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Form W•9
<br />(Rev. Oeo~rnber 2014)
<br />OoparlJ,to"I of Iha· Ttoooury
<br />lrtt~AUVOllU8 8orv!CII
<br />Request for Taxpayer
<br />Identification Number and Certification
<br />Olva Form to tho
<br />requostar, Do not
<br />sand to the IRS.
<br />1 n1110Jno shown Oil YoIIr 1111:oino l1Ut1ol . o nOI luuvii U,fR 1h10 bllJll~.
<br />Cdunly of Kittitas
<br />"1 2· tlillf\Ollli ruinirr{cflurooardd Gnl 1y name, 11 dll &ro nl rom obo~11 I Klllltus Oounly
<br />3',Cf llOk 11pprcp1luto box /or fodoral lax olaa1moalllm1 ohacR only ono ol tho lolowlng oovan boJ<U8 ~ [l k1dlvldlllll/at11n p/aJll\dtoror O O Corp<lf"ll on O S C111pomllon O Pur1nofahl11
<br />4 Gl<on!J)Qono (oodon DA ply onl y to cwtlJfn1pnUtluo, not lndlvtau11le1 see
<br />1110 111.10 ton~ an p.ago 3): 0 Trual/aalula
<br />1Ji, [l tlmllod ~nhll!ly aornp1111y, Ehlor Ilia lllX ctuulflbl\Uo n (O-.O co l'J)orAl!Clll, Bli8 /mrJllllnllon, l~,ip.arl narshlp) • ~ j Dlnglt>-(110m!Nlr LLO
<br />b Noto, Fors ~o!n-mol)lbor ll.c Ui.t lo dlJroirnrdo d, do not uhool< I.LO: oheok the appropriate box In the 1/n~r
<br />exampt pnyoo aoda _pr any) _J_
<br />Examptlon from FATCA reporting
<br />oode (II any) l; tho tnx m s IOootlbo of tli<i-iif/iolo-mnmbor ownur.,
<br />d! u D 011101 aeo lnwuollbno) •
<br />!§ 8 Add/01,a nun,ll ar, otroel , a~d apl , or BU\lij 110.)
<br />8, 206 West Gth Ava Suite 10G
<br />~ 8 IY, Dlqto, and ZIP oo do
<br />w El!ansburg, WA 98926
<br />7 L!fll account.11umbor(o) horo (cipllonn~.
<br />(AppN&• , •... ou,,, n,11,u,1110</ oullldo lhl IJ,,SJ
<br />floquo,l!lr 'o nm11a ond n es1 0111 nnl)
<br />Enl or yOl,lr TIN In \he apP,iopil,ate ,box. The TIN plOVldod muat match the name g!von on !ll'l e 1 to avoid
<br />b11,ok\J)) withholding. For l_ndl~Jduals, t_hl& la gonorally your aootal aeourtly numbor,jSSN). However, tor &1
<br />resident allan, eola ptop~ot91·, Qfidlal'ii'gardod .ant!ly, aeo th~ Pi!.rl 1-lnatru oU oll!l on page 3, For other
<br />entlllaa, It Is your orrtployor ld.ol'1\lllaotl\'.in n\lmbar (E!N), If you do not havo a nurnbor, n9 How lo get a
<br />TIN on paga 3,
<br />-I I I I I
<br />Noto. If tho aooount ls In mure _than_p,n ci name, see theJnstruotlona for line 1 and the chart on page 4 for
<br />guldallnes on whose num bet to enter.
<br />-6001349
<br />Cortlflo-i:1t1on
<br />Under pona tlaa of per)ury, I certify that:
<br />1, The number shown on this form le my correct taxpayer !dontlilca~\on number (pr 1 am waiting for II number to be Issued to ma): ond
<br />2. I em not ~ubjt){l t to b!\ol\llp wt!hholdlno bs011v se: (ii) J am exem pt from baokup w(lhhold lng, or (b) I h~ye not b aen ,n q@ ed by thEI k\'j,o(nll l Rovon ue
<br />S8!Y!oa (IRS) that I am su~JeQt to b~okup ,wilhh oldlng ae a re su (t or a falli m1 to report oil lnte rost or dlvld onds, or (o). lhtl IRS has no! fled mo lhet I am
<br />no lo nger subJeot to bMkup wlth holdlno; •Md '
<br />3, I am a U,B, cltlzM or other U.S. person (defined below): and
<br />4. Tho FATCA oode(e) entered on this form (If any) lndloatlng that I am exempt from FATOA reporting la oorreot.
