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Form W -9 Request for Taxpayer SubslltuleFarm Identification Number and Certification Give form to the requester. Do not Slate of Colorado 8.2007 send to the IRS. Na e m1 nr ` W� 1 ��\ c-�- m Y N Business name, if different fro 1 above �r Check appropriate box: 1—T $ Q Individual/ Sole Proprietor [3 Corporation Q Partnership Other p V , + Q Exempt from backup .%ithholding o 2 ► ..................q. Address (number, street, and a t. o r s lte Ito. ) Re uester: City, stale, and ZIP code. y Liszq nt nurnber(s) here (optional) hone tuber: identification Number I Enter your TIN In the appropriate box. For Individuals, this Is your social security number (SSN) However, Social Security number 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 Now to get a TIN on page 3. Note, If the account Is In more then one name, see the chart on page 3 forguldellnes on whose Employer identification number number to enter. 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. 1 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. 1 am a U.S. person (including a U.S. resident alien). 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 secu d property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments other than interetnd dividends, you are not required to sign the Certification, but you must n Minority and Women -owned Businesses (MIWBEs) Se114,Certlficatlon (Please check all boxes that apply) In an effort to track levels of participation by women and minorities doing business with the State of Colorado, the following Information Is requested. Please indicate the appropriate category of ownership for your company. "Owned' In this context means a business that is at least 51 percent owned by an Individual(s) who also control(s) and operate(s) it. "Control" In this context means exercising the power to make policy decisions. "Operate' means actively Involved In the day -to -day management. If you business Is jointly owned by both men and women or Is a large publicly held corporation, please check the box labeled "Not Applicable." Gender Information: ❑ Female -Owned ❑ Male -Owned Owner Ethnicity Information ❑ African American ❑ Asian/Pacific American ❑ Hispanic American ❑ Native American Small Business Information ,bcmot Applicable ❑ White (non - Hispanic) ❑ Not Applicable ❑ Other: Small Business (a business that Is organized for progl, is independently owned and operated, and has 25 or fewer full time equivalent employees.) ❑ Yes ❑ No