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<br />`""' W�g Re uest for 7axpayer
<br />m��..i,�,y aoon 9
<br />„�,,,,,,,,,,,,,,�,,,,,,,�. Identiircation Number and Certification
<br />Inem�l Nexnrr SeMce
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<br />Buslnass romc. M ailltt¢m hom
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<br />CMck appip�riate Co�: O Sole piapfelw
<br />/,tlal �P� K"��'�i leet. ab apl. a 3ufie rw
<br />Cay.
<br />Lisl accoud
<br />cive lorm [o the
<br />requester. Do not
<br />send to the IRS.
<br />❑ CapvaUon ❑ ParineislvP ❑ 011ic� Y ................... D�EwA1Jwld�mbxAup
<br />�����-('._ \ i�l N %•7� �'esl�'snameanOadQre.s(eD�bnan
<br />No ever,rfaNa�re den� I�rn �soleN o� intlividuais, IM1is is you� socia� security numDer �SSN).
<br />page 2. For olher enlitie5, il js your emp oyr1, idenlif�ali n n mbn�(EIN]51! �e Pan 1 fnswtttons on
<br />sre How to yct a TIN on p�9p 7_ yw tlo not have a number,
<br />Nole: Il fhc aCCounl i5 in mave fhan pne name, See NC Chart M payC Z �a �uidelines on wlqse number
<br />to rnter.
<br />Social secvrNr ��
<br />or
<br />Empbr<r iJenLfiea!bn n�mber
<br />UnUer penatlies ol pe jury, I certify ihat: � �
<br />1. The number shown on th¢ form is my correct WMpayrx iAenlilicalion num6r.r (or I �m wading !or a nu.mber lo be issuptl to me1. and
<br />2. I om not subject Io backup vnthryolding be[ause: (�) I am eMempl hom backup withholdi or
<br />Revenue Service QRS) Ihai 1 am suhjec� �o backup wi�7ihoiding as a resul� ot a faiWre to r� ro) � have not Oeen noli�eA by Ne Imernal
<br />nOtifieU rrM Nat I am no Ionger subjMl lo backup withhoMing, arM �« a�l inte�esf or dNidentl5, or (c) Ihe IRS hos
<br />J. 1 am a U.S. person fnclutlu�9 a U.S. residenl aGcn).
<br />Cenifiwt]on insuuctlons. You mus� �oss out item 2 above H you luve been nolified by the IRS �hal you are currenity subject to backup
<br />vrilhhofding bccause you have la'�led ro report ali inerest and tlivitlenCS on your lax retum. Por fe�ii eslate transattions, ilem 2 does not apply,
<br />Fa mongage intere5l pard. 2[quisition or ahandonmrnt of secured property, cancellation ol dehl, conMbuiions to an individwl reWemem
<br />anangement pfN), and generally, p�ymenLs oUicr than irncrezl ana tlividends, you nrc n�i r¢�uired to sign the Certificalion, bu� you mus�
<br />provitleyour centt� T1N. (Sce Ihe inslnxt'w ^ on pa e 2.)
<br />Sign Slgrewre ol /.�// .��J! �/1 /i :
<br />licrc U.s. oerson \
<br />Purpose of Form �
<br />A pvson who is rcqu'retl Io filo an inlpmalion
<br />ttturn wit� tl�C IRS mUSi get yrnrt Corte[�
<br />Ixx�uyer Itlmtifieatlon numCer (�IN) eo tepeq la
<br />eaample, Ir¢omc pald �o you; real eslute
<br />vansaUions, mongage intelest you pilA,
<br />acqWsliion a a6andcnmenl of sttwM p�ny
<br />cancWallon cl tleCt. a[Onbi2vlons you ma0i•
<br />lo an IRf�
<br />Use Form W.9 onhr i! yp� yc a V.S, prisp�
<br />(ncludng a wsidem alien). m give yov correp
<br />TIN fo Ihe petson requeriinn i� (ub ���sicr)
<br />arid, when applicab'e, lo:
<br />1. Certily Ne TIN you are giving �. carcrt (or
<br />you arc waiting for a rvmbn to De Issuc�,
<br />2. CMily yp� arc na subjttl ro Lackup
<br />wiNholding, p
<br />3. Cl�im ezernption from bacY.up v,iU�ndJing if
<br />7w are a U.S. eecmpl payec.
<br />If you ara a faci9^ Agwn �+se Ux
<br />appropriate Fam 1V.9. $ee Pup. 5�5.
