Pantheros Agent Contracting Direct Deposit and W-9 Information Form

DIRECT DEPOSIT FORM
I AUTHORIZE PANTHEROS TO ELECTRONICALLY DEPOSIT MY COMMISSIONS DIRECTLY INTO THE FINANCIAL INSTITUTION OF MY CHOICE AS SPECIFIED BELOW. THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL I PROVIDE THE COMPANY WRITTEN NOTICE OF ITS REVOCATION AND THE COMPANY HAS ADEQUATE TIME TO PROCESS THE APPROPRIATE TRANSACTIONS. I UNDERSTAND THE COMPANY IS PROVIDING THIS WITHOUT CHARGE, AND THE COMPANY WILL NOT BE HELD LIABLE FOR ANY CLAIMS OR DAMAGES ARISING, DIRECTLY OR INDIRECTLY, FROM THIS DEPOSIT ARRANGEMENT.
COMMISSION PAYMENT INFORMATION

Commissions are processed each month. All commissions are sent via ACH and will post in producers accounts the following business day. Each agency will be emailed their Commission Statements on the day commissions are paid. Please make sure each agency in your downline has provided the following information.
AGENCY CONTACT *

First NameLast Name
AGENCY ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CONTACT PHONE NUMBER*
Please enter a valid phone number.Format: (000) 000-0000.
COMMISSION ACCOUNTING EMAIL*
example@example.com
AGENCY BANKING INFORMATION
BANK NAME:*
BANK ROUTING #:*
BANK ACCOUNT #*
Form W-9 Request for Taxpayer Identification Number and Certification

Go to www.irs.gov/FormW9 for instructions and the latest information.
2. Business name/disregarded entity name, if different from above.*
Individual/sole proprietorC CorporationS CorporationPartnershipTrust/estateLimited liability company.Other
If you selected "Limited liability company", enter the tax classification (C=C corporation, S=S corporation, P=Partnership)*
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4. Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
Exempt payee code (if any)
Exemption from Foreign Account TaxCompliance Act (FATCA) reporting code (if any)
5-6. Address (number, street, and apt. or suite no.)*

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code
Requester's name*

First NameLast Name
Requester's address*

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code
7. List account number(s) here (optional)
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.
SSNEIN
TIN*
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*
Date*

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

DIRECT DEPOSIT FORM

COMMISSION PAYMENT INFORMATION

AGENCY BANKING INFORMATION

Form W-9 Request for Taxpayer Identification Number and Certification

Part I - Taxpayer Identification Number (TIN)

Part II - Certification