HomeMy WebLinkAbout6. W9 FormFormW1111119
Request for Taxpayer
Give Form to the
(Rev. December 2014)
Identification Number and Certification
requester. Do not
Department
of the Treasury
send to the IRS.
Internal Revenue Service
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
N
2 Business name/di eegarded entity name, if different from above
CO
,
V : �� ti ' t Lew
C:
3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
4 Exemptions (codes apply only to
U)
d
Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
LLC
certain entities, not individuals; see
instructions on page 3):
c
C' o
single -member
Limited liability company. Enter the tax classification C=C corporation, S=S corporation,
❑ tY P Y• ( p poration, P=partnership) ►
Exempt payee code (f any)
p 2
Note. For a single -member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for
ab
Exemption from FATCA reporting
cthe
tax classification of the single -member owner.
code (if any)
v
❑ Other (see instructions) ►
(Applies to accounts rnainMiWd outside the U.S.)
E
5 Address (number, street, and apt. or suite no.)
Requester's name and address (optional)
Q
ItJW
6 City, state, and ZIP code
�
7 List account numb s) here (optional)
ioentlTlcation Nurnoer fi
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding. For individuals, this is generally your social security number (SSN). However, fora - m -
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3. or
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for I Employer identification number
guidelines on whose number to enter. Mir) -1401C lcil_Ak�, I
Under penalties of perjury, I certify that:
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
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b)1 have not been notified by the Internal Revenue
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
no longer subject to backup withholding; and
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
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
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
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
SignI Signature n AM"I'` kvl Date 0.Here U.S.person►I'a1rJ I )�
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. Information about developments affecting Form W-9 (such
as legislation enacted after we release it) is at www.irs.gov/fw9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an information
return with the IRS must obtain your correct taxpayer identification number (TIN)
which may be your social security number ISSN), individual taxpayer identification
number (ITIN), adoption taxpayer identification number (ATIN), or employer
identification number (EIN), to report on an information return the amount paid to
you, or other amount reportable on an information return. Examples of information
returns include, but are not limited to, the following:
• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T
(tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident alien), to
provide your correct TIN.
It you do not return Form W-9 to the requester with a TIN, you might be subject
to backup withholding. See What is backup withholding? on page 2.
By signing the filled -out form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a number
to be issued),
2. Certify that you are not subject to backup withholding, or
• Form 1099 -INT (interest earned or paid) 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
• Form 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
any partnership income from a U.S. trade or business is not subject to the
• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) withholding tax on foreign partners' share of effectively connected income, and
• 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
brokers) exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
• Form 1099-6 (proceeds from real estate transactions) page 2 for further information.
• Form 1099-K (merchant card and third party network transactions)
Cat. No. 10231X Form W-9 (Rev. 12-2014)