,"*

!v-9
t

on your income tax

Name

Give Form to the

rcqueter. Do not

Request for Taxpayer

ldentification Number and Certification

mev. December 2014)

Department of the Treasury
lntffi| Rryenue eryke

2 Busnss

sndtothe

lRS.

requred on this In; do not leave this lire blank

entity ame ifdifferent frorn aboye

arr

d
q.

Chck appropriate box

f6 Heral

oE

*"E

slngle-memkrLLC

UmiteO tiaUitity company. Enter the tax lassiftGtior

bH
E!
Ae
Eu

tdx classifiat'cn; ch<k mly

ore

(Cd corpdatim.

5=S

other

(see

imtructions)

box

Exemptions {cods apply onlyto

certan entitks, not ndviduals; se
instructions on page 3):
Exempt payee code (ifany)

the line abovefdthetax

E(emion from
code (ifany)
{p6b

(number, street and apt or suite no.)

wa

FATCA

reporting

relr'tFddtgdedPUlJ

Requester's nam and addess {optr-onf}

ra

o
o 6

*ot.rt

<trporaton, F=parhership] >

Note. For a singie-membe LLCthat is disregarded do not che.k LLehtrktheapproprite

classification of the singlernember owner.

af the foflqxing selren boxes:

I ccorpontion n scorpontion f] Fartnership fl

606

City,state, and aP code

7 st account number{s} here

ldentication Number
Enter your TIN in the appropriate box. The TIN provided must match th name given on line 1 to avoid backup I;
withholdng. For individuals, this is generally your social secur number (55N). Hoever, for a resident alie n,
l' ,
sole proprietor, or disregarded entity. se the Part I intruGons on page 3. For other entities, it is your employer L:
identification number {ElN}. lf you do not have a number, see How fo get a 71N on page 3.
ol

[tlote. tf the account is n more dlan one name, see the instructions for line
guidelines on whose number to entef.

Under penahies of perjury,

certifu

1 and

Ff.,t{lT

the chart on page 4 for

that

1. ?he number shown on this form s my correct taxpayer identification number (or I am waiting for a number to be issued to me and

2. I am nol subject to backup withholding becaur: (a) I am exempt from backup withholdins. or (b) I have not been noded ry the lnternal Revenue SeMce (fR)
that I am subjeet to ba.kup trythholding as a resuh of a frilure to repon 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 US. citi:en or other U.5. person (defined

4, The FATCA code(s) entered on this

Cttication nstnrctors. You must

below) and
form (if any) indicating that I am exempt fro$ FATCA reporting
cross out item 2 above

ffyou have been notified

is

.orrect.

by the IRS that you are

curently subject to backup withholding because

]ol

Sign
Here

General lnstructions

. Fom 1098 (home rnortgage

Sstion references are to the lnternal Rerenue Code unless otheros nsted.
Flrdeyelopenrs. hformaio aboutdevdopments afuting Fom ttl-9

. Fcfm
(such as

leglslaon enacted after we release i0 is aww.its.q@t/fw9.

infomtion retum

with the IRS must obtain your conect taxpayer identication number (IlN) whkh may be
yoursocialsecuity number (SSN), irdividualta&ayridenticaon number 0nN),
adopion taxpayer idefioon number (ATIN), or emplo)rer identifiatlqn number (ElN).
to report on an information retumte amoum paid to you, sother amont reportabh
on an iEformaton retum. Examdas of infoflTtalion fetums nclude, hrt are not llmited to,

thefollowing:
. Fom 1 099lNT (interest eamed or pau)
. Form 109$DlV (dividendt ncluding those from sto(ks or mutral funds)
. Form 109$MISC (various qrpes of in<ore, prizes, a,trardg or grosi proceed)
. Fofm I 09+8 (tock or mutua fund sales and certain other transactiom by brokers)
. Fofm 10S-S (proceeds from real e*re tGnsactions)
. Form 109+K (merchant Eard and third party rletwork transaciions)

. Form 10994 (acquisilion

Us

I09&E Gardet loan interest), 109&T (tuition)

(cnceled debt)

abardonment ofsecured propsty)

Fofm W-9 only if you are a U.S. person (imludng a resident alien), to p.ovkle your

correct Tll{.

PurposeofForm
An ndividual or entity {Form W-9 requesrer} who is required to file an

109C

lf yd, do not retum Fatm WQ to *re requerter wi}' anil, you might be subied to
wfthholdin*
What is bsckup wirrhddingTon p4 Z

By

fufup

signingthefilhd-otn form, ycu:

Certiry that the tN you are givlng is conect {or yqr are waing for a number to be
issued),
1 .

2-Cenirythat trou are ot subJecttaback pwi*rholding,

3.Clalm exeilptionfrom bach&withholdilg if ysu area US.exmptpayee. tf
apSkable, y* arc also cerdfying ttat as a US. person, our allocable share of any

partnership income from a UJ. trade or busness 5 not $rbject to the wthhold;ng
foreign partnas' share of eeively conneded in(ome, and
4. Certify

til

on

that FATCA code{s} enterBd o rhis fcrm {f arry} indkating that you are
TATCA reporting, is core(t. SewhdtisFATcAreryrtington page 2for

e'(emptfromthe
furthr

infornatlor

c^*ltt-a-.

a^.,'