Form W_9 Request for Taxpayer Give Form to the
<br /> (Rev. December2014) Identification Number and Certification requester. Do not
<br /> Department of the Treasury send to the IRS.
<br /> Internal revenue Service
<br /> 1 Name(as shown on your income tax return).Name is required on this line;do not leave blank.
<br /> N
<br /> w
<br /> g, 2 Business name/disregarded entity name,if different from above
<br /> R
<br /> Q
<br /> 4 Exemptions(codes applyonlyto
<br /> 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: p
<br /> ❑Individual/Sole proprietor or ❑C Corporation ❑S Corporation ❑ Partnership ❑Trust/estate certain entities,not individuals;see
<br /> O.
<br /> p instructions on page 3):
<br /> Exempt Payee code(if any)
<br /> v ❑single-member LLC Limited liability company.Enter the tax classification(C=C Corporation,S=S Corporation,P=partnership)
<br /> p
<br /> i Exemption from FATCA reporting i Note.For a single-member LLC tha is disregarded,do not check LLC;check the appropriate box in the line above for code(if any)
<br /> C
<br /> N the tax classification of the single-member owner. (Applies to accounts maintained outside the U.S.)
<br /> E Other(see instructions)
<br /> 0- cj
<br /> L.= 5 Address(number,street,and apt.or suite no.) Requester's name and address(optional)
<br /> V
<br /> w
<br /> 0-
<br /> u)
<br /> U) 6 City,state,and ZIP code
<br /> w
<br /> w
<br /> U)
<br /> 7 List account number(s)here(optional)
<br /> Part I Taxpayer Identification Number(TIN)
<br /> Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number
<br /> backup withholding. For individuals,this is generally your social security number(SSN). However,for a _ _
<br /> resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3. For other
<br /> entities, it is your employer identification number(EIN). If you do not have a number,see How To Get a
<br /> TIN on page 3.
<br /> Note: If the account is in more than one name,see the instructions for line 1 and the chart on Employer identification number
<br /> page 4 for guidelines on whose number to enter. -
<br /> Part II Certification
<br /> Under penalties of perjury, I certify that:
<br /> 1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and
<br /> 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding,or(b) I have not been notified by the Internal
<br /> Revenue 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
<br /> notified me that I am no longer subject to backup withholding,and
<br /> 3. I am a U.S.citizen or other U.S. person(defined below),and
<br /> 4. The FATCA code(s)entered on this form(if any)indicating that i am exempt from FATCA reporting is correct.
<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
<br /> withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions,item 2 does not apply. For
<br /> mortgage interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement
<br /> (IRA),and generally, payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct
<br /> TIN. See the instructions on page 3.
<br /> Sign Signature of
<br /> Here U.S.person Date
<br /> • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T
<br /> General Instructions (tuition)
<br /> Section references are to the Internal Revenue Code unless otherwise noted.
<br /> •Form 1099--C(canceled debt)
<br /> Future developments. Information about developments affecting Form W-9 (such
<br /> as legislation enacted after we release it)is at wwwirs.gov/fw9. •Form 1099-A(acquisition or abandonment of secured property)
<br /> Purpose of Form Use Form W-9 only if you are a U.S.person(including a resident alien),to provide
<br /> your correct TIN.
<br /> An individual or entity (Form W-9 requester)who is required to file an information
<br /> return with the IRS must obtain your correct taxpayer identification number(TIN) If you do not return Form W-9 to the requester with a TIN,you might be subject to
<br /> which may be your social security number(SSN), individual taxpayer identification backup withholding.See What is backup withholding?on page 2.
<br /> (ITIN), adoption taxpayer identification number (ATIN), or employer identification
<br /> number(EIN),to report on an information return the amount paid to you, or other By signing the filled-out form,you:
<br /> amount reportable on an information return.Examples of information returns include,
<br /> but are not limited to,the following, 1. Certify that the TIN you are giving is correct (or you are waiting for a number
<br /> to be issued),
<br /> •Form 1099-INT(interest earned or paid)
<br /> 2.Certify that you are not subject to backup withholding,or
<br /> •Form 1099-DIV(dividends,including those from stocks or mutual funds)
<br /> 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
<br /> •Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) applicable,you are also certifying that as a U.S.person,your allocable share of any
<br /> partnership income from a U.S.trade or business is not subject to the withholding
<br /> •Form 1099-B(stock or mutual fund sales and certain other transactions by brokers) tax on foreign partners'share of effectively connected income,and
<br /> •Form 1099-S(proceeds from real estate transactions) 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
<br /> exempt from the FATCA reporting, is correct. See What is FATCA reporting?on
<br /> •Form 1099-K(merchant card and third party network transactions) page 2 for further information.
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