ALP 13

Form W -9
Request for Taxpayer
Give form to the
Substitute Form
Identification Number and Certification
requester. Do not
State of Colorado 8 -2007
send to the IRS.
Name
cri
La Plata Archuleta Water District
d
c
Business name, if different from above
0
2
Check appropriate box:
H
❑ Individual/ Sole Proprietor ❑ Corporation ❑ Partnership ❑ Other []Exempt from backup withholding
c 2
No- Tile 32 Sp ecial Dist
c c
Address (number, street, and apt. or suite no.)
Requester:
a 9
954 E. 2nd Ave., Suite #202
Richard T. Lunceford
Board President
City, state, and ZIP code.
in
Durango, CO 81301
m
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List Account number(s) here (optional)
Phone Number: (970) 259 -1028
Taxpayer Identification Number (TIN)
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 How to
get a TIN on page 3.
Note: If the account is in more than one name, see the chart on page 3 for guidelines on whose Employer identification number
number to enter. 8 1010121911J011 5
Certification I
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 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 on page 3.)
Sign Signature of
Here T, �-+,� � Q rv� c�
U.S. person Do- Date ►9/24/10
Minority and Women -owned Businesses (M/WBEs) Self Certification (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 ❑ Not Applicable
Owner Ethnicity Information
❑ African American ❑ Asian /Pacific American ❑ White (non- Hispanic) ❑ Not Applicable
❑ Hispanic American ❑ Native American ❑ Other:
Small Business Information
Small Business (a business that is organized for profit, is independently owned and operated, and has 25 or fewer full time equivalent
employees.)
❑ Yes ❑ No