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<br />12:2210 p.m. 05-18-2012 2l2
<br />Fon
<br />W-9
<br />Request for Taxpayer
<br />Give Form to the
<br />[Rev. December 2011)
<br />the Treasury
<br />=anus
<br />Identification Number and Certification
<br />isre arde n page
<br />resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other
<br />requester. Do not
<br />send to the IRS.
<br />Memel
<br />Revenue Service
<br />_ m -�
<br />entitles, It is your employer Identification number (EIN). If you do not have a number, see Wow to get a
<br />Noe shown on your Income tax return
<br />7�I (a,( i +0
<br />'-A V S 2u � � et -\
<br />C CQ U n -E
<br />Note. If the account Is in more than one name, see the chart on page 4 for guidelines on whose
<br />Iv1 c V e_
<br />number to enter.
<br />of
<br />Business name/disregarded k9yname, If different from above
<br />m
<br />m
<br />I.
<br />m
<br />Check appropdale box for federal tax classification:
<br />0
<br />N
<br />Q Individual/sale proprietor Q CCorpomtlon ❑SCorporation ❑ Partnership ❑TrusVestete
<br />as
<br />Lmited liabilitycompany. Enter the tax classification (C=C corporation, S=S corporation, P= artnershi P) ►
<br />El Exempt payeev
<br />0 2
<br />N
<br />yOther
<br />0
<br />lsee lnsWclfons)► Q r0-
<br />E
<br />Adtlress (number, street, and epi. or sults no,) I
<br />Requester's name and address (options)
<br />a
<br />3l O l -4 � c1 c U cL- (-d .S-4 e e j -
<br />m
<br />N
<br />City, state, and ZIP code h r�
<br />A
<br />List account number(s) here (optional)
<br />Taxpayer Identification Number (TIN)
<br />Enter your TIN In the appropriate box. The TIN provided must match the name given on the "Name" line
<br />I SOclal security number )
<br />to avoid backup withholding. For this Is your social security number However, fora
<br />isre arde n page
<br />resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other
<br />_ m -�
<br />entitles, It is your employer Identification number (EIN). If you do not have a number, see Wow to get a
<br />TIN on page 3.
<br />Note. If the account Is in more than one name, see the chart on page 4 for guidelines on whose
<br />I Employer identification number
<br />number to enter.
<br />n�-
<br />I_I
<br />I.
<br />Under penalties of perjury. I certify that:
<br />1. The number shown on this form fa my correct taxpayer Identification number (or I am wafting for a number to be issued to me), and
<br />2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
<br />Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notifled me that I am
<br />no longer subject to backup withholding, and
<br />3. 1 am a U.S, citizen or other U.S. person (defined below).
<br />Certification Instructions. You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding
<br />because you have failed to report all Interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
<br />interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and
<br />generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
<br />Instructions on oaca 4. ,n
<br />sign I Signature of �4l pj
<br />Here U.S.persono. V� r
<br />General lnstruction't
<br />Section references are to the Internal Revenue Code unless otherwise
<br />noted.
<br />Purpose of Form
<br />A person who Is required to file an Information return with the IRS must
<br />obtain your correct taxpayer Identification number (TIN) to report, for
<br />example, Income paid to you, real estate transactions, mortgage Interest
<br />you paid, acquisition or abandonment of secured property, cancellation
<br />of debt, or contributions you made to an IRA.
<br />Use Form W-9 only If you are a U.S. person (Including a resident
<br />alien), to provide your correct TIN to the person requesting It (the
<br />requester) and, when applicable, to;
<br />1. Certify that the TIN you are giving Is correct (or you are waiting for a
<br />number to be Issued),
<br />2. Certify that you are not subject to backup withholding, or
<br />3. Claim exemption from backup withholding if you are a U.S. exempt
<br />payee. If applicable, you are also certifying that as a U.S. person, your
<br />II bI hof rthl Income from a U S trade or business
<br />Date ►
<br />Note. If a requester gives you a form other than Form W-9 to request
<br />your TIN, you must use the requester's form if It is substantially similar
<br />to this Form W-9.
<br />Definition of a U.S. person. For federal tax purposes, you are
<br />considered a U.S, person If you are:
<br />• An individual who Is a U.S. citizen or U.S. resident alien,
<br />• A partnership, corporation, company, or association created or
<br />organized In the United States or under the laws of the United States,
<br />• An estate (other than a foreign estate), or
<br />• A domestic trust (as defined in Regulations section 301.7701-7).
<br />Special rules for partnerships. Partnerships that conduct a trade or
<br />business in the United States are generally required to pay a withholding
<br />tax on any foreign partners' share of income from such business.
<br />Further, In certain cases where a Form W-9 has not been received, a
<br />partnership is required to presume that a partner is a foreign person,
<br />and pay the withholding tax. Therefore, If you are a U.S, person that Is a
<br />partner In a partnership conducting a trade or business In the United
<br />States, provide Form W-9 to the partnership to establish your U.S,
<br />status and avoid withholding on your share of partnership Income.
<br />a oca e s are any pa oars p
<br />Is not subject to the withholding tax on foreign partners' share of
<br />effectively connected income.
<br />Cat. No. 10231% Fonn W-9 (Rev. 12-2011)
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