Request for Taxpayer Identification Number and Certification

Request for Taxpayer Identification Number and Certification (Form W-9)

Go to www.irs.gov/FormW9 for instructions and the latest information.
1. Name as shown on your income tax return. Name is required on this line; do not leave this line blank.*
2. Business name/disregarded entity name, if different from above
3. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.*

Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/estateLimited liability company.Other
If you selected "Limited liability company", enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
4. Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
5. Address*

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code
Part I - 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 generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Note: Enter an SSN or EIN. If you enter an SSN then the EIN field below will disappear. It will re-appear if you delete the SSN number.
Social Security Number (SSN)
Format: 555 55 5555*
Enter numbers only
Employer Identification Number (EIN)
Format: 55 5555555*
Enter numbers only
Part II - Certification
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. 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 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. I 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 for Part II, later.
Signature of U.S. person*
Date

MonthDayYear
Date
You can check out the details and general instructions below:
Should be Empty:

Request for Taxpayer Identification Number and Certification (Form W-9)

Part I - Taxpayer Identification Number (TIN)

Social Security Number (SSN)

Employer Identification Number (EIN)

Part II - Certification