|
I. W-9
<br />(Rev. November 20171
<br />InlninReveno» s=ry
<br />Request for Taxpayer
<br />Identification Number and Certification
<br />► Go to www.frs.gov/FormWti for instructions and the latest Information.
<br />Name tan snown on your ineome tax return). Name is required on this line, do not leave this line blank.
<br />SHALE TECH INTERNATIONAL SERVICES LLC
<br />Business nameldfsregartled entity name, if different from above
<br />jet .205 D 22
<br />Give Form to the
<br />requester. Do not
<br />send to the IRS.
<br />3 Check appropriate tort for federal tax classification of the person whose name Is entered on line 1. Check only one of the 4 F-xemplions (codes apply only to
<br />following seven boxes. certain entities, not individuals, see
<br />❑✓ Individual/sole proprietor or ❑ G Corporation ❑ 5 Corporation ❑ Partnership ❑ Tru wesmte instructions on page 3):
<br />skrgle-member LLC
<br />Exempt payee code (if any)
<br />❑ LirNted liability company. Enter the tax classification (C=C corporation, S=S corporation. P-Partnamhip)1
<br />Note: Check the appropriate fox in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting
<br />LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is
<br />another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that coda (if any)
<br />Is disregarded from the owner should check the appropriate box for the tax classification of Its owner
<br />LJ other (see Instructions) i-
<br />5
<br />5 Address (number, street, and apt. or
<br />1354 COUNTY RD 246
<br />5 City, state, and ZIP code
<br />RIFLE, CO 81650
<br />account number(s) here
<br />Enter
<br />Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
<br />backup withholding. For Individuals, this Is generally your social security number (SSM. However, for a
<br />resident alien, sole proprietor, or disregarded entity, sea the Instntctions for Part 1, later. For other
<br />entitles, it Is your employer Identificatlon number (EIM. If you do not have a number, see How to get a
<br />77N, later.
<br />Note: If the account is in more than one name, sea the instructions for line 1. Also see What Name and
<br />Number To Give the Requester for guidelines on whose number to enter.
<br />tars name and address (oplbna4
<br />111st
<br />Mining & Salo
<br />Social sacurity number
<br />_m
<br />or
<br />FWPloyer Identification number
<br /> --
<br />unver penenres or perjury, i cerury mat:
<br />1. The number shown on this form is my correct taxpayer identification number (or 1 am waiting for a number to be issued to me); and
<br />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 Intemal Revenue
<br />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
<br />no longer subject to backup withholding; and
<br />3.1 am a U.S. citizen or other U.S. person (defined below); and
<br />4. The FATCA code(s) entered on this form (if any) indicating that i am exempt from FATCA reporting is comact.
<br />CertiNcatlon instructions. You must cross out Item 2 above if you have been notified by the IRS that you ars currently subject to backup withholding because
<br />you have failed to report all Interest and dividends on your tax return. For read estate transactions, item 2 does not apply. For mortgage interest paid,
<br />acquisition or abandonment of secured property, canceBatkxt of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
<br />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 Il, later.
<br />%JIMIr I stgnalura of
<br />Here I U.S. person 11 -
<br />General
<br />General Instructions J
<br />Section references are to the Internal Revenue Code unless otherwise
<br />noted.
<br />Future developments. For the latest information about developments
<br />related to Form W-9 and its instructions, such as legislation enacted
<br />after they were published, go to www.1mgov/FormW9.
<br />Purpose of Form
<br />An Individual or entity (Form W-9 requester) who is required to file an
<br />Information return with the IRS must obtain your correct taxpayer
<br />identification number (TIN which may be your social security number
<br />(SSN), individual taxpayer Identification number (ITIN), adoption
<br />taxpayer identification number (ATIM, or employer Identification number
<br />(EIN), to report on an information return the amount paid to you, or other
<br />amount reportable on an Information return. Examples of Information
<br />returns include, but are not limited to, the following.
<br />• Form 1099 -INT (interest earned or paid)
<br />Data No 0 I
<br />• Form 1099 -DIV (dividends, including those from stocks or mutual
<br />funds)
<br />• Form 1099-MISC (various types of income, prizes, awards, or gross
<br />proceeds)
<br />• Form 1099-B (stock or mutual fund sales and certain other
<br />transactions by brokers)
<br />• Form 1099-S (proceeds from real estate transactions)
<br />• Form 1099-K (merchant card and third party network transactions)
<br />• Form 1098 (home mortgage interest), 1098-E (student loarrintemst),
<br />1098-T(tuition)
<br />• Form 1099-C (canceled debt)
<br />• Form 1099-A (acquisition or abandonment of secured property)
<br />Use Form W-9 only if you are a U.S. parson (including a resident
<br />alien), to provide your correct TIN.
<br />If you do not return Form W-8 to the requester with a TTN, you might
<br />be subject to backup wdthhofding. See What is backup withholding,
<br />tater.
<br />Cat No. 10231X Form Vii -9 (Rev. 11-2017)
<br />
|