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Form
<br /> Request for Taxpayer Give Form to the
<br /> (Rev.December.2014) identification Number and Certification requester.Do not
<br /> Department of the Treasury send to the IRS.
<br /> Internal 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 /> Ebsary Foundation Company
<br /> csi 2 Business name/disregarded entity name,if different from above
<br /> m
<br /> rn
<br /> ti
<br /> 0. 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to
<br /> certain entities,not individuals;see
<br /> ° ❑Individual/sole proprietor or ❑ C Corporation GI S Corporation ❑ Partnership ❑Trust/estate
<br /> • c instructions on page 3):
<br /> m single-member LLC
<br /> Li Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership) Exempt payee code(if any)
<br /> L
<br /> 'Exemption from FATCA reporting
<br /> ° 2 Note.For a single-member LLC that is disregarded,do not check LLC;check the appropriate box in the line above for
<br /> the tax classification of the single-member owner. code(if any)
<br /> •a• ❑Other(see instructions)t* (Applies to accounts maintained ocaside the U.S.)o
<br /> :e 5 Address(number,street,and apt.or suite no.) Requester's name and address(optional)
<br /> °
<br /> $ 2154 NW North River Drive ALL REQUESTERS FILL IN YOUR INFO
<br /> • 6 City,state,and ZIP code
<br /> co Miami,Florida 33125
<br /> 7 List account number(s)here(optional)
<br /> '1Part=1 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 I Social security number
<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 I instructions on page 3.For other - -
<br /> entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
<br /> TIN on page 3. or
<br /> Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identification number
<br /> guidelines on whose number to enter.
<br /> 5 9 - 0 2 2 9 1 5 0
<br /> ?Part/Ir. Certification
<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. I 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. 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 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 all 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 3.
<br /> Here Signature of ,/�% V. ` Date® 1 1�3 } S'
<br /> Here U.S.person> (//
<br /> - i
<br /> General Instructions •Form 1098(home mortgage interest),1098-E(student loan interest),1098-T
<br /> (tuition)
<br /> Section references are to the Internal Revenue Code unless otherwise noted. •Form 1099-C(canceled debt)
<br /> Future developments.Information about developments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property)
<br /> as legislation enacted after we release it)is at www.irs.gov/hv9.
<br /> Use Form W-9 only if you are a U.S.person(including a resident alien),to
<br /> Purpose of Form provide your correct TIN.
<br /> An individual or entity(Form W-9 requester)who is required to file an information If you do not return Form W-9 to the requester with a TIN,you might be subject
<br /> return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What is backup withholding?on page 2.
<br /> which may be your social security number(SSN),individual taxpayer identification. By signing the filled-out form,you:
<br /> number(ITIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number
<br /> identification number(EIN),to report on an information return the amount paid to to be issued).
<br /> you,or other amount reportable on an information return.Examples of information
<br /> returns include,but are not limited to,the following: 2.Certify that you are not subject to backup withholding,or
<br /> •Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding if you are a U.S.exempt payee.If
<br /> •Farm 1099-DIV(dividends,including those from stocks or mutual funds) 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 /> •Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and
<br /> •Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are
<br /> brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on
<br /> •Form 1099-S(proceeds from real estate transactions) page 2 for further information.
<br /> •Form 1099-K(merchant card and third party network transactions)
<br /> Cat.No.10231X Form W-9(Rev.12-2014)
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