the first
<br />Individual on the account'
<br />3. Custodian account of a minor
<br />The minor'
<br />(Uniform Ggt to Minors Ant)
<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 />not a legal or valid trust under
<br />state law
<br />5. Sale proprietorship or disregarded
<br />The owner'
<br />Shifty 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 />For9Js type of account:
<br />Give nameand SIR oA
<br />7. Disregarded enilty nat owned by an
<br />The owner
<br />individual
<br />B. A valid trust, estate, or pension trust
<br />Legal anthy'
<br />9. Corporation or LLG electing
<br />The corporation
<br />corporate status on Form 8832 or
<br />Form 2553
<br />10, Association, club, reilgious,
<br />The organlzatlon
<br />charitable, educational, or other tax-
<br />exempt organlzallon
<br />11. Partnership or rlultl-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 ogricuRurai
<br />program payments
<br />14. Grantor trust filing under the Form
<br />The trust
<br />1041 Filing Method or the Optional
<br />Form logo Filing Method 2 (see
<br />Regulations section 1.671-4(b)(2)m
<br />(Bl)
<br />List fist and circle the name of the person whose number you hurrah. if only one pomon on a
<br />Idea renogunt has an SBN, that person's number must be furnished
<br />e clrcbn the minor'. name and furnish the of...'s SSN.
<br />You must show your individual name and you may also enter your business or DBAnama on
<br />ilia °Buslness name/disregarded entity" namellne. You may use either your SSW at EIN Of you
<br />have anal, but the IRS encourages you to gas your SSW.
<br />° Usf first and circle the more of the facet, estate, se pension heat. (Do not famish the TIN of the
<br />personal representative or trustee unless the legal entity itself Is not desl... led area account
<br />title.) Also see Specfal rules kfpartnemhips on page 2.
<br />'Note. Grantoralao must provide a Form W-0 to tmates attract.
<br />Note. If no name Is circled when more than one name is listed, the number will be
<br />considered to be that of the fast 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 fob or may file 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 careful when choosing atax insparer.
<br />If your tax records are affected by Identity theft and you resolve a noting from
<br />the IRS, respond right away to the name and phone number prin ted 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 net<due to a lost or stolen purse or wallet, questionable credit card activity
<br />or credit report, contact the IRS Identity Theft Hotline at 1-800-9084490 or submit
<br />Form 14039.
<br />For mora Information, see Publication 4535, Identity Theft Preventlon and Victim
<br />Assistance.
<br />Victims of Identity theftwho are experiencing economic harm or a system
<br />pmglem, or are seeking help In resolving tax problems that have not been resolved
<br />through normal channels, may be eligible for Taxpayer Advocate Service (TAS)
<br />assistance. You can reach TAS by calling the TAS tolf-feea case intake line at
<br />1-877-777-4778 or 7TY/7DD 1-B00-829-4059.
<br />Protect yourself from suspicious emalls or phishing schemes. Phlshing is the
<br />creation and use of small and websites designed to mimic legitimate business
<br />emalls and wehsites. The rlost comlrlon act Is sending an email to a user falsely
<br />claiming to be an established legitimate enterprise in an attempt to scam the carr
<br />Into surrendering private information that will be used for Identity theft.
<br />The IRS does net Initiate contacts with taxpayers via emalls. Also, the IRF, 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 small claiming to bo from the IRS, forward this
<br />message to phlstWng@irs.gov. You may also report misuse of the IRS name, logo,
<br />or other IRS property to the Treasury Inspector General for Tax Administration
<br />(TIGTA) at'1-881-965-4404. You can forward suspicious smalls to the Federal
<br />Trade Oommiseion at; spam@ucti or contact them at wwwftagowldthaG or
<br />i-1177-IDTHEFT(1-877-438-4338).
<br />Visit IRS.gov to Team 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 persona (Including 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 interest you paid; the acqulsition or abandonment of secured
<br />property; the cancellation of debt; or contributions you made to an IRA, Archer
<br />MSA, or NSA. The person collecting this form uses the Information on the form to
<br />Gia Information returns with the IRS, reporting the above Information. Routine uses
<br />of this Information include giving it to the Department of Justice for civil and
<br />criminal litigation and to cities, stales, the District of Columbia, and U.S.
<br />commonwealths and possessions for use in administering their laws. The
<br />Information also may be disclosed to other countries under a treaty, to federal and
<br />stale agencies to enforce civil and criminal laws, or to federal law enforcement and
<br />intelligence agencies to combat terrorism. You must provide your TIN whetter or
<br />not you are required to file atax Tatum. Under section 3406, payers must generally
<br />withhold a percentage of taxable Interest, 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 />75R-50
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