Text extracted via OCR from the original document. May contain errors from the scanning process.
Form W-9 (Rev. 8-2013)
Page 3
Exempt payee code. Generally, indroduals (including sole proprietors) are not
exempt from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends. Corporations are
not exempt from backup withholding for payments made in settlement of payment
card or third party network transactions.
Note. If you are exempt from backup withholding. you should still complete this
loon to avoid possble erroneous backup withholding.
The following codes identify payees that are exempt from backup withholding:
1—An organization exempt from tax under section 501(a), any IRA. or a
custodial account under section 403(b)(7) if the account satisfies the requirements
of section 401 (f)(2)
2—The United States or any of its agencies or instnanentalities
3—A suite, the District of Columbia, a possession of the United States, or any of
their political sutxfivisicers or instrumentailies
4—A foreign government or any of its political subdivisions. agencies. or
instrumentalities
5—A corporation
6—A dealer in securities or commodities required to register in the United
States, the District of Columbia, or a possession of the United States
7—A futures commission merchant registered with the Commodity Futures
Trading Commission
8—A real estate investment trust
9—An entity registered at all times during the lax year under the Investment
Company Act of 1940
10—A common trust fund operated by a bank under section 584(a)
11—A financial institution
12—A middleman known in the investment community as a nominee or
custodian
13—A trust exempt from tax under section 564 Or described in section 4947
The following chart shows types of payments that may be exempt from backup
withholding. The chart applies to the exempt payees listed above. 1 through 13.
IF the payment Is for...
THEN the payment is exempt for ...
Interest and dividend payments
All exempt payees except
for 7
Broker transactions
Exempt payees 1 through 4 and 6
through 11 and all C corporations. S
corporations must not enter an exempt
payee code because they are exempt
only for sales of noncovered securities
acquired poor to 2012.
Barter exchange transactions and
patronage dividends
Exempt payees 1 through 4
Payments over $600 required to be
reported and direct sales over $5,000'
Generally, exempt payees
1 through 52
Payments made in settlement of
payment card or third party network
transactions
Exempt payees 1 through 4
'See Form 1099-MISC, Miscellaneous Income, and its instructions.
'However, the following payments made o a corporation and reportable on Form
1099'MISC are not exempt from backup withholding: medical and health care
payments, attorneys' fees, gross proceeds paid to an attorney, and payments for
services paid by a federal executive agency.
Exemption from MICA reporting code. The following codes identify payees
that are exempt from reporting under FATCA. These codes apply to persons
submitting this form for accounts maintained outside of the United States by
certan foreign financial institutions. Therefore. if you are only submitting the form
for an account you hold in the United States, you may leave this field blank.
Consult with the person requesting this form if you are uncertain if the financial
essteuton is subject to these requirements.
A—An organization exempt from tax under section 501(a) or any individual
retirement plan as defined in section 7701(a$37)
B — The United Stales or any 01 Its agencies or Instrumentalities
C —A state, the District of Columbia. a possession of the United States, or any
of their political subdivisions or instrumentalities
D —A corporation the stock of which is regularly traded on one or more
established securities markets. as described in Reg. section 1.1472-1(0)1)(i)
E —A corporation that is a member of the same expanded affiliated group as a
corporation described n Reg. section 1.1472-1(c)(iyo
F —A dealer on securities, commodities, or derivative financial instruments
(including notional principal contracts. futures. forwards. and options) that is
registered as such under the laws of the United States or any state
G —A real estate investment trust
H —A regulated investment company as defined in section 851 or an entity
registered at all times during the tax year under the Investment Company Act of
1940
I —A common trust fund as defined in section 584(a)
J—A bark as defined in section 581
K—A broker
1—A trust exempt from lax under section 664 or described in section 4947(a)(1)
M —A tax exempt trust under a section 403(b) plan or section 457(g) plan
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. If you are a resident alien and you do not
have and are not eligible to get an SSN, your TIN is your IRS uviissOual taxpayer
identification number 011N). Enter It in the social security number box. If you do not
have an ITIN. see How to get a TIN below.
it you are a sole proprietor and you have an EIN. you may enter either your SSN
or EIN. However. the IRS prefers that you use your SSN.
If you are a single-member U.0 that is disregarded as an entity separate from its
owner (see Limited Liability Company (LLC) on page 2). enter the owner's SSN (ix
EIN. if the owner has one). Do not enter the disregarded entity's EIN. If the LLC is
classified as a corporation or partnership, enter the entity's EIN.
Note, See the chart on page 4 for further clarification of name and TIN
combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately. To apply
for an SSN. get Form SS-5. Application for a Social Security Card, from your local
Social Security Administration o
'
online at twnessegov. You
may also get this form by calling 1
Use Form W-7. Application for
IRS Individual Taxpayer Identificat
.
apply for an ITIN. or Form SS-4.
Application for Employer Identification Number, to apply for an EIN. You can apply
for an EIN onlne by accessing the IRS websde at www.irs.govibusinesses and
clicking on Employer Identification Number (EIN) under Starting a Business. You
can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling 1-800-
TA)(-FORM
If you are asked to complete Form W-9 but do not have a TIN. apply for a TIN
and 'ante -Applied For in the space for the T1N, sign and date the form, and give it
to the requester. For interest and dividend payments. and certain payments made
with respect to readily tradable instruments. generally you will have 60 days to get
a TIN and give it to the requester before you are subject to backup withholdng on
payments. The 60-day rule does not apply to other types of payments. You win be
subject to backup withholding on all such payments until you provide your TIN to
the requester.
Note. Entering 'Applied For' means that you have already applied for a TIN or that
you intend to apply for one soon.
Caution: A disregarded U.S. entry that has a foreign owner must use the
appropriate Form 1011-8.
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or resident alien.
sign Form W-9. You may be requested to sign by the withholding agent even if
items 1, 4, or 5 below indicate otherwise.
For a joint account. only the person whose TIN is shown in Pan I should sign
(when required). In the case of a disregarded entity, the person identified on the
-Name' line must sign. Exempt payees. seeErarptpayeecodeeadier.
Signature requirements. Complete the certification as indicated in items 1
through 5 below.
1. Interest, dividend, and barter exchange accounts opened before 1984
and broker accounts considered active during 1983. You must give your
correct TIN, but you do not have to sign the certification.
2- Interest, dividend, broker, and barter exchange accounts opened after
1983 and broker accounts considered inactive during len You must sign the
certification or backup withholding will apply. If you are subject to backup
withhokIng and you are merely providing your correct TIN to the requester, you
must cross out item 2 in the certification before signing the form.
3. Real estate transactions. You must sign the certification. You may cross out
item 2 of the certification.
4. Other payments. You must give your correct T1N, but you do not have to sign
the certification unless you have been notified that you have previously given an
incorrect TIN. 'Other payments' include payments made in the course of the
requester's trade or business for rents, royalties, goods (other than bills for
merchandise), medical and health care services (including payments to
corporations). payments to a nonemployee for services. payments made in
settlement of payment card and third party network transactions, payments to
certain fishing boat crew members and fishermen, and gross proceeds paid to
attorneys (including Payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of secured
property, cancellation of debt, qualified tuition program payments (under
section 529). IRA. Cowden ESA. Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct TIN. but you
do not have to sign the certification.
CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e)
CONFIDENTIAL
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