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Confidential
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<br />Other entities, Enter your business nacre as shorn) on required federal
<br />tax documents an the 'Name" line. This name sriouid match the name
<br />shown on the charter or other legal document creating file entity You
<br />may enter any business, trade o, DBA name cdn the -Business name!
<br />disregarded entity name line
<br />Exempt Payee
<br />If you are exempt from backup withhoding enter your name as
<br />described above and check the ap {xopriste box for you, status . that,
<br />check me " Exempt payee tux in the line foll",lig the Business name?
<br />disregarded entity frame. sign and date the form_
<br />Generally, individuals pincludim sole p,W. setar,,,r are not exempt from
<br />backup withholding Corporations are exempt from backup v, ttthdding
<br />for ce'tam payments, such as interest and dividends
<br />Not *, If you are exempt from backup withholding, you should stilt
<br />G'Omplete this form to a-roid possible erroneous backup wdhhdding
<br />Tre following payees, are exempt frown backup withholding
<br />I An organization exempt from tax ender section 60va), any IRA. or a
<br />custodial account under section 403ibyf7f if file account satisfies the
<br />requirements of seobon 40104,2i
<br />2 The United States of arw of its agencies rx instrumentalities
<br />J. A state. the District of Columbia a paases$,on of tie United States,
<br />or any of their potincaf subdrwisrons or itstnrmentalities.
<br />4. A foreign govemment or any of Its political subdeuisioas, agencies,
<br />or instrumentalities, or
<br />6 An international organization or any of its agioncies or
<br />instrumentalities
<br />Other payees that may be exxrnpl from backup wit"dmg include.
<br />C, A cotrwrafion,
<br />7 A foreign central bank of issue,
<br />3 A dealer in soicuniles or commodities required to register in the
<br />United States. the Distinct of Columbia, or a possession of the United
<br />Stales,
<br />9 A Mures commilssion merchant reg stared with the Cornmoditf,
<br />fugues Trading Commissior, .
<br />10 A real estate rn •.eslment trust
<br />1 t. Art entil registered at oil times durrrtg me tax year under the
<br />investment Comparry Act of 1940.
<br />12 A common trust Lund operated by a than, sunder section 56,Vw,
<br />13. A manc,al institution,
<br />14. A rniddeman known in the investment community as a nominee a
<br />custodian_ or
<br />15 A treat exempt from tax under section Cvivt or described m section
<br />4947
<br />The friliawing kart shows types of payments that may be exempt
<br />Iron) backup ,ithhoid ng The chart applies to the exempt payees listed
<br />above, I through 15.
<br />IF the payment is for ... THEN the payment is exempt
<br />for...
<br />Interest and dividend paymernts All exempt payees except
<br />to, 9
<br />Broker transactions ..Exempt payees 1 through 5 and 7
<br />through 13. Also. C corporations
<br />Barter exchange transactions and Exempt paye®s t through 5
<br />patronage diodends
<br />Payments over $COO required to be exempt payees
<br />reported and direct safes over 1 through 7'
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<br />hGru ..a try., inaxw uxi yrmirvwa±=, nwk- to a .2xt *rr.atrtxn rrs.N,fiar;d;i4= <a taxi =i
<br />401st, rAi3i :nr rriat,xaenryrt frrxu t>- m_M7yr�, itigui, ilex {. rrsvvli _.d anJ tmaflh i,w,=
<br />1.a5�rrait. artrwixry r ,. 4ana•,;. pux ., mfr, rr.�i h= art ineexni ^...pRf pagnwnls 1+:r
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<br />Part i, Taxpayer identification Number (TIN)
<br />Enter your TIN in the appropriate box- If yo;, are a resident aeen and
<br />you do not hak=e and are not eligible to get an SSN- yea TIN is yaux iRS
<br />indodual taxpayer identiticatlon number i;ffft Enter it to the social
<br />security numbw box, if y(c,, do not ha,,* an ITIN. see How'to yet a T3N
<br />biyo,v
<br />If ym, are a sale proprietor and you ha•re an ON, you may enter either
<br />jour 5SN or LN. However. the IRS prefers that you use your SCI.