<br />L:N�holtliny of Tax on Ncnrez�am: Ai�e�a a��.;
<br />Porcign Enluics
<br />�:ote: N a rcpuesrn ob�es you a Icrm oNc• Nan
<br />Porrtr lR 9 to rcqursf yoir T1K, ��v musf use �q�•
<br />L(�.:C:lCI �i /[Nm d L lS :ub:ldNuiiy S�rthU! IU fl'i�
<br />Favn W.P
<br />What Ls bacAup xithhotdirgt Pasons making
<br />e[rt�in paymenu lo ypi musi undtt cettain
<br />condi�m; .•.n1Ao10 and pay lo wc IRS 3D?5 0!
<br />surh paymmts arter Ottembtt �7, 1pp� �yy
<br />aRer Decerrihtt 3L Zpp3J, 7ryis Is �ailM 'q�cAup
<br />wiUinotomg,' Paymenu Ihat rtuy D� :ulyca to
<br />hackup wiihhdd'n9lnNude inlMest, divia,=ntls.
<br />hrokM antl barta aMchonge Va;iy�plons. �critz.
<br />royattics, nonemployee n.iy. antl cenain
<br />P�ymenls trwn fishing po�t qxra�c+s. R�I
<br />eslatc VanSapions arc not suEjal to backup
<br />wilhhd0ing.
<br />You witl no1 Ge su0}ect �o backup withholding
<br />°^ Paym��s yw icceHe if you gi.t 17i¢
<br />reques7er your coneq 71N, moke I�e qaper
<br />' CCNfiCalion5. Bn0 feF[RI all you! ImtdblC Intele9
<br />and diWd:nr;s m yo�x lax reium.
<br />Paymenly yp� rMel�,c will bc subJect lo
<br />b�ckup wlihholding il:
<br />7. You do nd fumish y�ur TIN Io ine
<br />rrqucst�, ot
<br />2. Ycu do ncl cmlty Yo�i� 7�ry when iequi�eC
<br />Is� �hc Pan II inswct;ons on pa�e 2 lor
<br />tleWils). Cr
<br />�� TM! �R5 Ie115 Nc IcouMlG ihal yDu
<br />lun'�etl an in�q�pt� TIN, p
<br /><. jhe IP,S lelli �cu ih;,t yoV 0re SuCjcG ta
<br />ha:kup r.ilMoltliry ye-,�uy�, ycu Oid nd repp�
<br />a� your iMMasf anJ tliNtlends on yWr tat rc4nn
<br />lia repatade interesi cnJ dividentls cnty), tt
<br />Gt. No. 10231%
<br />balc
<br />5. You tlo not ccrtily 101h� ��yucsier tAa1 you
<br />a�e nw subject lo backup wiiMotEing pnCtt �
<br />abovo (ftt �epor�aWe h�eies� and tliviventl
<br />oeCounls opee�eC aner 79e3 onyJ,
<br />CcAain p�yees anu paymems are oremp�
<br />hom Cackup whhhdtlng. Scc i�e inSVucllc�s on
<br />P�ge 2 antl IJ�e uparoie Inztruqfort� lor thc
<br />Requesle+ of iarm 1Y-9.
<br />Penalties •
<br />Foilum lo NrnLsh 71N. If yrou Iall to /�rxsh yq��
<br />Correc( TIN fo � rcqucs(rr, ypi are suFjttl �p a
<br />prnahy of S50 lor c�ch wth Im7we unhzs your
<br />laitue is Due lo muonab�e cause and rrot lo
<br />wiII1N neg'eet.
<br />Clvil prnatly for faBr Inlormailon wnh respecl
<br />lo w�tdrolEcu,�, tf you make a laise stalempn�
<br />wifh no �c.uonaWc Dasis Uut �esuAs ii no
<br />backup wiNhdtling, yQu a�e suDject ta� � 5500
<br />penahy.
<br />Qiminal penxtty f«lxls!(ylrg tilorm:lion.
<br />WJIIUAy falsifying cmifcanms a ani�ailony
<br />m�y subjett you lo aiminal penrn�r_ inctib;rrg
<br />Rnes anNa impiwnmrnL
<br />Mfw;,� of Tlfts. II Ne requeapr tlisclosrs a
<br />ascs TiNs in violmjon d ieCeral law, I)ip
<br />�eqoes�a may p�+ suLje:� lo unl arW �mmx1
<br />pena�lies.
<br />- � �3
<br />r«m LV-9 wr.. i.7mb
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