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efta-01368938DOJ Data Set 10OtherEFTA01368938
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DOJ Data Set 10
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efta-01368938
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Form W-9
(Rev. December 2014)
Depxtment of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
O
0
a le
N
1 Name (as
n on your Income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, ri different from above
3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
K Individual/sole proprietor or
K
C Corporation
D S Corporation ID Partnership
O TrusVestate
singlemember LLC
K Limited lability company. Enter the tax classification (C•C corporation S•5 corporation, P•pannership)►
Note. For a see:Ile-member LW that is disregarded. do not check LW: check the appropriate box in the hne above for
the tax classification of the angle-member owner.
O Other (see instructions).
$ Address (number. street. and apt. or suite no.)
4 Exemptions (codes apply only to
certain entities, not individuals: see
instructions on page 3):
Exempt payee code
win
Exemption from FATCA reporting
code (if any)
frophe to scOwnlis moveavioa obit, UU 51
City, state, and ZW code
Requester's name and address (optional)
7 List account numbers) here lePliorin)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, 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 instructions for line 1 and the chart on page 4 for
guidelines on whose number to enter.
Part II
I Social security number
or
Employer Identification number
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. I 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 withholdng 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. I am a U.S. citizen or other V.S. person (defined below); and
4. The FATCA codeis) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
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
Here
Signature of
U.S. person ►
Date ►
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. Information about developments affecting Form W-9 (such
as legislation enacted after we release it) is at www.rs.gov/fw9.
Purpose of Form
M individual or entity (Form W-9 requester) who is required to Me an information
return with the IRS must obtain your correct taxpayer identification number (TIN)
which may be your social security number (SSN). individual taxpayer identification
number ((TIN), adoption taxpayer identification number (ATIN). or employer
identification number (EIN), to report on an information return the amount paid to
you, or other amount reportable on an information return. Examples of information
rearm include, but are not limited to. the following:
• Form 1099.INT (interest earned or paid)
• Form 1099'OIV (dividends, including those from stocks or mutual hinds)
• Form 1099-MISC (various types of income, prizes. awards. or gross proceeds)
• Form 10998 (stock or mutual fund sales and certain other transactions by
brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099.K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest). 1098-1
(tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident alien). to
provide your correct 11N.
II you do not return Form W-9 to the requester with a TIN, you might be sublet(
to backup withholding. See What is backup withholding? on page 2.
By signing the filledout form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a number
to be issued).
2. Certify that you are not subject to backup withholding. or
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
applicable, you are also certifying that as a U.S. person, yaw allocable share of
any partnership income from a U.S. trade or business is not subject to the
withholding tax on foreign partners' share of effectively connected income, and
4. Certify that FATCA code(s) entered on this form Of any) indicating that you are
exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
page 2 for further information.
Cat. No. 10231X
Form W-9 (Rev. 12-2014)
CONFIDENTIAL - PURSUANT TO FED. R. GRIM. P. 6(e)
DB-SDNY-0060947
CONFIDENTIAL
SDNY_GM_00207131
EFTA01368938
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