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Form W-9 (Rev. 12-2014)
<br />Part H. Certification
<br />To establish to the withholding agent that you are a U.S. person, or resident alien,
<br />sign Form W-9. You may be requested to sign by the withholding agent even if
<br />Items 1, 4, or 5 below Indicate othenvise.
<br />For a joint account, only the person whose TIN is shown in Part I should sign
<br />(when required). In the case of a disregarded entity, the person identified on line 1
<br />must sign. Exempt payees, see Exempt payee code earlier.
<br />Signature requirements. Complete the certification as indicated in Items 1
<br />through 5 below.
<br />1. Interest, dividend, and barter exchange accounts opened before 1984
<br />and broker accounts considered active during 1983. You must give your
<br />correct TIN, but you do not have to sign the certification.
<br />2 Interest, dividend, broker, and barter exchange accounts opened after
<br />1983 and broker accounts considered inactive during 1983. You must sign the
<br />certification or backup withholding will apply. If you are subject to backup
<br />Withholding and you are merely providing your correct TIN to the requester, you
<br />must cross cut item 2 in the certification before signing the form.
<br />3. Real estate transactions. You must sign the mortification. You may cross out
<br />item 2 of the certification.
<br />4. Other payments. You must give your correct TIN, but you do not have to sign
<br />the certificatlon unless you have been notified that you have previously given an
<br />Incorrect TIN. "Other payments" include payments made in the course of the
<br />requester's trade or business for rents, royalties, goods (other than bills for
<br />merchandise), medical and health care services (including payments to
<br />corporations), payments to a nonemployee for services, payments made in
<br />settlement of payment card and third party network transactions, payments to
<br />certain fishing boat crew members and fishermen, and gross proceeds paid to
<br />attorneys (Including payments to corporations).
<br />S. Mortgage interest paid by you, acquisition or abandonment of secured
<br />property, cancellation of debt, qualified tuition program payments (under
<br />section 529), IRA., Coverdell ESA, Archer MSA or HSA contributions or
<br />distributions, and pension distributions. You must give your correctTIN, but you
<br />do not have to sign the certification.
<br />What Name and Number To Give the Requester
<br />For this type of account:
<br />Give name and SSN of:
<br />1. Individual
<br />The individual
<br />2, Two or more individuals (loin
<br />The actual owner of the account or,
<br />account)
<br />if combined funds, the first
<br />Individual on the amount'
<br />3. Custodian account of a minor
<br />The minor`
<br />(Uniform Gift to Minors Act)
<br />4. a. The usual revocable savings
<br />The grantor -trustee
<br />trust (grantor is also trustee)
<br />b. So-called trust account that is
<br />The actual owner
<br />not a legal or valid hurt under
<br />state law
<br />5. Sole proprietorship or disregarded
<br />The owner'
<br />entity owned by an Individual
<br />Be Grantor trust filing under Optional
<br />The grantor
<br />Form 1099 Filing Method 1 (see
<br />Regulations section 1.671-4(b)(2)(1)
<br />(A))
<br />For this type of account:
<br />Give name and EIN of:
<br />7. Disregarded entity not owned by an
<br />The owner
<br />individual
<br />B. Avalid trust, estate, or pension trust
<br />Legal entity'
<br />S. Corporation or LLC electing
<br />The corporation
<br />corporate status on Form 8832 or
<br />Form 2553
<br />10. Association, dub, religious,
<br />The organization
<br />charitable, educational, or other tax-
<br />exempt organization
<br />11. Partnership or mufti -member LLC
<br />The partnership
<br />12. A broker or registered nominee
<br />The broker or nominee
<br />13. Account with the Department of
<br />The public entity
<br />Agriculture in the name of a public
<br />entity (such as a state or local
<br />government, school district, or
<br />prison) that receives agricultural
<br />program payments
<br />14. Grantor trust filing under the Form
<br />The trust
<br />1041 Filing Method or the Optional
<br />Form 1099 Filing Method 2 (see
<br />Regulations section 1.671-4(b)(2)(i)
<br />(ED
<br />' List first and circle the name of Ore person whose number you furnish. if only one person on a
<br />joint account has an SSN, that person's number must be buMshed.
<br />' Clroleshe minors name and furnish the minors SSN.
