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Form W-9 Request for Taxpayer Give Form to the
<br />(Rev. December2014) Identification Number and Certification requester. Do not
<br />Department cf the Treasury send to the IRS.
<br />lrltemaJ Revenue Service
<br />1 N.wne (8ll-sllown on yol.l" 111!:ome tax rotulT)). Nam!! 11' req\,lfted on ihls llno; do not leave this line blank.
<br />County of Kittitas
<br />t\i 2 Business n11meJ'.dlB(egard9d entity name, ·r~ qlff8fllllf from · abov~
<br />& Kittitas Couhty
<br />Ill
<br />0. 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 0\0'1'1p1)ons (codes apply only to
<br />C:
<br />0 0 Individual/sole proprietor or 0 C Corporation 0 S Corporation 0 Partnerahip 0 Trust/estate c:e,toln entities, not individuals; see
<br />CD CD ulng~ber u.c instructions on page 3):
<br />0. s Exempt payee code (If any) 3 ~= 0 Urntted l!ablllly company. Enter the tax classification (C=C corporation, SaaS corporation, P=partnership) •
<br />.. C) Note. For II slngle,member LLC ttiat Is disregarded, do not check U.C; check the appropriate box in the line above for Exemption from FATCA reporting
<br />0 i:!
<br />1: ~ the lox dassJflcafiorl of the lllngle-inem ber owner. code ilf any)
<br />'t:-0 Other (~ 111structlons) • ~IO--~'""""'ll'III U.SJ a. C)
<br />!E 5 Address (rllJ!Tlbel:, s1re¢, and.apt-or suite 110,J Requester's name and address (op_trorµilj
<br />C)
<br />G 205 W 5th Ave, Ste 105 I
<br />CD 6 City. state, and ZIP cxxf11
<br />ID Ellensburg, WA 98926 en
<br />7 Ust account nµmbl!f(S) here (opt_lcnal)
<br />. Taxpayer ldentlflcation Number (TINJ
<br />I Social !!ec.urity number I Enter you~ TIN in the app_ropriate box. The TIN provided must_ match the name given on line 1 to avoid
<br />backup withholding. For individuals, this Is generally your social security number (SSN). However, for a
<br />resident alf~n, sore proprietor, or disregarded entity, see the Part I i nstructions on page 3. For other
<br />entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
<br />TIN on page 3.
<br />0IJ -[D -I I I I I
<br />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
<br />guidelines on whose number to enter.
<br />I EmploJer ldcnllfic::.Uon number
<br />91-6001349
<br />Certification
<br />Under penalties of perjury, I certify that
<br />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
<br />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
<br />Service (IRS) that I am subject to backup withhofdlng 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 wtthholdlng; and
<br />3. I 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 rear 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 oh page 3. •
<br />Si_gn Signature of
<br />Here u.s. pen.on • -
<br />General Instructions
<br />Section references are to the Internal Revenue Code unless otherwise noted.
<br />Futlll'e ~evelopments, lnformeilcf'l about devolopmonts aff~g Fenn W-9 _(such
<br />as legislation enacted alter we release it) Is at www.ir.s.gov/fw9.
<br />Purpose of Form
<br />An Individual ot et1llly (f'o.rm W•9 requester! who Is l'e<:1\lil'ed to 111e an Information
<br />reWm witll the IRS m1.161 ootalnr.our C01Tect taxpayW ldenlif1C311on number (TIN)
<br />whlcl1 may be your soc!al sei:urtty number (SSNJ, indivitfual taxpay« lderltifk:atlon
<br />1100111« (ITIN), adoptlor, talq)a)'lll' identlficatlor, r,umber (ATJN), ci: mployllf .
<br />!dernmoa«on numti.!f (EIN), to report on an lnfOtlllil,tjon retum Ille an-rount paid to
<br />you, or other amount reportable on an infonnation 111tum. Examples of infonnation
<br />returns include, but are not limited to, the following:
<br />• Fenn 1099-M [interest earned or paid)
<br />• Fonn 1 ~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 c!lrtain other transactions by
<br />brokers)
<br />• Fann 1099-S (proceeds from real estate transactkms)
<br />• Form 1099-K (merchant card and third party network transactions)
<br />Date • II I . lK
<br />• Fann 1096 (home mortgage interest), 109&-E (student loan interast), 1098-T
<br />(tuition)
<br />• Fann 1099-C (canceled debt)
<br />4 Fann 1099-A(ac:qul'sttlor, 01' abandonment ol SIICUred property!
<br />Use Form W-9 only if you are a U.S. person (11ch.ldin9 a resident alien), to
<br />provide your oorrect TlN.
<br />If you do not return Form W-9 lo the requester with II TIN, you might be subject
<br />lo bactwp withholding. See What is backup withholding? on page 2.
<br />By signing the filled-out fonn, you:
<br />1. Certify 1hat 1he TIN you are giving is correct (or you are waiting for a number
<br />to be issued),
<br />2. Certify that you are not subject to backup wlthholdlng, or
<br />3. Clam exemption from backup withholding if you are a U.S. exempt payee. If
<br />appl"icable, you are also certifying that as a U.S. pe,son, your allocable share of
<br />any partnemilp income from a U.S. trade or business is not subject to 1he
<br />withholding tax on foreign partners' share of effectively conriec:ted income, and
<br />4. Certify that FATCA code(s) entered on this fonn (rf any) indicating that you ara
<br />exempt from the FATCA reporting, is correct. See What is FATCA rt!pOrling? on
<br />page 2 for further information.
<br />Cat. No. 10231X Form W-9 (Rev. 12-2014)
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