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Farm
<br />W 9
<br />Request for ?Taxpayer
<br />Give Form to the
<br />(Rev.pecember20
<br />Identification Number and Certification
<br />requester. Do not
<br />peparimeniofthe7-reaseasury
<br />Internal Revenue Service
<br />Send to the IRS.
<br />1 Name (p 7hn4onur income tax ret . Names required On this line; do not leave this line blank.
<br />2 Business n /disregarded entity name, if different from above
<br />as
<br />a
<br />3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
<br />4 Exemptions (codes apply only to
<br />o
<br />0
<br />❑ Individuallsole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trustlestate
<br />cenaln entities, not individuals; see
<br />Instructions on page 3):
<br />m c
<br />single -member LLC
<br />❑ Limited I€ability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
<br />Exempt Payee code {if any)
<br />o
<br />Note. For a single -member LLC that Is disregarded, do not check LLC; check the appropriate box in the line above for
<br />Fxempt€on from PATCA reporting
<br />the tax ciassificaflon of the single member owner,
<br />code (if any)
<br />0
<br />Other (see instructtom)r
<br />(Applftsra a.muntsmatnlai00 oulsidulfie U.s.)
<br />w
<br />w
<br />5 Address (number, street, and apt. rsu€te no.)
<br />Requester's name and address (optional)
<br />C
<br />�t O
<br />6 Cy, state, _ZIP c de
<br />_jand
<br />4(V
<br />(00 1
<br />7 List account number(s) here (optional)
<br />mentitication Number (I IN
<br />EnteryourTIN In the appropriate box. The TIN provided must match the name given on line 1 to avoid
<br />backup withholding. For individuals, this is generally your social security number (SSN)- However, for a
<br />resident alien, sofe proprietor, or disregarded entity, see the Part I instructions on page 3. For other
<br />entities, it is your employer identification number (ON). 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 then one name, see the Instructions for line 1 and the chart on page 4 for
<br />guidelines on whose number to enter.
<br />Social security number
<br />rM_111_1T
<br />or
<br />Employer Identification number
<br />uertirication
<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 wafting for a number to be issued to me); and
<br />2. I am not subject to backup withholding bocause: (a) I am exempt from backup withholding, or (b) I have not been notified by the Infernal Revenue
<br />Service (IRS) that f am subject to backup withholding as a result of a failure to report all interest or dividends, or (a) the IRS has notified me that I am
<br />no longersuhject to backup withholding; and
<br />3. lam a U.S, citizen or other U.S. person (defined below); and
<br />4. The FATCA codes) 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 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 indlvlduai 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 page 3. n
<br />Sign g I _-- -
<br />SI nature of ;; P7 + r
<br />Here erson U.S. p4l Q �^ Y Date ► �' S l
<br />General Instructions
<br />Seetlon references are to the Internal Revenue Code unions otherwise noted.
<br />Future developments, Information about developments affecting Form W-9 (such
<br />as legislation enacted after we release 0) is at www.1rs.gov/f 9.
<br />Purpose of Form
<br />An individual or entity (Form W 9 requestor) who Is required to file an Information
<br />return with the IRS must obtain your correct taxpayer identification number (IN)
<br />which may be your soc€a[ security number (SSN), Individual taxpayer Identification
<br />number (€TIN), adoption taxpayer Identification number (ATIN), 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, the following;
<br />worm 1099-INT (Interest eamed or paid)
<br />form 1099-DIV (dividends, Including those from stocks or mutual funds)
<br />Worm 1099-MISC (various types of income, prizes, awards, or gross proceeds)
<br />[Norm 1099-B (stock or mutual fund sales and certain other transactions by
<br />brokers)
<br />Dorm 1099-5 (proceeds from real estate transactions)
<br />19orm 1099-K (merchant card and third party network transactions)
<br />Ifform 1096 (home mortgage interest), 1098-E (Strident loan interest), 1098-T
<br />(tuition)
<br />Rorm 1009-0 (canceled debt)
<br />Worm 1099-A (acquisition or abandonment of secured property)
<br />Use Form W-9 only If you area U.S. person (Including a resident alien), to
<br />provide your correct TIN.
<br />If you do not return Form W-9 to the requestor with a TIN, you might be subject
<br />to backup withholding. See What is backup withholding? on page 2.
<br />By signing the tilled -out form, you:
<br />1. Certify that the TIN you are giving IS oorrect (or you are waiting for a number
<br />to be Issued),
<br />2. Certify that you are not subject to backup Withholding, or
<br />S. Claim exemption from backup withholding if you are a U.S. oxempt 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 codes) 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 />page 2 for further information.
<br />Cat. No. 10231X Form W 9 (Rev. 12-2014)
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