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Form W'9
<br />Request for Taxpayer
<br />Give Form to the
<br />(Rev. January 2011)
<br />Identification Number and Certification
<br />requester. Do not
<br />send to the IRS.
<br />= Department of the Treasury
<br />onus Service
<br />Name (as shown on your income tax return)
<br />N
<br />Business name /disregarded entity name, if different from above
<br />N
<br />rn
<br />W
<br />0 -
<br />Check appropriate box for federal tax
<br />0
<br />classification (required): ❑Individual /sole proprietor ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
<br />ID c
<br />0
<br />Exempt payee
<br />C
<br />F] Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= partnership)
<br />p
<br />❑ Other (see instructions)
<br />E
<br />Address (number, street, and apt. or suite no.)
<br />Requester's name and address (optional)
<br />N
<br />Q.
<br />City, state, and 21P code
<br />Cl)
<br />List account number(s) here (optional)
<br />Taxpayer Identification Number (TIN)
<br />Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line Social security number
<br />to avoid backup withholding. For individuals, this is your social security number However, fora
<br />resident alien, sole proprietor, or disregarded entity, see the Part I instructions on n page 3. for other
<br />FM - M -
<br />antitiac it ie vni it mmninvnr idantifinntion number (EIN1. If you do not have a number. see Now to qet a
<br />TIN on page 3.
<br />Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification
<br />number to enter. F m
<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 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 (defined below).
<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 alt 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 4.
<br />Sign Signature of
<br />Here I U.S. person ► Date
<br />General Instructions
<br />Section references are to the Internal Revenue Code unless otherwise
<br />noted.
<br />Purpose of Form
<br />A person who is required to file an information return with the IRS must
<br />obtain your correct taxpayer identification number (TIN) to report, for
<br />example, income paid to you, real estate transactions, mortgage interest
<br />you paid, acquisition or abandonment of secured property, cancellation
<br />of debt, or contributions you made to an IRA.
<br />Use Form W -9 only if you are a U.S. person (including a resident
<br />alien), to provide your correct TIN to the person requesting it (the
<br />requester) and, when applicable, to:
<br />1. Certify that the TIN you are giving is correct (or you are waiting for a
<br />number 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
<br />payee, if applicable, you are also certifying that as a U.S. person, your
<br />allocable share of any partnership income from a U.S. trade or business
<br />is not subject to the withholding tax on foreign partners' share of
<br />effectively connected income.
<br />Note. If a requester gives you a form other than Form W -9 to request
<br />your TIN, you must use the requester's form if it is substantially similar
<br />to this Form W -9.
<br />Definition of a U.S. person. For federal tax purposes, you are
<br />considered a U.S. person if you are:
<br />• An individual who is a U.S. citizen or U.S. resident alien,
<br />• A partnership, corporation, company, or association created or
<br />organized in the United States or under the laws of the United States,
<br />• An estate (other than a foreign estate), or
<br />• A domestic trust (as defined in Regulations section 301.7701 -7).
<br />Special rules for partnerships. Partnerships that conduct a trade or
<br />business in the United States are generally required to pay a withholding
<br />tax on any foreign partners' share of income from such business.
<br />Further, in certain cases where a Form W -9 has not been received, a
<br />partnership is required to presume that a partner is a foreign person,
<br />and pay the withholding tax. Therefore, if you are a U.S. person that is a
<br />partner in a partnership conducting a trade or business in the United
<br />States, provide Form W -9 to the partnership to establish your U.S.
<br />status and avoid withholding on your share of partnership income.
<br />Cat. No. 10231X Form w -9 (Rev. 1 -2011)
<br />Attachment number 3
<br />F -6 Page 147
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