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Form WM9
<br />Request for Taxpayer
<br />Give Form to the
<br />(Rev. December 2014)
<br />Identification Number and Certification
<br />requester. Do not
<br />Departmem of theTresaury
<br />send to the IRS.
<br />internal Revenue Servicre
<br />1 Name (as shown on your income tax return). Name Is required on this line; do not leave this line blank.
<br />MILLER MENDEL, INC.
<br />ni
<br />2 Business name/disregarded entity name, If different from above
<br />m
<br />s Check appropriate box for federal tax classification; check only one of the following seven boxes:
<br />4 Exemptions (codes apply only to
<br />individuals;
<br />❑ Individual/sole proprietor or ❑ C Corporation ❑✓ S Corporation ❑ Partnership ❑ Trust/estate
<br />certain entities, not see
<br />instructions on page 3):
<br />y
<br />single -member LLC
<br />❑ Limited liability company. Enter the tax classification (C=C corporation, 8=5 corporation, P=partnership) ►
<br />Exempt payee code (if any)
<br />d
<br />Note. For a single -member LLC that is disregarded, do not check LLC; check the appropriate box In the line above for
<br />Exemption from FATCA reporting
<br />the tax classification of the single -member owner.
<br />code (If any)
<br />y—
<br />V
<br />❑ Other (see Instructions)►
<br />(APWi. mewwn , nmmetl dq me us.)
<br />5 Address (number, street, and apt. or suite no.)
<br />Requester's name and address (optional)
<br />1425 BROADWAY, #430
<br />p
<br />8 City, state, and ZIP code
<br />ui
<br />SEATTLE, WA 98122
<br />7 List account number(s) here (optional)
<br />Wn
<br />Taxpayer Identification Number IN
<br />Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
<br />Social security number
<br />backup withholding. For individuals, this Is generally your social security number (SSN). However, fora
<br />resident alien, sole proprietor, or disregarded entity, sea the Part I instructions on page 3. For other
<br />entities, it Is your employer identification number (EIN). If you do not have a number, see How to get a
<br />TIN on page 3, or
<br />Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for
<br />
<br />Under penalties of perjury, 1 certify that:
<br />The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued tome); 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 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 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 individual 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 pace 3.
<br />Here I Signature
<br />oo► {f(�tAy. 7wwv"" Date I- June 18, 2015
<br />General Instructions
<br />Section references are to the Internal Revenue Code unless otherwise noted.
<br />Future developments. Information about developments affecting Form W-9 (such
<br />as legislation enacted after we release it) Is at wwwJragov/fw9.
<br />Purpose of Form
<br />An individual or entity (Form W-9 requester) who is required to file an information
<br />return with the IRS must obtain your correct taxpayer identification number (TIN)
<br />which may be your social security number ISSN), individual taxpayer identification
<br />number (ITIN), 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 />• Form 1099 -INT (Interest earned or paid)
<br />• Form 1099 -DIV (dividends, including those from stocks or mutual funds)
<br />• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
<br />• Form 1099-0 (stook or mutual fund miss and certain other transactions by
<br />brokers)
<br />• Farm 1099-S (proceeds from real estate transactions)
<br />• Form 1099-K (merchant card and third party network transactions)
<br />• Form1098(home mortgage interest), 1098-E (student loan Interest), 1098-T
<br />(tuition)
<br />• Form 1099-C (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 alien), to
<br />provide your correct TIN.
<br />If you do not return Form W-9 to 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 form, you:
<br />1. Certify that the TIN you are 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 are a U.S. exempt payee, if
<br />applicable, you are also certifying that as a U.S. person, your allocable shere 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 code(s) 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)
<br />
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