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efta-01384429DOJ Data Set 10OtherEFTA01384429
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DOJ Data Set 10
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efta-01384429
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,.., W.9
Rev. November 2017)
Department°, tre Treats?
intent Revenue Service
Request for Taxpayer
Identification Number and Certification
le Go to www.irs.gov/ForrnW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.
Print or type.
See Specific Instructions on page 3.
1 Name (as shown on your Interne Lax return). Name is required on the line: do not loam this toe bran.
Gratitude America. Ltd
2 Bus mess name:disregarded entity name. If different from above
3 Check appropriate
following seven boxes.
0
Inoivielual/sole
single-member
0 Limited lability
Note: Check the
LLC rt the LLC
another LLC that
is disregarded
r2 Other (see insuuctions)
box for federal tax ciassiticWion of the person whose name is enured on line 1. Check only one of the
O
Trust/estate
4 Exemptions
certain entities,
instructamt
Exempt payee
Exemption
CO
of any)
''''''"
r•,•».
Ina
'"'"
(codes aPPIY only to
not individuals: see
on page 3Y
code (if any)
proprietor or
•
C Corporation 0 S Corporation
0
Partnership
LLC
company. Enter the tax classification (C=C corporation. SAS COrPOration, P=Partnership)fr
appropriate box in the line above for the tax Clataikation of the single-member owner.
is classified as a single-member LLC that is disregarded from the owner unless the
is not disregarded from the owner for U.S. Worn tax purposes. Otherwise, a single
from the owr.or should check the appropriate box for the tax clas*ification of its owner.
I.
Exempt Private Organization
from FATCA reposing
Do not check
owner of the LLC is
-member LLC that
4" . "" n "
an. We l't 1 '
)
5 Address (number. streel, and apt. or suite no.) See instructions.
9100 Poart of Sale Mall, Ste 15
I Requester's name and addnn.s toptiunab
6 City. stale, and ZIP code
St. Thomas, USVI 00802
7 List acount number(s) here Motional)
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 instructions for Part I. later. For other
entities. It is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Part II
1 Social security number
or
Employer identification number
6 6
0 7 8 9 6 9 7
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 withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I ant
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The MICA coefe(s) 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 for Part II, later.
Sign
Signature of
Here
us. person la
Date la
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to vivemirs.gov/FormVV9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file 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 (111N). adoption
taxpayer identification number (ATIN). or employer identification number
(EIN), to report on an information return the amount paid to you, Of other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards. or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099S (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-T (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 TIN.
if you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X
Form W-9 (Rev. 11.2017)
CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e)
CONFIDENTIAL
SONY GM_00230790
DB-SDNY-0084606
EFTA01384429
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