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Form W -9 (Rev. 1 -2011)
<br />4. Other payments. You must give your correct TIN, but you do not
<br />have to sign the certification unless you have been notified that you
<br />have previously given an incorrect TIN. "Other payments" include
<br />payments made in the course of the requester's trade or business for
<br />rents, royalties, goods (other than bills for merchandise), medical and
<br />health care services (including payments to corporations), payments to
<br />a nonempioyee for services, payments to certain fishing boat crew
<br />members and fishermen, and gross proceeds paid to attorneys
<br />(including payments to corporations).
<br />S. Mortgage interest paid by you, acquisition or abandonment of
<br />secured property, cancellation of debt, qualified tuition program
<br />payments (under section 529), IRA, Coverdell ESA, Archer MSA or
<br />HSA contributions or distributions, and pension distributions. You
<br />must give your correct TIN, but you 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 Qoint
<br />The actual owner of the account or,
<br />account)
<br />if combined funds, the first
<br />individual on the account'
<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 trust under
<br />state law
<br />5. Sole proprietorship or disregarded
<br />The owner'
<br />entity owned by an individual
<br />6. Grantor trust filing under Optional
<br />The grantor`
<br />Form 1099 Filing Method 1 (see
<br />Regulation section 1.671- 4(b)(2)(i)(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 />8. A valid trust, estate, or pension trust
<br />Legal entity'
<br />9. Corporation or LLC electing
<br />The corporation
<br />corporate status on Form 8832 or
<br />Form 2553
<br />10. Association, club, religious,
<br />The organization
<br />charitable, educational, or other
<br />tax - exempt organization
<br />11. Partnership or multi- 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 />Regulation section 1.671- 4(b)(2)(i)(B))
<br />Y List first and circle the name of the person whose number you furnish. if only one person on a
<br />joint account has an SSN, that person's number must be furnished.
<br />2 Circle the minor's name and furnish the minor's SSN.
<br />' You must show your Individual name and you may also enter your business or "DBA" name on
<br />the "Business name /disregarded entity" name line. You may use either your SSN or EIN (If you
<br />have one), but the IRS encourages you to use your SSN.
<br />d List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the
<br />personal representative or trustee unless the legal entity itself is not designated In the account
<br />title.) Also see Special rules forpartnerships on page 1.
<br />'Note. Grantor also must provide a Form W -9 to trustee of trust.
<br />Page 4
<br />Note. If no name is circled when more than one name is listed, the
<br />number will be 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
<br />such as your name, social security number (SSN), or other identifying
<br />information, without your permission, to commit fraud or other crimes.
<br />An identity thief may use your SSN to get a job or may file a tax return
<br />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 />If your tax records are affected by identity theft and you receive a
<br />notice from the IRS, respond right away to the name and phone number
<br />printed on the IRS notice or letter.
<br />If your tax records are not currently affected by identity theft but you
<br />think you are at risk due to a lost or stolen purse or wallet, questionable
<br />credit card activity or credit report, contact the IRS Identity Theft Hotline
<br />at 1- 800 - 908 -4490 or submit Form 14039.
<br />For more information, see Publication 4535, Identity Theft Prevention
<br />and Victim Assistance.
<br />Victims of identity theft who are experiencing economic harm or a
<br />system problem, or are seeking help in resolving tax problems that have
<br />not been resolved through normal channels, may be eligible for
<br />Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
<br />calling the TAS toll -free case Intake line at 1 -877- 777 -4778 or TTY/TDD
<br />1- 800 - 829 -4059.
<br />Protect yourself from suspicious emails or phishing schemes.
<br />Phishing is the creation and use of email and websites designed to
<br />mimic legitimate business emails and websites. The most common act
<br />is sending an email to a user falsely claiming to be an established
<br />legitimate enterprise in an attempt to scam the user into surrendering
<br />private information that will be used for identity theft.
<br />The IRS does not initiate contacts with taxpayers via emails. Also, the
<br />IRS does not request personal detailed information through email or ask
<br />taxpayers for the PIN numbers, passwords, or similar secret access
<br />information for their credit card, bank, or other financial accounts.
<br />If you receive an unsolicited email claiming to be from the IRS,
<br />forward this message to phishing@irs.gov. You may also report misuse
<br />of the IRS name, logo, or other IRS property to the Treasury Inspector
<br />General for Tax Administration at 1- 800 - 366 -4484. You can forward
<br />suspicious emails to the Federal Trade Commission at: seam @uce.gov
<br />or contact them at www.ftc.gov11dtheff or 1- 877- IDTHEFT
<br />(1- 877 - 438 - 4338).
<br />Visit IRS.gov to learn more about identity theft and how to reduce
<br />your risk.
<br />Privacy Act Notice
<br />Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with
<br />the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation
<br />of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS,
<br />reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District
<br />of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies
<br />to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to
<br />file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a
<br />TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.
<br />F -6
<br />Attachment number 3
<br />Page 144
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