Business name/disregarded entity name, if different from above
Check appropriate box for federal tax classification (required):
Street Address (number, street, and apt. or suite no.)
City, State, and ZIP code
Requester"s name and address (optional)
List account number(s) here (optional)
Social security number
Employer identification number
Enter your TIN in the appropriate box. The TIN provided must match the name given
on the Name line to avoid backup withholding. For individuals, this is your
social security number (SSN). However, for a resident alien, sole proprietor, or
disregarded entity, see the Part I instructions.
For other entities, it is your employer identification number (EIN). If you do not
have a number, see How to get a TIN.
Note. If the account is in more than one name, see the
chart for guidelines on whose number to enter.
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding 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 report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (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 withholding because you have failed to report all 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 property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN.
I certify that the information provided above is accurate.