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Form
<br />W'9
<br />Request for Taxpayer
<br />Give Form to the
<br />(Rev. December 2014)
<br />Identification Number and Certification
<br />requester. Do not
<br />oepatment
<br />of the Treasury
<br />send to the IRS.
<br />Iotemal
<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 />tV
<br />2 Business name/disregarded entity name, If different from above
<br />v
<br />N
<br />n
<br />3 Check approprisla box for federal tax classlficailon; check only ane of the following seven boxes:
<br />4 Exemptions (cedes apply to
<br />o
<br />m
<br />❑ Individual/sole proprietor or ❑ G Corporation ❑ S Corporation ❑ Partnership ❑ TrusVestate
<br />certain ions os, not individuals; sea
<br />ls; see
<br />Instructions on page 3J:
<br />v C
<br />p. p
<br />.F'
<br />single -member LLC
<br />E] Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership►
<br />Exempt payee code (If any))
<br />o
<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 />y
<br />the tax classification of the single -member owner.
<br />code (f any)
<br />4 U
<br />❑ Other (see Instructions)►
<br />(Applba to acmanls,,Wnnlnedoulsrm to. aa.)
<br />5 Address (number, street, and apt, or suite no.)
<br />Requester's name and address (apklona)
<br />e
<br />a
<br />m
<br />6 City, state, and ZIP code
<br />0
<br />o]
<br />7 List account numbers) here (optional)
<br />Taxpayer Identification Number (TIN)
<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 />_m
<br />backup withholding. For Individuals, this is generally your social security number (SSN). However, (ora
<br />resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other
<br />entitles, It Is your employer identification number (LIN). If you do not have a number, see How to gets
<br />TIN on 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 thin 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 fallum 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 />S. I 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 crass 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, acqulsitlon 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 I'equll'ed to sign the certification, but you must provide your correct TIN. See the
<br />instructions on page 3.
<br />Sign Signature of
<br />Here I U.S. person t Date ll�
<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 atter we release it) Is at www.ka.goWfw9.
<br />Purpose of Form
<br />An Individual or entity (Form W-9 requester) who In required to file an hgormatlon
<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 (A FIN), or employer
<br />identification number (LIN), 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 of paid)
<br />• Form 1099 -DIV (dividends, Including those hom stocks or mutual funds)
<br />• Form 1099-MISC (various types of Income, prizes, awards, or gross proceeds)
<br />• Farm 1099-B (stock or mutual fund sales and ceheln other transactions by
<br />brokers)
<br />• Form 1099-5 (proceeds from real estate transactions)
<br />• Form 1099-K(merchant card and third party network transactions)
<br />• Farm 1098 (home mortgage Interest), 1098-E (student loan Interest), 1098-T
<br />(tuition)
<br />• Form 1099-0 (canceled dsbl)
<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 on 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. Gently 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 />S. 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 on foreign partners' share of effectively connected Income, and
<br />4. Gatti fy that FATCA certain) 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 />Cal. No. 10231X
<br />75P-42
<br />Form VV -`J (Rev. 12-20141
<br />
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