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Form W- Request for 'Taxpayer Give Form to. the
<br />(Rev, gecember20f4) requester. Do not
<br />(e v. Pacember2Lie 14) identifiiration Numbor and Certification send to the IRS.
<br />internal Revenue Servloe
<br />1 Narrle'(k shovin on your income tax return), Name Is requlrod on. Sues line, ao no[ ieaye mis fine oianiL
<br />GRY of S©uth Bend
<br />2 Business name/dlsre9ardod entity name, If different from above
<br />N
<br />Ql
<br />N
<br />❑
<br />3 Check appropriate box for federal tax alasslflaatfon check enfy one of the falloWing seven boxes:
<br />4 Exemptions (codes apply only to
<br />cattalo apt€ties, not fndfviduels; see
<br />°
<br />°
<br />❑ lndividuallsole proprietor or El Corporation El Corporation ❑ Partnership ❑ TrusUestate
<br />InslrQcltons'cn page 3):
<br />fir [
<br />single -member LLC
<br />❑ Limited Ilability company, Enter the tax olassitioallon (C=C corporation, S=S corporation, P=partnarshlp) F
<br />Exempt payee cods (if any)
<br />q
<br />Mote. Forx single -member LLC that Is disregarded, do not. check LLC: check the appropriate box in the line above for
<br />E~xemptton from FATCA reporting
<br />code (If a n y)
<br />+'
<br />the tax ctassifoelfott of the single member owner.
<br />❑ Other(see instructtons)w Government
<br />wvea'., ro•�Wp�n; �yWmed ou ,Brr.0 etlsd
<br />.-
<br />S Address (number, street, and apt, or suite no,) Regdastor's nine and address (optiona)
<br />227 W .Jefferson Blvd.
<br />0 pity, state, and Z(pcode
<br />co
<br />South Send IN 46601
<br />7 List .account numbers) here (optional)
<br />Taxpayer IdpntifjGati0 Nurhbf?Y irlN)
<br />Enter yburTlN in the appropriate I?Dx. 1he I IN provlaeo must maccn ute name grver r U r 11HU i w aver u -
<br />backup withholding. ale For individuals, Ibis is d generally your social security number (Sag). However, for a A m
<br />resident alien, sole proprietor, or disregarded entity, see the Para ] Instructions on page 3. For other
<br />entities, It is your employer identification number (M), If you do not have a number, see Now to get a
<br />TIN on pages. or
<br />Note. If the account is In more than one name, see the instructions for title 1 and the chart on page 4 for Employer identification nghrhar
<br />guidelines on whose number to enter, 3 5 _6 t) 0 1 2 4 1
<br />ME Certification
<br />Linder penalties of perjury, t 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. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b)1 have not been notified by the Internal Revenue
<br />Service (IRS) that 1 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 oi' other U.S, persoh (defined below); and
<br />4, The FATCA code(s) entered on this form (ffady) indicating that I am exempt from FATCA repotting is correct.
<br />certificationinstructions. 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 tronsactfons, item 2 does not apply. For mortgage
<br />Interest paid, acquisition or abandonment of secured property, carioellatiorl of debt, oontdbutiofis to an individual retirement arrangement (IRA), and
<br />generally, payments Tither than interest and dividends, you ate not required to sign the certification, but you must provide your correct FIN. See the
<br />Instructions on page3:
<br />Sign
<br />r�
<br />1 7t�.re U.S.fparson]"
<br />General instructions
<br />sentlon references are to the Internal Revenue Code Unless otherwise noted-
<br />Futura developtments. Information about developments affecting Form W-9 (such
<br />as legislation enacted efterwe release It) Is at www.frs.gov1AV9.
<br />Purpose of Form
<br />An individual or entity (Form W-9 requester) who Is required (o file an intormation
<br />return with the ins must obtain your cotrect taxpayer identification number (TIN)
<br />which may be, yoursoclaf security number (SSN), Individual, taxpayer idunlifcallon
<br />dumber (ITIN), adoption taxpayer Identlficilion number (AT]", or employer
<br />(dentlflcatlon number (FIN), to report on an Information return the amount paid to
<br />you, or other amount reportable on an infotmallon return. Examples of Information
<br />returns include, but are not limited to, the following:
<br />. Form 1009-INT(Infetest'earned or paid)
<br />Form 1099-DIV (dividends, Including those from stocks or mutual funds)
<br />• Form 1099-M€SC (various types of income, prizes, awards, or gross proceeds)
<br />! Form 1099-B (etopk or mutual fund sales and certain other transactions by
<br />brokers)
<br />• Form 1099-S (proceeds from real estate transactions)
<br />+ Form 109b-K (merchant nerd and third party network transactions)
<br />• Form 1CJ90 (home mortgage Interest),1 OBB-E (student loan interest). I05B-T
<br />(tultioh)
<br />• Form 1 o89-c (camelad debt)
<br />• Form i oue-A (acqu)s)tiort or abandonment of secured property)
<br />Use norm W-9 only If you are a U.S. person (including a res)dent alien), to
<br />provide your correct TK
<br />Ifyou do not return Form W-9 fo the requester With a TIN, you might be subject
<br />to hackup withholding. Sea What Is backup WIthhotding? on page 2,
<br />By signing the filled -put form, you:
<br />1. Certfy that the TIN you qre 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 area U.S. exempt payee. I I
<br />applicable, you are also certifying that ass U.S'. person, yourallocable share of
<br />any parbtership Income from it US, 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 form (It any) Indicating that you are
<br />exempt from the FATCA reporting, is correol. See Whatis FATCAreportBlg7 on
<br />page 2 for further information.
<br />Cat. No.10231 X Form W-9 (RQv, 12-20i4)
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