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Farm
<br />W-9
<br />Request for Taxpayer
<br />Give Form to the
<br />(Rev. Docember2014)
<br />Identification Number and Certification
<br />entities, It Is your employer identification number (EIN). If you do not have a number, see How fo gets
<br />requester, Do not
<br />Department
<br />of the Treasury
<br />TIN on page 3.
<br />send to the IRS.
<br />Internal
<br />Revenue Service
<br />1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
<br />of
<br />2 Business name/dlsragarded entity name, if different from above
<br />a
<br />rn
<br />°
<br />c
<br />3 Check appropriate box for federal tae classification; check only one of the following seven boxes:
<br />4 Exemptions (codes apply only to
<br />certain entities, not Individuals; see
<br />°
<br />❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ partnership ❑ Trust/estate
<br />Instructions an page 3);
<br />0 o
<br />;0
<br />single -member LLC
<br />E]Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) t
<br />Exempt payee code (If any)
<br />o
<br />Note. Fora 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 />H
<br />the tax classification ofthe single -member owner.
<br />code (If any)
<br />c
<br />y
<br />❑ Other (see instructions)►
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<br />5 Address (number, street, and apt. or suite no.)
<br />Requesters name and address (optional)
<br />0
<br />°
<br />a
<br />m
<br />s City, state, and Zip code
<br />m
<br />7 List account number(.) here (optional)
<br />Taxpayer Identification Number (TIN)
<br />Enter your TIN In the appropriate box. The TIN provided must match the name given online Ito avoid
<br />Social security number
<br />backup withholding. For individuals, this is generally your .ental security number (Sag). However, fora
<br />resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other
<br />^ m —
<br />entities, It Is your employer identification number (EIN). If you do not have a number, see How fo gets
<br />t_L_Ll
<br />TIN on page 3.
<br />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 I Employer Identification number
<br />guidelines on whose number to enter. n� �� F7_1
<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 tome); and
<br />2. lam 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 status 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 (deflned below); and
<br />4. The FATCA mode(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 page 3.
<br />bign Signature of
<br />Here I U.S, person* Date l•
<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 www.lra.gov/fw9.
<br />Purpose of Form
<br />An Individual ar 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 he your social security number(SSN), individual taxpayer Identification
<br />number (ITIN), adoption taxpayer Identification number (ATIN), or employer
<br />identification number (FIN), 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 -MI SC (various types of income, prizes, awards, or gross proceeds)
<br />• Form 1091 (stack or mutual fund sales and certain other transactions by
<br />brokers)
<br />• Form logg-S (preceads from real estate lransaclions)
<br />• Form 1099-k (merchant card and third party network transactions)
<br />• Form 1998 (home mortgage Interest), 1998-E (student loan interest), 1099-T
<br />(tuition)
<br />• Form 1099-0 (canceled debt)
<br />• Farm 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 />4you do not return Form W-9 to the requester with a TIN, you might be subject
<br />to backup withholding. See What Is backup wlthbolding7 on page 2.
<br />By all the filled -out farm, you:
<br />1. Certify that the TI you are giving is correct (or you are walting 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 share of
<br />any partnership Income from a U.S, trade or business Is not subject to the
<br />withholding tax an famiga partners' share of effectively connected Income, and
<br />4. Certify that FATCA simulate) 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 />Gat No. 10231x
<br />75K-53
<br />12-2014)
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