|
orm W-9 Request for Taxpayer Give form to the
<br />(Rev. J anuary 20021 Identification Number and Certification requester. Do not
<br />Delaartm ent o1 me Treasury Send tO the IR$.
<br />Internal Revenue sernce '
<br />N Name
<br />a
<br />m
<br />m
<br />a Business name, if different from above
<br />c
<br />0
<br />~
<br />lu
<br />r o Individual/ Exempl from backup
<br />hi
<br />^ O
<br />Ch
<br />k
<br />i
<br />b
<br />^ S
<br />l
<br />i
<br />^ C
<br />i
<br />^ P
<br />h
<br />~
<br />i
<br />hh
<br />l
<br />i
<br />^
<br />` ~ artners
<br />p
<br />ec
<br />appropr
<br />ate
<br />ox:
<br />a
<br />e propr
<br />etor
<br />orporat
<br />on
<br />t
<br />er
<br />................... w
<br />ng
<br />t
<br />o
<br />d
<br />o
<br />N
<br />c
<br />Atltlress (number, street, antl apt. or suite no.l
<br />Requester's name antl address (optionaq
<br />c
<br />tl V
<br />c City, state. and ZIP code
<br />
<br />n
<br />y List account number(s) here (optional)
<br />v
<br /> Tax a er Identification Number (TIN)
<br />Enter your TIN in the appropriate box. For indivitluals, this is your social security number (SSN). social security number
<br />However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on
<br />page 2. For other entities, it is your employer identificadon number (EIN). If you do not have a number,
<br />see How to get a TIN on page 2. or
<br />Note: /I the account is in more than one name, see fhe chart on page 2 for guidelines on whose number Employer iderrtiacatlon number
<br />to enter.
<br />Under penalties of perjury. I certify that:
<br />t. 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
<br />2. I am not subject to backup withholding because: (a) I am exempt from backup withholtling, or (b) I have no[ been notified by the Internal
<br />Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) [he IRS has
<br />no[ihed me that I am no longer subject to backup withholding, and
<br />3. 1 am a U.S. person (including a U.S. resident alien).
<br />Certification instructions. You must cross out item 2 above if you have been notifed by the IRS that you are currently subject to backup
<br />withholtling because you have failed to report all interest antl dividends on your tax return. For real estate transactions, item 2 does no[ apply.
<br />For mortgage interest paitl, acquisition or abandonment of secured property, cancellation of tlebt conuibutions [o an individual retirement
<br />arrangement (IRA), and generally, payments other than interest and divitlends, you are not required to sign the Cenifcation, but you must
<br />provide your coned TIN. (See the instructions on page 2.)
<br />Sign Signature of
<br />Here U.S. person - Date -
<br />Purpose of Form
<br />A person who is requiretl to file an information
<br />return with the IRS must get your correct
<br />taxpayer itlentificauon number QIN) to report, for
<br />example, income paid to you, real estate
<br />Vansactions, mwtgage interest you paid.
<br />acquisition or abandonment of secured property,
<br />cancellation of debt, or contdbudons you matle
<br />to an IRA.
<br />Use Form W-9 only if you are a U.s. person
<br />(indutling a resitleni alien), to give your coned
<br />TIN to the person requesting i[ ([he requester)
<br />antl, when applicable, to:
<br />1. Certify the TIN you are giving is coned for
<br />you are waiting for a number to be issued),
<br />2. Certify you are not subject to backup
<br />withholtling, or
<br />3. Claim exemption from backup withholding if
<br />you are a U.S.~exempt payee.
<br />If you are a Toreign person, use the
<br />appropriate Form W-a. See Pub. 515,
<br />Withholding of Taz on Nonresitlen[ Aliens antl
<br />Foreign Entities.
<br />Note: I/ a requester gives you a form other than
<br />Form W-9 [o request your TIN, you must use the
<br />requester's form i! it is substantially similar to this
<br />Farm W-9.
<br />What is backup withholding? Persons making
<br />certain payments to you must under certain
<br />conditions withhold and pay [o the IRS 30% of
<br />such payments after December 31. 2001 (29%
<br />after December 31, 2003). This is Calletl "bacKUp
<br />wi[hhgltling." Payments [ha[ may De subject to
<br />backup withholdiny idUude interest,+tlividentls.
<br />broker and barter exchange Vansactions, rents,
<br />royalties. nonemployee pay, and certain
<br />payments from Flshing boat operators. Real
<br />estate Vansactions are no[ subject to backup
<br />withholding.
<br />You will not be subject to backup withholding
<br />on payments you receive if you gwe the
<br />requester your tome[[ TIN. make the proper
<br />certifcaticns, and report all your taxable interest
<br />and dividends on your [ax return.
<br />Payments you receive will be subject [o
<br />backup withholding if:
<br />1. Vou tlo not furnish your TIN [o [he
<br />requester, w
<br />2. You do not certify your TIN when requiretl
<br />(see [he Part II instructions on page 2 for
<br />details), or
<br />3. The IRS tells the requester that you
<br />furnished an incorrect TIN, or
<br />4. The IRS tells you that you are subject to
<br />backup withholding because you tlld not report
<br />all your interest and dividentls on your tax return
<br />(tor reportable interest and dividends only), or
<br />s. Vou tlo not Certify to [he requester that you
<br />are not subject to backup withholding under 4
<br />above (for reportable interest and dividend
<br />accounts openetl after 1983 only).
<br />Certain payees and payments are exempt
<br />from backup withholding. See the instructions on
<br />page 2 and the separate InsiNCUene tar the
<br />Requester of Forth W-s.
<br />Penalties
<br />Failure to famish TIN. If you fail tc furnish your
<br />correct TIN to a requester, you are subject to a
<br />penalty of $50 for each such failure unless your
<br />failure is due to reasonable cause and not to
<br />willful neglect.
<br />Civil penalty for false information with respect
<br />to withholtling. If you make a false statement
<br />with no reasonable basis that results in no
<br />backup wimholtling. you are subject to a 8500
<br />penalty.
<br />Criminal penalty for falsifying information.
<br />Willfully falsifying certifications or affirmations
<br />may subject you to criminal penalties including
<br />fines and/or imprisonment.
<br />Misuse of TINS. If [he requester tliscloses or
<br />uses TINS in violation of Fetleral law, the
<br />requester may be subject to civil and criminal
<br />penalties.
<br />Cat. No. 10231X Form W-g (Rev. 1-2002)
<br />
|