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Confidential
<br />I'cribW fairU' 1 :1 liri t;
<br />4. Other payments. You must give your correct TIN, but you do not
<br />ha' ,,e to sign the certaica;ioll ;Mess you have been notiteci that you
<br />haae [?r6,,iouaiy >al. *en an incoirect TIN. Other payments Include
<br />payments made in the course of the requester's fraue or business for
<br />refits Ioya'lles. goods 1,other than bills for merchandise) rrre hca€ aril
<br />health care ssrcncos h.ncluchrig pajm6nts to COrporealsons), pay,^.ienis to
<br />a ricinernpioyee tot seances, payments to certar fishing boast crew
<br />members and fishermen and gross proceeds paid to attorneys
<br />(mclud rig payments to cWoratloh«.',.
<br />5. Mortgage interest paid by you, acquisition ot abandonment of
<br />secured property, cancellation of debt, qualified tuition program
<br />payments (under section 529), IRA, Coverdeil ESA, Archer MSA or
<br />HSA coninbutions or distributions, and pension distrkautions. You
<br />must give your correct TIN, but you do not have to s,gn th6 certification
<br />What Name and Number To dive the Requester
<br />For this type of account
<br />GnW name and SSN wC
<br />..It
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<br />mYa.hail"grxat
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<br />itsrnila,u, tart x, NirttX4 nlrn
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<br />G k+' t tru• i ,� x.xa t9�rt e`
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<br />tfi i aE ,n�mrr
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<br />t7,a,ttx II In4r tut ! a,<I,d '. 11A,—I
<br />ff,- 'Slrnntrx`
<br />11
<br />ti ,tldetrx aa:<'.r till- 41,t.aalP >ri+�i.
<br />For this type of account
<br />Grie Hams and EIN at
<br />:i'ir �ient,•lu,aith,,,a,N- nrab :sl
<br />ii�rr. -,r,v
<br />nxir „ +h ini
<br />i3. A Ad tr,1,3. ,1,4, :sr i” +aril �i inx,i
<br />I ,�gal,.latni
<br />! }. (: t tar tr l i Y t
<br />ttr- arq.0 v,xh raft
<br />tixvi. 'ws
<br />P: Ir .di «,. alt,, a,1a11<.I�,,
<br />itN +.¢1tulnU <>rr
<br />ri f -d,Q�- •:�kr fl<x gel, rw Aa` *� ^e
<br />tai ysipt �aq ^remxrtB,a,
<br />I I rt r s61r> or r' -Nt n vlrix�t l t
<br />ft,,-i. alsw;,icP
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<br />i:i. H� .lair va-itE it. t), y>:lA inuvit ni
<br />It, 1e46 <mhrr
<br />Atii�c4atrn,- u, its. iunxr nt a Ix1trr�,.
<br />w tit - gwuia sr� t ql -.x bar`
<br />i,i, rv-nrcxfia I.,aM- 11�in,:,1. :;e
<br />fir cu al:n rw: �.gillilxlitur.ii
<br />pe,rp:ahx 11;e .a,U:
<br />1 4 . [1, i19Us 1"'1 th 4i 1,n It,,, i—t
<br />Ih, U."I
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<br />anal Mol.A �' i''r
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<br />4
<br />Note- It no name is cecled whin more fitan one name is listed, the
<br />number bull! be considered to be that of the fe h rarne, listed
<br />Secure Your Tax Records from identity Theft
<br />identily theft occurs when somawii USeS Your p� ' -scsnal information
<br />such as yct it name_ social security nurnber r` SNp or other Identitying
<br />intormatroi) without your permrsson- to summit fraud o other crimes
<br />An Identity thief may use your SSN to get a job or may file a tax return
<br />using your SSN to receive a refund
<br />To reduce your nsk
<br />• Protect your SSN-
<br />. Ensure your amptoyer is protrrtzN your SSN, and
<br />• Se carefi 'z when <:hoosing a tax proparer
<br />if yon tax records are affected oy identity theft and You receive a
<br />notice from the IRS respond right away to ft% name and phone number
<br />printed on the IRS notice or lettex .
<br />it your tax records are not ctarently affected bi, identity theft but you
<br />think you are at risk due to a lost or atdtan purse or wallet, questionable
<br />creckt card act' ity° or oradit repay, contact the IPS Identity Theft Hotline
<br />at t - !Ti?0- 9G8 -449ir ot submil Form 14039
<br />For mote intormalion. see Publicatmn 453`. identify Theft PrESgnl*n
<br />and Victim AWStWIC6
<br />V'r,bms of identity theft who are experiencing PConpmo harm or a
<br />system problem- or are seeking heap in resolving tax problems That have
<br />not beiIn resolved through normal channels, may be, eligible for
<br />Taxpayer Advocate 5er,§ce (TAS) ass,stanc& Yoc, can reach TAS by
<br />calling the TAS toll -free case frstake line at 1-177.777 4771 of TTYITDD
<br />-800- 629 -4059
<br />Protect yourself from suspicious emails or i5hishing schemes.
<br />Phis ing is the creation and use of ornad and wirbsstes designed to
<br />mimic legit =mate business emails and 'web5d*s. The most common act
<br />Is sending an email to a user fals'el'y Claiming to be an esiatilished
<br />legitimate enr9rsrise in an attempt to scam the user into surrendering
<br />Dn,ate mkt mauoh that will be used for Identity theft
<br />The IRS does net initiate contacts rRh taxpayers � errI;Yls. Aso. the
<br />IRS does not TequeS'1 personal detailed Information through emad or ask
<br />taxpayers for the PIN numbers passwords, c, similar se,,ret access
<br />infororaticn to their credit card. bank or other financai accounts
<br />ft you rerel.e an unsoficiled emad ciaim,ng to be from tike IRS..
<br />ra.arard thi3 message to pttistkrigO,re, g®i• You may aISo report misuse
<br />of the IRS name- logo, or other IRS property to the Tlea.st y Inspector
<br />General for Tax Administrat,on at 1 -800- 368 -4484 You can forvvard
<br />Gusplctdlals emaiis to the Federat Trade Commission at sclairam,ce tt..av
<br />or contactthen,atuv ft - yrae}dznatYort- 877- IpTHEFT
<br />0 -5 77 -438- 4336).
<br />trlsr IRS go= to learn more about rdivitav theft and hio•N to reduce
<br />You, rink
<br />Privacy Act Notice
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