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<br />(Rev.November20D5) E6i1?�6'i$o�'6ur,�L 11 yet, n=�
<br />Department of the Troa s'y �U� IV GA6u�f� u �i l��t;.11 ��f li. 110�4�c�i l.il d9�U internal Rnvenvo Service
<br />ni Name fas shown on your income tax return)
<br />m
<br />m
<br />�- Business name, if ciffferent from above
<br />c
<br />0
<br />a to
<br />17 0 ❑ IncilvidustV
<br />Check appropriate box: sole proprietor
<br />n Address (number, street, and apt. or suite no.)
<br />a o
<br />City, .fate, and ZIP code
<br />a
<br />List account number(.) here (optional)
<br />m
<br />v�
<br />Give form to the
<br />requester. Po not
<br />send to the IRS,
<br />❑ Corporation ❑ Partnershlp ❑ Other o _ _ Exempt from backup
<br />withholding
<br />Requester's name and address (optional)
<br />Identification Number
<br />City of South Bend
<br />Department of Public Works
<br />south Bend, In 46601
<br />Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid social security number
<br />backup withholding. For Individuals, this is your social security number ISSN). However, for a resident I
<br />alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it Is
<br />your employer identification number (FIN). If you do not have a number, see How to get a TIN on page 3. or
<br />Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer Identification number
<br />number to enter. I I I I I I ,
<br />t;ertifl cation
<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 subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
<br />Revenue 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
<br />notifled me that i am no longer subject to backup withholding, and
<br />3. i am a V.S. person (including a U.S. resident alien).
<br />Certification Instructions. You must cross out item 2 above if you have been notifled by the IRS that you are currently subject to backup
<br />withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
<br />For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
<br />arrangement ORA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
<br />provide your correct TIN. (See the instructions on page 4.)
<br />Sign I signature of %y `
<br />Here I U.S. nerson W.l Iol"i a A i/lA
<br />Purpose of Form t' t%.
<br />A person who is required to file an Information return with the
<br />IRS, must obtain your correct taxpayer identification number
<br />(TiN) to report, for example, income paid to you, real estate
<br />transactions, mortgage interest you paid, acquisition or
<br />abandonment of secured property, cancellation of debt, or
<br />contributions you made to an IRA.
<br />U.S. person. Use Form W-9 only if you are a U.S. person
<br />(including a resident alien), to provide your correct TiN to the
<br />person requesting it (the requester) and, when applicable, to:
<br />1. Certify that the TIN you are giving is correct (or you are
<br />waiting for a number 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
<br />U.S. exempt payee.
<br />In 3 above, if applicable, you are also certifying that as a
<br />U.S. person, your allocable share of any partnership income
<br />from a U.S. trade or business is not subject to the
<br />withholding tax on foreign partners' share of effectively
<br />connected income.
<br />Note. If a requester gives you a form other than Form W-9 to
<br />request your TIN, you must use the requester's form if it is
<br />substantially similar to this Form W-9.
<br />For federal tax purposes, you are considered a person if you
<br />are:
<br />Date ► J— 7-07
<br />• An Individual who Is a citizen or resident of the United
<br />States,
<br />• A partnership, corporation, company, or association
<br />created or organized in the United States or under the laws
<br />of the United States, or
<br />• Any estate (other than a foreign estate) or trust. See
<br />Regulations sections 301.7701-6(a) and 7(a) for additional
<br />information.
<br />Special rules for partnerships. Partnerships that conduct a
<br />trade or business in the United States are generally required
<br />to pay a withholding tax on any foreign partners' share of
<br />income from such business. Further, in certain cases where a
<br />Form W-9 has not been received, a partnership is required to
<br />presume that a partner is a foreign person, and pay the
<br />withholding tax. Therefore, if you are a U.S. person that is a
<br />partner in a partnership conducting a trade or business in the
<br />United States, provide Form W-9 to the partnership to
<br />establish your U.S. status and avoid withholding on your
<br />share of partnership income.
<br />The person who gives Form W-9 to the partnership for
<br />purposes of establishing its U.S. status and avoiding
<br />withholding on its allocable share of net income from the
<br />partnership conducting a trade or business in the United
<br />States Is in the following cases:
<br />• The U.S. owner of a disregarded entity and not the entity,
<br />Cat. No. 10231X Form W-9 (Rev. 11-2005)
<br />
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