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., <br />Jan 18 05 10:11a Cit?of North Olmsted 440 777 5774 p•2 <br />?,.....? <br />?rrr <br />Request for Taxpayer Give farm to the <br />_^fm W.9 I ?quescer, oo not <br />Rev. Dece (dentifcation Numb'er and Certification send to the IRS. <br />mnet 20001 <br />_rcanmeni a mc fressW <br />-;nnai Revenue iennce <br />I Name (5ee Spccnic Insm?cawt? a? Page 2J <br />f N rth 0lmsted <br />c <br />r <br />0 <br />c <br />.0. <br />a <br />a0 <br />City. o - Buscness name, d tlifferenc Kom enove. (See SpK+f« ?^S°uons on paqe 2.) <br />Check appro0nate box: ? Individual/Sole pro?ne[w n Corpaanon <br />Aaaress tnumder. screet. antl aGC. or surce no.1 <br />5200 Dover Center Road <br />City. swce. anu 71P coae North Olmsted Ohio _44070 <br />Enter your 7IN in [he appropriace hox. For <br />,ndividuals, this is your sccial securiry number <br />(SSN). kowever, for a residetrt atfe ? Part i <br />propriator, ar dtsregarded ?+?Y• <br />inswctions on page 2. For ather entiues. it is your <br />emoloyer idenuCicauon number (EIN). If you do na[ <br />have a number. see How to get a TIN on page z. <br />Note: !f the account is in more than one name. see <br />fhe chart on page 2 foI gurdelines on whose numoer <br />to enter. <br />Requester s name ana aoaress lapuonan <br />Ust accauu numDerls) here japaonap <br />ffffff= <br />ot <br />EmPbYO:t identification rnm+bet <br />? 314 _6 0 0 ? 2?A 4 8 <br />l_.1_. ?r <br />For U.S. Payees Exempt From <br />Backup 1Nithholding (See tYie <br />mswctians on paae 2.1 <br />?----- <br />llnder penalues af perjury. I cecvfy thar. <br />1. The number sriou+m on this f? <br />Z. I am nat subjecc to hdd ng becaus X(a) l ameezaxnpt irom hackup wichholding. or (b) i have not b heen no[iCied by the Intemal <br />badcup <br />Revenue Service (IRS) that l am suhject to backup Wthholding as a result at a faifure to report ali tnterest or dividends. nr (c) the IRS s <br />no[ified me cha[ I am no loroger subject to backup wnchholding, and <br />3. I am a 11.5. persan (iactuding a US. resident alien). cLuTend <br />backup CertiRcetion in a???ave faed to ?ePort all interes? and idlv dends on yaur notifi tax cetum. for rea?estace trans ctio sy ieesub mj Z does noc aPPlY. <br />por mortqage interesc paid, acquisition or abanaonmenL af secured propert7l, cancettatian of debt conVibutions to an ind'ividual retiremens <br />withholding bec Yo <br />artangemen[ (IRAI. and generally, payments other than mcerest and dividends. you are noc required to sign the Certification. but yau must <br />ptovide your canect TiN• (See che inswctions on page 2.) <br />Sign Signature of <br />Her'e I U.S. pers- <br />Purpose af Form <br />A person who is reQuved t?61e? carectation <br />reuun wrch [he IRS must g yo <br />taYpayrt idendfiration nunber 111M w rePOrL fa <br />example. income paid ca yai, rem e-to <br />vansecuons. mortgage ineerest you Psid, <br />acquisition or abandonment ot seaaed DroPertY' <br />'cancellation o( deht ar contribuoorIS YoU Made <br />:o an IRA. <br />Use Porsn W9 anf7 'rf rou are a U.S. person <br />(iduding a