<br />Page 4
<br />You must show your Individual name and you mey also enter YOU Wevess or DBAname on
<br />the `Business namovoisregarded enEty` name line. You may use eitherycur SSN or EIN (f you
<br />have one), but the IRS encourages you to use your SSN.
<br />• Dst first and drole the name of the trust, estate, or pension trust. lea but tumish the TIN of
<br />personal representative or in atee unless the legal entity itself is not designated inthe account
<br />title) Also see Special rules for parme¢hipe on page 2.
<br />'Note. Grantor also must provide a Form W-9 to trustee of dust
<br />Note. if no name is circled when more than one name Is listed, the number will be
<br />considered to be that of the first name listed.
<br />Secure Your Tax Records from Identity Theft
<br />Identity theft occurs when someone uses your personal information such as your
<br />name. SSN, or other identifying information, without your permission, to commit
<br />fraud or other crimes. An identity thief may use your SSN to get a job or may file a
<br />tax return using your SSN to receive a refund.
<br />To reduce your risk:
<br />• Protect your SSN,
<br />• Ensure your employer is protecting your SSN, and
<br />• Be careful when choosing a tax preparer.
<br />It your tax records are affected by Identity theft and you receive a notice from
<br />the IRS, respond right away to the name and phone number printed on the IRS
<br />notice or letter.
<br />If your tax records are riot currently affected by identity theft but you think you
<br />are at risk due to a lost orshien purse or wallet, questionable credit card activity
<br />or credit report, contact the IRS Identify Theft Hotline at 1-900-908-4490 or submit
<br />Form 14039.
<br />For more Information, see Publication 4535, Identity Theft Prevention and Victim
<br />Assistance.
<br />victims of Identity theft who are experiencing economic harm or a system
<br />problem, or are seeking help in resolving tax problems that have not been resolved
<br />through normal channels, may be eligible for Taxpayer Advocate Service (TAS)
<br />assistance. You can reach TAS by calling the TAS toll-free case Intake line at
<br />1-877-777-4778 wTTY/TDD 1-800-829-4059.
<br />Protect yourself from suspicious smalls or phishing schemes. Phishing is the
<br />creation and use of email and websites designed to mimic legitimate business
<br />smalls and websites. The most common act Is sending an email to a user falsely
<br />claiming to be an established legitimate enterprise in an attempt to scam the user
<br />into surrendering private information that will be used for Identity theft.
<br />The IRS does not initiate contacts with taxpayers via emalls. Also, the IRS does
<br />not request personal detalled Information through small or ask taxpayers for the
<br />PIN numbers, passwords, or similar secret access Information for their credit card,
<br />bank, or other financial accounts.
<br />If you receive an unsolicited email claiming to be from the IRS, forward this
<br />message to phfshing®im.gov. You may also report misuse of the IRS name, logo,
<br />or other IRS property to the Treasury Inspector General for Tax Administration
<br />(rIGTA) at 1-800-366-4484. You can forward suspicious smalls to the Federal
<br />Trade Commission at: spam®uce.gov or contact them at www.ttc.90 ylidrheff or
<br />1-877-1OTHEFf (1-877-438-4338).
<br />Visit IRS.govto learn more about Identity theft and law to reduce your risk.
<br />Privacy Act Notice
<br />Section 6109 of the Internal Revenue Code requires you to provide your correct
<br />TIN to persons QncludIng federal agencies) who are required to file information
<br />returns with the IRS to report Interest, dividends, or certain other Income paid to
<br />you; mortgage Interest you paid; the acquisition or abandonment of secured
<br />property; the cancellation of debt; or contributions you made to an IRA, Archer
<br />MSP, or HSA. The person collecting this form uses the information on the form to
<br />file information returns with the IRS, reporting the above information. Routine uses
<br />of this Information Include giving it to the Department of Justice for civil and
<br />criminal litigation and to cites, states, the District of Columbia, and U.S.
<br />commonwealths and possessions for use in administering their laws. The
<br />information also may be disclosed to other counts les under a treaty, to federal and
<br />state agencies to enforce civil and criminal laws, or to federal law enforcement and
<br />intelligence agencies to combat terrorism. You must provide your TIN whether or
<br />not you are required to file a tax return. Under section 3406, payers must generally
<br />withhold a percentage of taxable Interest, dividend, and certain other payments to
<br />a payee who does not give a TIN to the payer. Certain penalties may also apply for
<br />providing false or fraudulent information.
<br />75D-150
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