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<br />EpdvTjho!Fowfmpqf!JE;!2193E418.88DB.5943.:22G.914D7G:28845EpdvTjho!Fowfmpqf!JE;!ED64EEGG.2G1:.5:C6.C4CB.73549671:658 <br />Cspxbse!Tifsjgg(t!Pggjdf!Cje!2:142NGX! <br />Gpsn!X.:!)Sfw/!21.3129* <br />Qbhf!3 <br />! <br />Criminal penalty for falsifying information. Xjmmgvmmz!gbmtjgzjoh! <br />IF the entity/person on line 1 is THEN check the box for . . . <br />dfsujgjdbujpot!ps!bggjsnbujpot!nbz!tvckfdu!zpv!up!dsjnjobm!qfobmujft! <br />a(n) . . . <br />jodmvejoh!gjoft!boe0ps!jnqsjtponfou/! <br />!Dpsqpsbujpo!Dpsqpsbujpo! <br />Misuse of TINs. Jg!uif!sfrvftufs!ejtdmptft!ps!vtft!UJOt!jo!wjpmbujpo!pg! <br />!Joejwjevbm! <br />gfefsbm!mbx-!uif!sfrvftufs!nbz!cf!tvckfdu!up!djwjm!boe!dsjnjobm!qfobmujft/! <br />Joejwjevbm0tpmf!qspqsjfups!ps!tjohmf.! <br />nfncfs!MMD! <br />!Tpmf!qspqsjfupstijq-!ps! <br />Specific Instructions <br />!Tjohmf.nfncfs!mjnjufe!mjbcjmjuz! <br />dpnqboz!)MMD*!pxofe!cz!bo! <br />Line 1 <br />joejwjevbm!boe!ejtsfhbsefe!gps!V/T/! <br />gfefsbm!uby!qvsqptft/! <br />Zpv!nvtu!foufs!pof!pg!uif!gpmmpxjoh!po!uijt!mjof<!do not mfbwf!uijt!mjof! <br />cmbol/!Uif!obnf!tipvme!nbudi!uif!obnf!po!zpvs!uby!sfuvso/! <br />!MMD!usfbufe!bt!b!qbsuofstijq!gps! <br />Mjnjufe!mjbcjmjuz!dpnqboz!boe!foufs! <br />Jg!uijt!Gpsn!X.:!jt!gps!b!kpjou!bddpvou!)puifs!uibo!bo!bddpvou! <br />V/T/!gfefsbm!uby!qvsqptft-! <br />uif!bqqspqsjbuf!uby!dmbttjgjdbujpo/! <br />nbjoubjofe!cz!b!gpsfjho!gjobodjbm!jotujuvujpo!)GGJ**-!mjtu!gjstu-!boe!uifo! <br />)Q>!Qbsuofstijq<!D>!D!dpsqpsbujpo<! <br />!MMD!uibu!ibt!gjmfe!Gpsn!9943!ps! <br />djsdmf-!uif!obnf!pg!uif!qfstpo!ps!foujuz!xiptf!ovncfs!zpv!foufsfe!jo! <br />ps!T>!T!dpsqpsbujpo*! <br />3664!up!cf!ubyfe!bt!b!dpsqpsbujpo-! <br />Qbsu!J!pg!Gpsn!X.:/!Jg!zpv!bsf!qspwjejoh!Gpsn!X.:!up!bo!GGJ!up!epdvnfou! <br />ps! <br />b!kpjou!bddpvou-!fbdi!ipmefs!pg!uif!bddpvou!uibu!jt!b!V/T/!qfstpo!nvtu! <br />!MMD!uibu!jt!ejtsfhbsefe!bt!bo! <br />qspwjef!b!Gpsn!X.:/! <br />foujuz!tfqbsbuf!gspn!jut!pxofs!cvu! <br />b/!Individual. Hfofsbmmz-!foufs!uif!obnf!tipxo!po!zpvs!uby!sfuvso/!Jg! <br />uif!pxofs!jt!bopuifs!MMD!uibu!jt! <br />zpv!ibwf!dibohfe!zpvs!mbtu!obnf!xjuipvu!jogpsnjoh!uif!Tpdjbm!Tfdvsjuz! <br />opu!ejtsfhbsefe!gps!V/T/!gfefsbm!uby! <br />Benjojtusbujpo!)TTB*!pg!uif!obnf!dibohf-!foufs!zpvs!gjstu!obnf-!uif!mbtu! <br />qvsqptft/! <br />obnf!bt!tipxo!po!zpvs!tpdjbm!tfdvsjuz!dbse-!boe!zpvs!ofx!mbtu!obnf/! <br />!Qbsuofstijq!Qbsuofstijq! <br />Note: ITIN applicant: Foufs!zpvs!joejwjevbm!obnf!bt!ju!xbt!foufsfe!po! <br />!Usvtu0ftubuf!Usvtu0ftubuf! <br />zpvs!Gpsn!X.8!bqqmjdbujpo-!mjof!2b/!Uijt!tipvme!bmtp!cf!uif!tbnf!bt!uif! <br />obnf!zpv!foufsfe!po!uif!Gpsn!215102151B02151F\[!zpv!gjmfe!xjui!zpvs! <br />Line 4, Exemptions <br />bqqmjdbujpo/! <br />Jg!zpv!bsf!fyfnqu!gspn!cbdlvq!xjuiipmejoh!boe0ps!GBUDB!sfqpsujoh-! <br />c/!Sole proprietor or single-member LLC. Foufs!zpvs!joejwjevbm! <br />foufs!jo!uif!bqqspqsjbuf!tqbdf!po!mjof!5!boz!dpef)t*!uibu!nbz!bqqmz!up! <br />obnf!bt!tipxo!po!zpvs!215102151B02151F\[!po!mjof!2/!Zpv!nbz!foufs! <br />zpv/! <br />!3/! <br />Exempt payee code. <br />d/!Partnership, LLC that is not a single-member LLC, C <br />!Hfofsbmmz-!joejwjevbmt!)jodmvejoh!tpmf!qspqsjfupst*!bsf!opu!fyfnqu!gspn! <br />corporation, or S corporation. Foufs!uif!foujuz(t!obnf!bt!tipxo!po!uif! <br />cbdlvq!xjuiipmejoh/! <br />foujuz(t!uby!sfuvso!po!mjof!2!boe!boz!cvtjoftt-!usbef-!ps!ECB!obnf!po!!mjof! <br />3/ <br />!Fydfqu!bt!qspwjefe!cfmpx-!dpsqpsbujpot!bsf!fyfnqu!gspn!cbdlvq! <br />e/!Other entities. Foufs!zpvs!obnf!bt!tipxo!po!sfrvjsfe!V/T/!gfefsbm!xjuiipmejoh!gps!dfsubjo!qbznfout-!jodmvejoh!joufsftu!boe!ejwjefoet/ <br />ubyepdvnfout!po!mjof!2/!Uijt!obnf!tipvme!nbudi!uif!obnf!tipxo!po!uif! <br />!Dpsqpsbujpot!bsf!opu!fyfnqu!gspn!cbdlvq!xjuiipmejoh!gps!qbznfout! <br />dibsufs!ps!puifs!mfhbm!epdvnfou!dsfbujoh!uif!foujuz/!Zpv!nbz!foufs!boz! <br />nbef!jo!tfuumfnfou!pg!qbznfou!dbse!ps!uijse!qbsuz!ofuxpsl!usbotbdujpot/ <br />cvtjoftt-!usbef-!ps!ECB!obnf!po!mjof!3/! <br />!Dpsqpsbujpot!bsf!opu!fyfnqu!gspn!cbdlvq!xjuiipmejoh!xjui!sftqfdu!up! <br />f/!Disregarded entity. Gps!V/T/!gfefsbm!uby!qvsqptft-!bo!foujuz!uibu!jt! <br />ejtsfhbsefe!bt!bo!foujuz!tfqbsbuf!gspn!jut!pxofs!jt!usfbufe!bt!b! <br />uibu!qspwjef!nfejdbm!ps!ifbmui!dbsf!tfswjdft!bsf!opu!fyfnqu!xjui!sftqfdu! <br />.3)d*)3*)jjj*/!Foufs! <br />up!qbznfout!sfqpsubcmf!po!Gpsn!21::.NJTD/! <br />uif!pxofs(t!obnf!po!mjof!2/!Uif!obnf!pg!uif!foujuz!foufsfe!po!mjof!2! <br />Uif!gpmmpxjoh!dpeft!jefoujgz!qbzfft!uibu!bsf!fyfnqu!gspn!cbdlvq! <br />tipvme!ofwfs!cf!b!ejtsfhbsefe!foujuz/!Uif!obnf!po!mjof!2!tipvme!cf!uif! <br />xjuiipmejoh/!Foufs!uif!bqqspqsjbuf!dpef!jo!uif!tqbdf!jo!mjof!5/! <br />obnf!tipxo!po!uif!jodpnf!uby!sfuvso!po!xijdi!uif!jodpnf!tipvme!cf! <br />2Bo!pshboj{bujpo!fyfnqu!gspn!uby!voefs!tfdujpo!612)b*-!boz!JSB-!ps! <br />sfqpsufe/!Gps!fybnqmf-!jg!b!gpsfjho!MMD!uibu!jt!usfbufe!bt!b!ejtsfhbsefe! <br />b!dvtupejbm!bddpvou!voefs!tfdujpo!514)c*)8*!jg!uif!bddpvou!tbujtgjft!uif! <br />foujuz!gps!V/T/!gfefsbm!uby!qvsqptft!ibt!b!tjohmf!pxofs!uibu!jt!b!V/T/! <br />sfrvjsfnfout!pg!tfdujpo!512)g*)3*! <br />qfstpo-!uif!V/T/!pxofs(t!obnf!jt!sfrvjsfe!up!cf!qspwjefe!po!mjof!2/!Jg!!uif! <br />ejsfdu!pxofs!pg!uif!foujuz!jt!bmtp!b!ejtsfhbsefe!foujuz-!foufs!uif!gjstu!pxofs! <br />3Uif!Vojufe!Tubuft!ps!boz!pg!jut!bhfodjft!ps!jotusvnfoubmjujft! <br />uibu!jt!opu!ejtsfhbsefe!gps!gfefsbm!uby!qvsqptft/!Foufs!uif!ejtsfhbsefe! <br />4B!tubuf-!uif!Ejtusjdu!pg!Dpmvncjb-!b!V/T/!dpnnpoxfbmui!ps! <br />fouj <br />qpttfttjpo-!ps!boz!pg!uifjs!qpmjujdbm!tvcejwjtjpot!ps!jotusvnfoubmjujft <br />pxofs!pg!uif!ejtsfhbsefe!foujuz!jt!b!gpsfjho!qfstpo-!uif!pxofs!nvtu! <br />5B!gpsfjho!hpwfsonfou!ps!boz!pg!jut!qpmjujdbm!tvcejwjtjpot-!bhfodjft-! <br />dpnqmfuf!bo!bqqspqsjbuf!Gpsn!X.9!jotufbe!pg!b!Gpsn!X.:/!Uijt!jt!uif! <br />ps!jotusvnfoubmjujft! <br />dbtf!fwfo!jg!uif!gpsfjho!qfstpo!ibt!b!V/T/!UJO/! <br />6B!dpsqpsbujpo! <br />Line 2 <br />7B!efbmfs!jo!tfdvsjujft!ps!dpnnpejujft!sfrvjsfe!up!sfhjtufs!jo!uif! <br />Jg!zpv!ibwf!b!cvtjoftt!obnf-!usbef!obnf-!ECB!obnf-!ps!ejtsfhbsefe! <br />Vojufe!Tubuft-!uif!Ejtusjdu!pg!Dpmvncjb-!ps!b!V/T/!dpnnpoxfbmui!ps! <br />foujuz!obnf-!zpv!nbz!foufs!ju!po!mjof!3/! <br />qpttfttjpo! <br />Line 3 <br />8B!gvuvsft!dpnnjttjpo!nfsdibou!sfhjtufsfe!xjui!uif!Dpnnpejuz! <br />Gvuvsft!Usbejoh!Dpnnjttjpo! <br />Difdl!uif!bqqspqsjbuf!cpy!po!mjof!4!gps!uif!V/T/!gfefsbm!uby!! <br />dmbttjgjdbujpo!pg!uif!qfstpo!xiptf!obnf!jt!foufsfe!po!mjof!2/!Difdl!pomz! <br />9B!sfbm!ftubuf!jowftunfou!usvtu! <br />pof!cpy!po!mjof!4/! <br />:Bo!foujuz!sfhjtufsfe!bu!bmm!ujnft!evsjoh!uif!uby!zfbs!voefs!uif! <br />Jowftunfou!Dpnqboz!Bdu!pg!2:51! <br />21B!dpnnpo!usvtu!gvoe!pqfsbufe!cz!b!cbol!voefs!tfdujpo!695)b*! <br />22B!gjobodjbm!jotujuvujpo! <br />23B!njeemfnbo!lopxo!jo!uif!jowftunfou!dpnnvojuz!bt!b!opnjoff!ps! <br />dvtupejbo! <br />24B!usvtu!fyfnqu!gspn!uby!voefs!tfdujpo!775!ps!eftdsjcfe!jo!tfdujpo! <br />5:58! <br />80370312:!22;67!BN!q/!76! <br /> <br /> <br />