Form W-9

Form W-9 (Rev. December 2011) Depertmere or de Thesury Internal Revenue Sernce Request for Taxpayer Identification Number and Certification Give Form to the requester, Do not send to the IRS. Print or type See Specific Instructions on page 2. Nam s shown on your InOOMI tag return) MOUNT SINAI SCHOOL OF MEDICINE 0 Exempt payee &eine= name/dIsregened witty name, if afferent from abase Chock appropriate 0 Individual/sole cox for federal tax otessireatiox proprietor taCCorlacreson 0 S Collsoraca Dnannotelie I i I rust/erste company. Enter !no tax classification ( C emaciation, S=S carp:ration e=pannarsn p) e v. • Limited Ilablity M I Other (see ire:auctions) Address (number. street, and act or are no.) 1 Gustave L Levy Place Requesters name and edema (optional) City, state, ad ZIP code New York, NY 10029 List account nurnber(s) here (optional) Part 1 Taxpayer Identification Number (TIN) Enter your 11N In the appropriate box. The TIN provided must match the name given on the "Name" he to avo d backup withholding. For Individuals, MIS is your social seetilty number (SSN). However, for • resident alien, sole propnetor. or &regarded entity, see the Pat I instructions on page 3. For other entitles, It Is your employer identification number (EN). II you do not have a number. see How to got a TIN on page 3. Note. If the rear Is In more than one name, see the chart on page 4 for guidelines on vinose number to enter. Part Certification I &eclat security number 1111111110 Under penalties of putty, I certify that: 1. The number shown on this form b my correct taxpayer Identification number (or I em wailing for a number to be lasted to me), and 2. I am not subject to backup withholeing 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 wort all interest or dindends, or (c) the IRS has notified me that I an no longer subject to backup withhoking, and 3. I am a U.S. citizen or other U.S. Portion (defined below). Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withnoldirg because you have failed to report al 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 p cancellation of debt, contributions to an individual retrement arrangement OM, and generaty, payments Mbar than Interest and you not required to sign the certification. but you must provide your correct TIN. See the instructions on page 4. Sign asoastic„r Here U.S. person e General Instructions Section references we ea the Internal Revenue Code Unless dthelwtso noted. Purpose of Form A person who la required to fee an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you. real estate transactions, mortgage interest you paid, acquisition or abandonment of seared property, cancellation of debt, or contribtalons you made to an IRA Use Form W-9 only if you em a U.S. person (Including a resident alien), to provide your correct TIN to the person requesting It (the requester) and. when applicable, to: 1. Certify that the TIN you are giving b correct (or you aro waiting for a number to be issued). 2. Certify that you are not subject to backup withholding, at 3. Claim exemption from backup wIthnolding if you are a U.S. exempt payee. If applicable, you are also cutting that as a U.S. person, your allocable share of any partnership ncome from a U.S. trade or business is not &nice! to tee viltnholdng tax on foreign partners share or effectively connected income. 3/14/2012 Date II. Note. II a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if a Is substantially similar to figs Form W-9. Definition of a U.S. person. For federal tax purposes. you are considered a U.S. person If you are: • M individual who is a U.S. citizen or U.S. resident elan, • A partnership, corporation. company. or association created or organized In the United States or under the laws of the United States, • Ni estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701.7). Special rules for partnerships. Partnersits that conduct a trade or business in the United States are generally required to pay a withholong tax on any foreign partners' share of Income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership Is required to presume that a partner is a foreign person. and pay the withholding tax. TherefOre, If you are a U.S. person that Is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid criticizing on your share of partnership ncome. Cat. No. 102SIX Form W-9 (Rev. 12-2011) EFTA01137278