Case File
efta-01392985DOJ Data Set 10OtherEFTA01392985
Date
Unknown
Source
DOJ Data Set 10
Reference
efta-01392985
Pages
1
Persons
0
Integrity
Extracted Text (OCR)
Text extracted via OCR from the original document. May contain errors from the scanning process.
IV. TAX ELECTI0WDECLARATI0N OF TAX STATUS
This Account Agreement is designed 10, use by both U.S. Persons and Non-U.S. Persons. Please check the box next to the applicade nem below.
Ct ent certifies that Client will notify DBSI in writing Immediately it the representation certified to below ceases to be two and correct.
1.O U.S. Citizen or U.S. Resident Alien
Form W9
quent for Texpayer Identikcation Number and Certification
Substitute Th6g,
Vle tin
t"
NYVA.Inr
I ri
X
1-1-1.
Part
Narne (as shown on your income tax return)
Business name/disregarded entity route rl different from above
Check appropriate box for federal tax classification (required)
O Individual/sole proprietor O C Corporation CI S Corporation I
Pennerithge O
Trustleffete
O Limited liability company. Enter the tax classification (CeC corporation 5.5 corporation, Priparmership)
Other k
li
El Exempt payee
Address (number. See. end apt or suite no.)
City. State. and ZIP code
,Taxpayer Identification Number (T1N)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name' line
to avoid backup withholding. For Individuals. this Is your social security number ISSN). For other
entitles, h is your employer identification number (EINI.
Pan II
Sign
Here
Sous' Secwty Number
Employer Idemillostron Number
Certification
Under penalties of perjury. I certify that:
1. The number shown on this form is my coifed taxpayer identilicaticn number (or I am waiting for a number to ho issued to me). and
2. am not subject to backup withholding because: (a) I am exempt from backup withholding, or WI I have not been notified by the Internal Revenue
Service (IRS) that I am subject t0 bedroll withholding as a mull of e 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. crtnen or other U.S. Denton (defined In the instructions).
Certification Instructions. You nnisactoss
• em 2 above If you have been
Te-IRS that you are currently subject to backup withholding
because you have failed to report ell interest an dividends on your
Signature of
u.S. person ►
2.0 Non.U.S Person
Dale
I am not a U.S. person (including a U.S. resident alien). i am submitting the applicable Form W-8 with this form to certify my foreign status and, if applicable.
claim tax treaty benefits
For example: Client Is not a U.S. person 'including a U.S. resident alien). Client agrees to provide DBSI with this application the applicable Internal Revenue
Service (IRS) Form W-8 to cent fy the client's foreign status. W-8 forms and instructions are avaliable on the IRS weblike at www.Irs.gov.
13-AWM-0196
6
012145 032813
CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e)
DB-SDNY-0098325
CONFIDENTIAL
SDNY_GM_00244509
EFTA01392985
Technical Artifacts (1)
View in Artifacts BrowserEmail addresses, URLs, phone numbers, and other technical indicators extracted from this document.
Domain
www.irs.govForum Discussions
This document was digitized, indexed, and cross-referenced with 1,400+ persons in the Epstein files. 100% free, ad-free, and independent.
Annotations powered by Hypothesis. Select any text on this page to annotate or highlight it.