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W�7
<br />Request for Taxpayer
<br />Give Form to the
<br />Form
<br />(Rev, Decemher 2074)
<br />Identification Number and Certification
<br />requester. Do not
<br />send to the IRS.
<br />Dlevrt1
<br />ntor the04)Wy
<br />Internal
<br />Pevenue Service
<br />1 Name (as shown on your income tax return). Name Is required on this line; do not leave this line blank.
<br />City of so,uth Bend
<br />2 Busihess nwneldisregarded entity name, if different from above
<br />N
<br />W
<br />m
<br />N
<br />°-
<br />3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
<br />4 Exemptions (caries apply pnylo
<br />tiesin enti, not individuals; see
<br />ccerta
<br />❑ Individualiscle proprietor or ❑ C Corporation ❑ S Corporation ❑ partnership ❑ TmsUestate
<br />instructions' on page 3):
<br />° c
<br />single -member LLC
<br />Exempt payee coded any)
<br />tt °
<br />Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)►
<br />0 2
<br />Note. Fora single -member LLC that is disregarded, do rot check LLC; check the appropriate box in the line above for
<br />Exemption from FATCA reporting
<br />y
<br />the tax classification of the single -member owner.
<br />code(if any)
<br />= 5
<br />Other (see instructfons)► Government
<br />rMcue. i. c .e;wo.M.d Art .'W US)
<br />—
<br />,Q
<br />SAddress(humber; street, and apt. or suite no.)
<br />requester's name and address (options)
<br />227 W Jefferson Blvd.
<br />-
<br />6 City, state, and ZIP code
<br />a -
<br />N
<br />South Bend IN 46601
<br />7 Lis account numbers} here (optional)
<br />Taxpayer Identification Number (TIN)
<br />Enteryour TIN in the appropriate box. The TIN provided must match the name given online Ito avoid Iaoaei se°umr nuoenr
<br />backup withholding. For individuals, this is generally your social security number (SSN). However, fora _ m —�
<br />resident alien, sole proprietor, or disregarded entity, see the Par[ 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 fo gate FM
<br />TIN on page 3. or
<br />Note. If the account is in more than one name, see the instructions for fine 1 and the chart on page 4 for IEmployer identification number
<br />guidelines on whose number to enter. 3 6 — 6 0 0 1 -2 0 1
<br />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 wailing for a number to be issued to me); and
<br />2. 1 am not subject to backup withholding because: (a) 1 am exempt from backup withholding, or (b)1 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 notified 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); and
<br />4. The FATCA code(s) entered on this form (if any) indicating that I am exempL 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 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 otherthan interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
<br />instructions on pace
<br />3-
<br />,�iqn Signature o
<br />General Instructions
<br />Section references are to the Internal Revenue Code unless otherwise noted.
<br />Future developments. Information about developments affecting Form W-9 (such
<br />as legislation enacted after we release It) Is at www.irs.govffiv9.
<br />Purpose of Form
<br />An individual or entity (Form W-9 requester) who is required io file an information
<br />return with the IRS must obtain your correct taxpayer identification number (TIN)
<br />which may be your social security number (SSN), individual taxpayer identification
<br />number (ITIN), adoption taxpayer identification number (ATIM.'or employer
<br />Identification number (EIN), to report on an information return the amount paid to
<br />you, or other amount reportable on an information return. Examples of information
<br />returns include, but are not limited to, Lire following:
<br />• Form 1099-INT (Interest earned or paid)
<br />• Form 1099-DIV (dividends, Including those from stocks or mutual funds)
<br />• Form 1099-MI SC (various types of income, prizes, awards, or gross proceeds)
<br />r Form 1099-B (stock or mutual fund sales and certain other transactions by
<br />brokers)
<br />• Form 1099-5 (proceeds from real estate transactions)
<br />• Form 1099-K (merchant card and third party network transactions)
<br />• Form 1098 (home mortgage interest), 1098-E (student loan interest), 109E-T
<br />(tuition)
<br />• Form 1099-C (canceled debt)
<br />• Form 1099-A (acquisition or abandonment of secured property)
<br />Use Form W-9 only if you are a U.S. person including a resident alien), to
<br />provide your correct TIN.
<br />ltyou do not return Farm W-9 to the requester with a TM, you might be subject
<br />to backup withholding. See What Is backup withholding? on page 2.
<br />By signing the filled -out forth, you:
<br />1. Certify that the TIN you are giving Is correct (or you are waiting for a number
<br />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 payee. If
<br />applicable, you are also certifying that as a U.S'. person, your allocable share of
<br />any partnership income from a U.S. trade or business is not subject to the
<br />withholding tax on foreign partners' share of effectively connected income, and
<br />4. Certify that FATCA code(s) entered on this Ions (if any) Indicating that you are
<br />exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
<br />page 2 for further information.
<br />Cat. No. 10231x Form
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