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Form!1t.F1be!A&.1yse
<br />Request for Taxpayer
<br />Give Form to the
<br />(Rev. D4J
<br />Identification Number and Certification
<br />Depedm
<br />send totr„Itonot
<br />send to the IRS.
<br />Internal
<br />Revenue Service
<br />I Name (as shown on your income tax return). Name Is required an this line; do not leave this line blank.
<br />oi
<br />2 Business name/dlaregarded entity name, If different from above
<br />m
<br />a
<br />3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
<br />4 Exemptions (.odea apply only to
<br />°
<br />m
<br />❑ lndlvidual/sole proprietor or ❑ C Cor oratlon
<br />p ❑ 5 Corporation ❑ Partnership ❑ TruaVaatats
<br />certain entities, not individuals; see
<br />Safe, Instructions es page 3):
<br />m e
<br />e
<br />y,
<br />single -member LLC
<br />❑Limited liability company. Enter the tax classification (C=C corporation, 5=S corporation, P.partnarshlp) ►
<br />Exempt payee code (if any)
<br />`o in
<br />Nate. For a single -member LLC that Is disregarded, do not check LLC; check the appropriate box In the line above far
<br />Exemption from FATCA repaving
<br />the tax classification of the single -member owner,
<br />code (If any)
<br />u: 5
<br />❑Other (see Instructions)►
<br />Wnre=ro a�mune mm,rcyeda„nrd•m=¢e)
<br />!:
<br />v
<br />6 Address (number, street, and apt. or suite no.)
<br />Requester's name and address (oplbrmll
<br />m
<br />a
<br />m
<br />6 City, state, and ZIP code
<br />m
<br />N
<br />7 List account numbers) here (optional)
<br />Identification Number
<br />Enter your TIN In the appropriate box. The TIN provided must match the name given online Ito avoid
<br />backup withholding. For individuals, this Is generally your social security number (SSN). However, for a
<br />resident alien, sole proprietor, or disregarded entity, see the Part] Instructions on page 3. For other
<br />entitles, it is your employer identification number (i If you do not have a number, see Now to get a
<br />TIN an page 3.
<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 />guidelines on whose number to enter.
<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 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 han 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 codes) 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 boon 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 dam not apply. For mortgage
<br />interest paid, acquisition or abandonment of secured properly, 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 cerliloation, but you must provide your correct TIN. See the
<br />Instructions on page 3.
<br />algn Signature of
<br />Here u.S.person► Date►
<br />General Instructions
<br />Section references are loth. Internal Revenue Code unless olhonulas noted.
<br />Future developments. Information about developments affecting Form W-9 (such
<br />as legislation enacted after we release It) Is at www.1ncgcv//w9
<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 cahoot taxpayer Identification number (TIN)
<br />which may be your social security number ISSN), individual taxpayer identlticatlon
<br />number (]TIN), adoption taxpayer identification number (ATI N), or employer
<br />ident]flcat]an number (EIN), to report on an Information return the amount paid to
<br />you, or other amount reportable an 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 groan proceeds)
<br />• Form 1000-B (stock or mutual fund sales and certain other transactions by
<br />brokers)
<br />• Form 1099-S (proceeds from real estate transactions)
<br />• Form 1 099-K (merchant card and third party network transactions)
<br />• Form 1098 (home mortgage Interest), '1098-E (student loan Interesl),109B-T
<br />(tuition)
<br />• Farm 1099-C (canceled debt)
<br />• Form 'I099 -A (acquisition or abandonment of secured Property)
<br />Use Form W -S only If you are a U.S. person (including a maiden alien), to
<br />provide year correct TIN.
<br />If you do not return Form W-9 to the requester with a TIN, you might be sub/cot
<br />to backup withholding. See What is backup withholding? on page 2.
<br />By signing the fllled-out form, you:
<br />1. Certify that the TIN you are giving Is corract (or you are walling for a number
<br />to be issued),
<br />2. Certify that you am not subject to backup withholding, .r
<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 allocabia share of
<br />any partnership Income from a U.S. trade or busineae Is not subject to the
<br />withholding tax on foreign partners' share of effectively connected Income, and
<br />4. Certify that FATCA codes) entered on this form (if any) Indicating that you are
<br />exempt from the FATCA reporting, is correct. See Wharfs FATCA reporting? on
<br />papa 2 for further information.
<br />Cat. No, 10201X
<br />75L-58
<br />Foan W-9 (Rev. 12-2014)
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