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Far, W'9 Request for Taxpayer Give Form to the
<br /> ot
<br /> ® Deeppartmentof Trr1�rY Identification Number and Certification
<br /> requester.e RS.
<br /> Internal Revenue Service
<br /> 1 Name(as shown on your Income tax return).Name is required on this fine;do not leave this line blank.
<br /> Visionworx, LLC
<br /> mi 2 Business name/disregarded entity name,if different from above
<br /> g dba CCS Presentation Systems
<br /> a 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to
<br /> c ❑individual/sole proprietor or ❑ C Corporation 0 S Corporation ❑ Partnership ❑Trust/estate certain amities,not indlvlduels see
<br /> c s'ngte-member LLC instructions on page 3):
<br /> ia 0 Limited liability company.Enter the tax classification(CRC corporation,S=S corporation,Paparfi ,srahip) S Exempt payee code(d arty)
<br /> `o Note.For a single-member LLC that is disregarded,do not check LLC check the appropriate box in the line above for mption from FATExe ,CA reporting
<br /> the tax classification of the single-member owner. code(rf any)
<br /> d- ❑Other(see instructions)► *o w to=aunt,m•S h•d outside eM use
<br /> a'
<br /> 1 5 Address(number,street,and apt.or suite no.) Requester's name and address(optional)
<br /> 5530 S.Florida Mining Blvd.
<br /> a 6 City,state,and ZIP code
<br /> a Jacksonville,FL 32257
<br /> 7 Ust account number(s)here(optional)
<br /> Part I 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 Sociai security number I
<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 /> entitles,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 /> 2 0 - 3 3 1 2 4 1 0
<br /> Part II 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 I st 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 /> Sign sIgnatu.s.ptrson �G�t/1R1 Si c�0 1�
<br /> Here u.s.person �/ Date►
<br /> �/
<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 tvww.lrs.gov/Iw9.
<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 N 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 flied-out form,you:
<br /> number(niN),adoption taxpayer Identification number(ATIN),or employer
<br /> Identification number(EIN),to report on an Information return the amount paid to 1.Certify that the TIN you are giving is correct(or you are waiting for a number
<br /> to be issued)'
<br /> you,or other amount reportable on an information return.Examples of Information
<br /> rm
<br /> returns Include,but are not limited to,the following: 2.Cerny 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 /> •Form 1098-0IV(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 er 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 horn 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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