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Form W.0 I
<br />(Rev. November 7"') usit of the "aa,,
<br />into awal Revenue Service I
<br />I Il (as shown on your
<br />City of South Bend
<br />2 Rkjghtrm!inmnol
<br />Request for Taxpayer Give Form to the
<br />Identification Number and Certification requester. Do not
<br />Ill Go to wwwJrs.gov1FormW9 for instructions and the latest information. send to the IRS.
<br />unir,le tay. rallpon). N77, is 7=-qoirod on the iln-, do not leave -=Ns line Tblank,
<br />entity —naWia, if dlffen.,nt —frarnabnvo
<br />3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
<br />following seven boxes.
<br />El Individual/sole proprietor or El C Corporation El S Corporation El Partnership Trust/estate
<br />single -member LLC
<br />❑ Limited liability company. Enter the tax classification (G-C corporation. 8=3 corporation, P=Partnership) l
<br />Note: Check the appropriate box in the line above for the tax classification of the single-rnernber owner. Do not check
<br />LLC if the LLC is classified as a single -member LLG that is disregarded from the owner unless the owner of the LLC is
<br />another LLC that is not disregarded from the owner for U,S. federal tax purposes. Otherwise, a single -member LLC l
<br />is disregarded from the owner should check the appropriate hall for the tax classification of its owner.
<br />Other tsoie instructions) Ill Government (APP11" 1. uS,)
<br />street, and apt. or Pout 710 Instructions, Requester's name and address foul mil
<br />4 Exemptions (codes apply only to
<br />certain entities, not individuals; gee
<br />Instructions on page 3):
<br />Exempt payee code (if any)
<br />227 W Jefferson Blvd
<br />"i"Eity, state, and ZIP code
<br />South Bend IN 46601
<br />7 List ao'count numl hot
<br />Taxpayer Identification Number (TIN)
<br />Eviller Year TIN in the appropriate box, 'I he'l IN provided must rnatch the ran to given on [I I ne I to avoid
<br />7
<br />backup withholding. For individuals, this is gorierally your social security' nun-iber l However, for a
<br />resident allion, solo proprietor or dlsregordoat enfity, sale the insVoctiolil for Part I, kater, For other
<br />el It is your, ampll ldenlIllcatkw nurnher (Ei It YOU do 1101 have a number, see How to got a
<br />TIN, pater.
<br />Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
<br />Number To Give the Requester for guidelines on whose number to enter.
<br />Exemption from FATCA reporting
<br />code (if any)
<br />�so',., sa�cT urn —he r
<br />F_
<br />or
<br />ENUMMUMUMME
<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. 1 am not nubl to bil withholding because: (a) I am exempt from backup withholding, or(b)1 hive not been notil bythe Internal Revenue
<br />Sil (IRS) that I atop subtact to backup) withholding as a result of a fails re to report all interest or dividends, or (c) the IRS has notified trio, that I am
<br />no longer subject to backup withholdil and
<br />3. 1 am a U,S, citizen or other U.S. person (defined below); and
<br />4. The FATCA codl entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
<br />Certification instructions. You mil cross Dill ften"i 2 above If You have b"n notified by Ina IRS that your are currontily subject to backpip withholding because
<br />you have failed to report all interest sond dividends on yow tax retuill For wall estate fransactiors, liarn 2 l not apply, For mull rrhlrosrpaid,
<br />acquistion or abandonment of secured property, cancellation of debts contributions, to an indf0dual rotirennent arratingentoril (JRA)„ and generally, payrnents
<br />other Ihan interest and dividends, you are not raquired, to slign the certification, but you must provide your correct'hN. See, the Instructions for Part fl, later.
<br />Sign Signature of
<br />Here I U.S. person ►
<br />Section references are to the Internal Revenue Code unless otherwise
<br />noted.
<br />Future developments, For the latest inforniatbri abotit developments
<br />related to Fol W-9 and its Instructions„ such as legislation enacted
<br />alter they Were PUNIShed, go to
<br />Purpose of Form
<br />Ali kidividual or el (Form W-9 requester) who Ls required to file, an
<br />Information return with than IRS must obtain your correct taxpayer
<br />Identification number iTiN)i which may be yarlir socall security number
<br />(,913N), lndividual taxpayer Identilicatiori number l l adopOoll
<br />taxpayer idenlification number (ATIN), or employer identification number
<br />l to report out sill Information returiv the amount paid to you, or offier
<br />amount reportable on an information return. Examples of information
<br />returns include, but are not Ilmited to, the following.
<br />s, Form 1 099-INT (interest earned or paid)
<br />Date Ill 4 1—( 14
<br />- Form 1099-DN (dividends, including those from stocks or mutual
<br />funds)
<br />- Form 1089-MISC (various types of income, prizes, awards, or gross
<br />proceeds)
<br />- Form 1099-B (stock or mutual fund sales and certain other
<br />transactions by brokers)
<br />• Form 1099-S (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),
<br />1098 -'1' (tuition)
<br />• Form 1099-0 (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
<br />alien), to provide your correct TIN.
<br />If you do not reterrn Forri i W-9 to the rogzdaster with a 7'ill you might
<br />be �ubject to backup withholding. See What Is backup withholding,
<br />later.
<br />Cat. No. 10231X Form W-9 (Rev. 11 -2017)
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