<br />Certification lnstruotlona. You must cross out Item 2 above It YOIJ hovo been no.tined by tho IRS that yoiu1ro ourroi,lly eubjoot to baokup •WJ thho lcilng
<br />beoauee you have fa llo d le> report 11!1 lntoreuLand divide nds on your lei< roturn, For re£1I sstnta 1nma 1101toos1 llem 2 does not apply. For l'l\ortoa~e
<br />Interest p.uld, 110qulalllt:ln ot 11b:ondonmilnt ol socuri:id property, onnoonatlon of deb!, oontrlbutlons to on lndlvldu.nl rotl romat1.l ll/'1'angem11ni (IRA), !!/Id
<br />gon\ll'olly, poymen!s 0U1et than lnll)fest and dlvldenda, you are not requi re d to sign lhs.oartlflcatlo11, but you mus I provldo yovr oorr6al TIN, Sa.o iha
<br />lr)qtruollo ns on page~.
<br />Section rofereMea oro to tho lntQrnol Revenue Code unless olherw/aa noted,
<br />ruturo dovalopJ111111bl, tnfarnuitlon about deVolopments orroollng Form W•9 (such
<br />as leglslnllon en aoleil ult11r"wo ro'9a ee 11) 1, lll Wlw1./a.go v/fly!),
<br />Purpose of Form
<br />All lntljyldulli or onttly (forln W·O roqll01 tt~ who le rcq~lrod lo fOo an ln ldrmodon
<br />ro tum wlU\ 11\o IR8 muut ob tain your o~rroot IW1p11yer 1<1ont/float1on 11\.WTibo, (TIN)
<br />whloh mny b.o your soatnl ~~011i11 y numh or ISSN), Ind/I/Idun .t~pnyor k1 01illf1011tlan
<br />n1t mbor ·QTIN), fldop l!~n t1111p11)1or ldJ)l1llr!oQ fon number ~TINJ, ur emp!oyor
<br />ldo11tllklnt1011m1in'ottr (SN), toropcill on nn lnform~tton roiur n lh9 amount paid to
<br />9ou, or otl\Or amount 1/Jjlortablo on nn lnlorm~Uon return. Eltamp loo of loro,matlon
<br />rolurns fnoludo, but are not lmltad 101 u,o loll ow!ng: ·
<br />• Form 1090•INT (lntorest oarned or puld)
<br />• Fonn 1099,0IV (dlvldanda , lncl11dlng thoe11 lrom atocka or mutvnl runds)
<br />• Form t OBO•MISO (varloua lypea of lnooma, p(liao, award a, or groea proceed&)
<br />• f'ann 1099•8 (eloak or mutual Jund eQlea and certain ot/1or tranaaotlans by
<br />b10k0/IJ)
<br />• Form 1088•S (proooada from real estate tranaRotlonij)'
<br />• Form 1099-K (merohnnt oard and third party n~lw01k tranaaotl(ms)
<br />• l'arm 1098 lhoma mortgaao lnlereel), 1088·E (aludant loan Interest), 1090•T
<br />(tuition)
<br />• Form 1 oas-o (canceled debQ
<br />• Form 1 OOll•A (aoquta\llan or abandonmonl of aooured proper!'>')
<br />Use r-orm W·9 ont y If you aro a u,s, poreon (fnoludlng a reatdont allan), to
<br />provide ),'O\Jr corrooL TIN,
<br />If you d(I 110 1 ,vlur11 Fom, W·9 lo lhQ n,quo~·lur 1v/lh a TIN, ~ mlallt be st1bjeot
<br />lo ba a~up wll/1110 ld!11a. 800 W/Jql Is boak11p w/11!110/d/no? on pag e 2,
<br />By algnlng Iha llllod-oul ftinn, you:
<br />1, CQ rtlly·lh at lho TIN you are giving Is oorteot (or you are waiting lor a numbar
<br />to bo feauod),
<br />2, Certify 1h31 you are not subject to backup wllhholdlng, or
<br />a. Otnirn oxi>mpllo'n rrom b?tku 11 w111~1ald\ho If you oro a· U,6 , til<n111(ll payoo, If
<br />ip11nonblo, you n.ro .oJa O: oartlfylng that as a U.B, ilil~on. your nl kmuble eliure ot
<br />any partnornhlp lnMo lro111 a IL$, 1n1t10 or buslnous la not eull(oot 10 lho
<br />w11i~10lal~p lox on forolun i>arln~ra' erniro of otroottvqly 001111oolod llwomo, ond
<br />4. OorWy th«I FATOA aode(al onlorod 011 /Ji.ls form (II any) \ndJqot!nl! lhal ~tl\J nrfl
<br />01«1mpt Irani lho F/\TOII ropqrt ng , fa corrool , Sae W/fqf la FArCA1oparlfna1 on
<br />flOD1l 2 tor ll111hGr lnrom,allon.
<br />:.Cl"at, No, 10231 X Form W-9 (flciv. 12-20141 ·
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