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Farm
<br />W-9
<br />Request for Taxpayer
<br />ctveForm to.the
<br />(Rev. oecemtiar 2g14)
<br />(Rev.DopaQentofthe0.14)
<br />identification Number and Certification
<br />requester. Do not
<br />send. to the IRS.
<br />Internal Revenue Service
<br />1 Name lea shown on your income tax return), Name is required on thislinwi do not leave this line blank
<br />City of South Bend
<br />2 siness naive/disregarded entity name, if diffemotfrom above
<br />Bu
<br />N
<br />a
<br />m
<br />m
<br />a
<br />3 Check appropriate box for federal tax classification; check only ode of the following seven boxes:
<br />4 Exemptions (cocas apply only sea
<br />not individuals; sea
<br />certain ears,
<br />°
<br />❑IOdiViduaVsole proprietor or ❑ CCorpom[lon ❑SCorporation ❑ Partnership ❑Tmsges[ate
<br />an,
<br />insiNctions an page 3):
<br />m M
<br />O
<br />"�
<br />single -member LLC
<br />❑ limited liability company. Enter the tax classification (C-C corporation, S=S corporation, P=padnership)1
<br />Exempt payee code (1fany)
<br />0 2
<br />Note. For a single -member LLC that is disregarded, do not check LLC;checkthe appropriate box in the line above for
<br />Exemption from FATCA reporting
<br />w
<br />the tax classlrioankm of thesingla-member owner.
<br />code (If any)
<br />5c
<br />R.
<br />O Otter (see instructions)i Government
<br />rAeq+•+m.cmynnmmW aa•o-raeueusi
<br />,a
<br />street, and apt. brsniteno.)
<br />5' Address (.number. p .
<br />'Requester's name and address (optional)
<br />227 W Jefferson Blvd.
<br />6 City, state, add ZIP code
<br />to m
<br />to
<br />South Bend IN 46601
<br />7 Listapcounenumber(s) here (optional)
<br />Taxpayer Identification Number (rIN)
<br />n
<br />r TIN in [he appr°pna;e hox The TIN pYoyided must match the name given on Fne i (a avoid social security number
<br />ithholding. For mdnnduals; this rs generally your social security number (SSN). However; fora — m —�
<br />alien, sale proprietor or disregarded. entity, see the Part I instructions ogpage 3. For other
<br />t is your employenge 3.lia account is in mos an whose number to enter. _ 3 5 — 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 waiting for a numberto be issued to me); and
<br />2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) f 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 arty) 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.withholding
<br />because you have failed to report all interest and dividends on your tax return. Far real estate transaclions, 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 />ceneraliv, Payments other than interest and dividends, you aid not required to sign the cedificaiton, but you must provide your correct TIN. See the
<br />Jign Signature of
<br />Here I U.S. person0-
<br />General Instructions
<br />Section references are to the Internal Revenue Code unless otherwise noted.
<br />Fpture developments. Information about developments affecting Form W-9 (such
<br />as legislation enacted after we release it) is at www.Bs.goVA`w9.
<br />Purpose of Form
<br />An Individual or entity (Form W9 requester) who is required to file an information
<br />return with the IRS must obtain your correct taxpayer identification number inN)
<br />whis may be yoursocla) secudty number (SSN), indyidual taxpayer identification
<br />number (ITIN), adoption taxpayer identification number (Ati",'or employer
<br />IIden0fication numbor(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, the following:
<br />• Form 1099414T (interest earned or paid)
<br />• Form I099-DN (dividends, Including those from stocks or mutual funds)
<br />• Farm 1099-M ISC (vadous types of income, prizes, awards, or gross proceeds)
<br />• Form 1099-13 (stock or mutual fund sales and certain other transactions by
<br />brokers)
<br />• Form 1099-8 (proceeds from real estate transactions)
<br />• Form 1099-I( (merchant card and Third party network transactions)
<br />Date I "�) �o(_Ui (V
<br />1098 (home mortgage interest),1098-E (student loan interest). 10913-T
<br />• Form 10gg-Clcanceled debl)
<br />• Form 1099-A (acquisition or abandonment of secured property)
<br />Use Form W1-9 only if you are a U.S. person (including a resident alien), to
<br />provide your correct TIN.
<br />If you do not return Form W-9In the requester with a TIN, 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: Canty that the TIN you are giving Is correct (or you are waiting for a number
<br />to b'e is'sued),
<br />1. Certify that you are vat subject to backup withholding, or
<br />3; CWld exemption from backup withholding if you are a U.S, exempt payee. it
<br />applicable, you are also part lying that as a U.S. person, yourallocabie share of
<br />any partnelship income from a, U.S. trade or business is not subject lathe
<br />withholding fax an foreign partners"share of e6ecthely connected income, and
<br />4. Certify that FATCA code(s) entered on this form Gravy) indicating that you she
<br />exempt from the FATCA reporting, is correct. See Whafis FATCA reporting? on
<br />page 2 for further information.
<br />-Cat. No. 10 IX Form W-9 (Rev.12-2014)
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