<br />11 you are a single- mzmaber LLC that is disregarded as an e,4ufy
<br />separate train its oraner isee Limited Lrab,fy Company {LLC" orb page 2)
<br />eraer the ci vter's SSN for EIN. if the o mier has one) Do not enter the
<br />disregarded entity s EIN. i< the LLC is classified as a corporation or
<br />partnership, enter the entitys EIN.
<br />Note. See the chart on page 4 lot further cialificalidn of name and TiN
<br />combinations
<br />How to gat a TIN, If you do not have a Tlfd, apply= for one rmmed =ately.
<br />To apply for an SSN, get Formi SS. 5, Apph,,ation for a Social Security
<br />Card, from your local Social Secu my Administration office or get this
<br />farm tynh n* at w:mr.ssagov You may also get this form by calling
<br />I -nQ 772 1213. Use Form W -7, Application for IRS Individual Taxpayer
<br />identification Number to app4y for an MN,. or Form °,3.S -4, Appiication for
<br />Employer Identification Number, to apply tot an EIN You oar, apply fax
<br />art EM online by accessing the IRS ivebsite at won. =v:,,irs gounxtstriesses
<br />and clicking on Employer identification Number (EIN? under Starting a
<br />Bimness. You can get Forms W -7 and Sa-d Iron) the IRS by visiting
<br />IRS go or by Calling 1- 800- TAX -FORM {1,600 - 829- 3E7E,1.
<br />It you are asked to complete Form W-0 but do not have a TIN, write
<br />Applied For' in the space for the TIN, sign and date the form . and giv=e
<br />It to the Ot(lurstm. For interest and d>,4drind payments, and certain
<br />payments made with respect to readiy, tradable instruments, generat!y
<br />YOU will have d9 dai=s tO get a I IN area give it to the requester before you
<br />are lubiaCt to backup vithhooling on payrrnents The 60 -day rule does
<br />not apply to other types of payments You will be sub)er_t to backup
<br />Withholding on all such payments unit/ you provide your TIN to the
<br />requester
<br />Note. Entering ..Applied For' means that you have already applied for a
<br />TIN or trial you intend to apply for ors soon.
<br />Caution: A disragah ed davroyfitkr einctq that n -as a foregn ovnrcer attnast
<br />ose the appropoafe Fcym 4N -6
<br />Part If. Certification
<br />To establish to the mthholcleig agent that you are a U.S person or
<br />resident alien- sign Form V,1.9. YOU may ire requested to sign by the
<br />wibhholdng agent ),an if item t, belm,, and items 4 and 5 on page 4
<br />¢xHc-ate otherwise
<br />Far a joint account, only the person chose TIN is shown in Part I
<br />should sign r when requiredf in the rase of a regarded evi rty, the
<br />peilon identified on file "Name fine must sign. Exempt payees, nee
<br />Extrrttpt Aay'ce on page 3.
<br />Signature requirements, Complete the cennttcaticn as indicated Vn
<br />items 1 through 3. below, and items 4 and 5 on page 4.
<br />1, Interest, dividend, and barter exchange accounts opened
<br />before 1984 and broker accounts considered active during 1983.
<br />You must give your correct TIN_ but you do not have to s:yn the
<br />certification
<br />2, Interest, divtd and, broker, and barter exchange accounts
<br />opened after 1983 and broker accounts considered inactive during
<br />83. Yov must sign the certification or backup cvtthhokting writ apply. It
<br />you are sublect to backup withholding and you are merely providing
<br />;lour correct TtN to the requester, you must cross cat item 2;a the
<br />certification before signing the form
<br />3, Real estate transactions- You must sign the certification. You may
<br />cross out Itcun 2 of the certification.
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