residerrc afi ).nt°9? r???g <br />TIN to Ne person requ 9 iana. when aPPlicahle, ta <br />l. Certrty tne TIN you are gmn9 is correcc for <br />you are v+aam9 fa a number [o be issuedl• <br />Z Certrfy you are not subjea w bnclmP <br />witMtoldina. or <br />3. Claim exempuon from badcuP %`^thh0Ldi^9 tt <br />you are 8 U.S. exempc PaYee• <br />tf ? are a foreign p?s?T? use t? <br />appropnate Forrtt W-8. See Pub- <br />Withholding of Tax on Nonresiaent Aliens and <br />faeign Corporauons. • <br />Nate: !f a requester ?MaV musr use the <br />Form W-9 to requesYaw <br />ieques[er's (orm d rt is Suostannalty srmrrar to Mrs <br />Form W-9. <br />Oate ? <br />What is bacicup v+itht+ddi^9T Persons making <br />cena+n PaYmerrts m you mus[ wrthhold and PaY <br />to the lRS 31% ot such PaY're'ts u", croin <br />cottditbrts. Thia is called 'badcto 6ackup?? . <br />payrtems that may be su? . <br />wdholding inducle u'Raesc diwdenUS. broker <br />and bartef exchenge transactions, ren? <br />royalues. noneinpbyea PeY, ? Real <br />paymenxs frarto fistiing haat Operators- <br />escace transac[ions are noc subjed tn batkup <br />wrthholding. <br />I( you give ttie requeuer Yar cotrect TIN, <br />make she proPer cWdfid4orts. and repat all <br />yatr wxable intetest a?? wiH na he ?1? <br />reuan. paYm?r?s Ym ta br..IaiP wit'inddm5• Pay?rc'Ks 7ou reuire <br />witl be wbJect to bachrp withtw*kiin9 if: <br />t. You do not furrvsh yoct 1'N to the <br />reques[er. or <br />2. You do not tertify yatr nN whe^ tequired <br />(see the Part III inSwCdoru on page 2for <br />details). a <br />1, The IRS tells the reques[er tha[ you <br />fumtshed an incorrec[ 7IH• ar <br />q, it,e iR?Sht?el?Is?Y b?usea urd d notLepart <br />oackup w 9 Yo ? ?ax rewm <br />all yeur inceJest and dividentls an Y? <br />If? feporiaple jrneres[ ana dividends onlyf. or <br />Cac No. io231X <br />? PannersniP 5] omef ? ---------------- <br />5. You tlo nat certi(y to Ne requeste? d= Y°u <br />2re not subjeM to baCkuP Mfit1hokilin3 Wdw 4 <br />above Ka reponable incorest and dividecd <br />accouncs opened after 7983 only). <br />CstaeT ;:.y- Wd Fzy^'e= a= =xerl.x <br />FG.. b..'Ch'.1^r `-'rit-hhold»:?. cm --- p;.n 1! <br />insvucdores and the separam ?nstruc+ions for <br />the Requesw o! Fortn W-4. <br />Penalties <br />pa?ure m turnish 1lN_ It you Eaft to ttATlish yaa <br />cmect T1N to a requesseJ, yau are subjea ta a <br />pe,atry at 55Q for eac3? such taAure unless your <br />tailure is due to reasonable causa and noc w <br />v+ilNtt neglecx. <br />Civit pettslty (oC fakse irrfocmatim wit'?,nierP°a <br />to witlht+oidiin9• U You maka n ta4se sumTWK <br />wich no rrasonable bass that resuRS in no <br />bacWP w,imholding, you are subject to a 5500 <br />Penalft1- <br />Criminal penslty for talsifying ir?mutiOm <br />Wilt(ulty talsdying certificaaons or affirtnaoart <br />may subiec[ you to aiminal penalties indudin9 <br />fines anpla impnsonment. <br />Misuse of T1Ns.lf the requester discloses ar <br />uses T1Ns in violatian of federet law. the <br />requestet may be subject to civil an0 cnminat <br />penalees. <br />Fam W-9 (Rev. 12-20001