Request for Taxpayer Identification Number and Certification

Department of the Treasury Internal Revenue Service
Request for Taxpayer Identification Number and Certification
Enter EITHER the Name (as shown on your income tax return)
or the Business name, if different from above
Address *

Street Address

Street Address Line 2

City State

Zip Code
Check appropriate box:

Individual/ Sole proprietor Corporation Partnership Other Exempt from backup withholding
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup withholding. For individuals, this is your social security number (SSN However, for a 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.

The 1099 will be generated using your Social Security Number or your Employer Identification Number. Enter either in the fields below but not both.
Enter either a Social Security Number for a single person or
Enter a Employer Identification Number for a business
Penalties
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: