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Formw-9
<br />(Rev. December 2014)
<br />Department of the Treasury
<br />Intemal Revenuo Service
<br />1 Name (as shown on your Income tax
<br />County of Kittitas
<br />Kittitas
<br />Request for Taxpayer
<br />Identification Number and Certification
<br />name,
<br />on
<br />duove
<br />Give Form to the
<br />requester. Do not
<br />send to the IRS.
<br />3 Check appropriate box for federal tax classification; check only one of the following seven boxes, 4 Exemptions(codes apply only to
<br />❑ Individual/sole proprietor or F -1C Corporation El Corporation EJ Partnership certain entities, not Individuals; sec
<br />p ❑ Trust/estate instructions an page 3):
<br />single -member LLC
<br />❑ Limited liability company, Enter the tax classification (C -C corporation, S=S corporation, Pttpartnership) ► Exempt payee code Of any) 3
<br />Note. For a single -member LLC that is disregarded, do not check LLC; check the appropriate box In the line above for Exemption from FATCA reporting
<br />the tax classification of the single -member owner, code (if any)
<br />❑ Other (see instructions) ► (Applies to accwnts Mlntalned autstda the V.9)
<br />5 Address (number, street, and apt, or suite no.) Requester's name and address (optional)
<br />205 West 5th Ave Suite 105
<br />Ellensburg, WA 98926
<br />7 List account number(s) here
<br />Z
<br />Enter your TIN In the appropriate box. The TIN provided must match the name given on line 1 to avoid social security number
<br />backup withholding. For individuals, this is generally your social security number (SSN), However, for a
<br />resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other
<br />entities, it is your employer Identification number (EIN), If you do not have a number, see Now to get a -FT
<br />TIN on page S. or
<br />Note. If the account is In more than one name, see the Instructions for line 1 and the chart on page 4 for I Employer identification
<br />guidelines on whose number to enter, F-7-71 F-
<br />-r--1--
<br />Under penalties of perjury, I certify that:
<br />1. The number shown on this farm is my correct taxpayer identification number (or I am waiting for a number to be Issued to me); and
<br />2. 1 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
<br />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
<br />no longer subject to backup withholding; and
<br />3, 1 am a U.S, citizen or other U.S, person (defined below); and
<br />4. The FATCA code(s) entered on this form (If any) Indicating that I am exempt from FATCA reporting is correct.
<br />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
<br />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
<br />interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
<br />generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
<br />instructions on page 3.
<br />veyrr I Signature of
<br />Hera U.B. person )-
<br />General
<br />General Instructions`
<br />Section references are to the Internal Revenue Code unless otherwise noted,
<br />Future developments, Information about developments affecting Form W-9 (such
<br />as legislation enacted after we release it) is at www.1rs.gov/fw9.
<br />Purpose of Form
<br />An individual or entity (Form W-9 requester) who is required to file an information
<br />return with the IRS must obtain your correct taxpayer Identification number (TIN)
<br />which may be your social security number (SSN), individual taxpayer Identification
<br />number (ITIN), adoption taxpayer Identification number (ATIN), or employer
<br />identification number (EIN), to report on an information return the amount paid to
<br />you, or other amount reportable on an information return. Examples of Information
<br />returns Include, but are not limited to, the following:
<br />• Form 1099 -INT (Interest earned or paid)
<br />• Form 1099 -DIV (dividends, including those from stocks or mutual funds)
<br />• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
<br />• Form 1099-B (stock or mutual fund sales and certain other transactions by
<br />brokers)
<br />• Form 1099-S (proceeds from real estate transactions)
<br />• Form 1099-K (merchant card and third party network transactions)
<br />Date ► l�-lfy 4(
<br />• Form 1099 (home mortgage Interest), 1098-E (student loan interest), 1099-T
<br />(tuition)
<br />• Form 1099-C (canceled debt)
<br />• Form 1099-A (acquisition or abandonment of secured property)
<br />Use Farm W-9 only If you are a U.S, person (including a resident alien), to
<br />provide your correct TIN,
<br />If you do not return Form W-9 to the requester with a TIN, you might be subject
<br />to backup withholding. See What Is backup withholding? on page 2,
<br />By signing the filled -out form, you;
<br />1. Certify that the TIN you are giving is correct (or you are waiting for a number
<br />to be issued),
<br />2. Cartify that you are not subject to backup withholding, or
<br />3. Claim exemption from backup withholding If you are a U.S. exempt payee. If
<br />applicable, you are also certifying that as a U.S, person, your allocable share of
<br />any partnership Income from a U.S. trade or business Is not subject to the
<br />withholding tax on foreign partners' share of effectively connected Income, and
<br />4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
<br />exempt from the FATCA reporting, is correct, See What Is FATCA reporting? on
<br />page 2 for further Information.
<br />Cat. No. 10231X Form W-9 (Rev. 12-2014)
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