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Form""FormWIM9 Request
<br />Dep:(RevmentofDecember 2Q1as Identification Num
<br />Department of the Treasury
<br />Internal Revenue Service
<br />1 Name (as shown on your Income tax return). Name is required on this line;
<br />County of Kittitas
<br />N 2 Business name/disregarded entity name, if different from above 'T
<br />Kittitas County
<br />3 Check appropriate box for federal tax classification, check only one of the following seven boxes:
<br />o g 4 Exemptions (codes apply only to
<br />[] individual/sole proprietor or certain entities, not individuals; see
<br />C Corporation ❑ S Corporation ❑ Partnership L] Trust/estate
<br />0.o single -member LLC instructions on page 3):
<br />EJ Limited liability company, Enter the tax classification (C=C corporation, S=S corporation, P=partnership) s Exempt payee code {if any) 3
<br />U
<br />p` 2 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 />c the tax classification of the single -member owner.
<br />ti e ❑ Other (see instructions) 0, code (if any}
<br />V tgopims to accounts maintained outside the U.S.)
<br />5 Address (number, street, and apt. or suite no.)
<br />Requester's name and address (optional}
<br />CL
<br />205 West 5th Ave Suite 105
<br />6 City, state, and ZIP code
<br />Ellensburg, WA 98926
<br />T List account number(s) here (optional)
<br />for Taxpayer
<br />ber and Certification
<br />not leave this line blank.
<br />Give Norm to the
<br />requester. Do not
<br />send to the IRS.
<br />LUM Taxpayer identification Number (T N)
<br />Enter your TIN in the appropriate box. The -TIN provided must match the name given on fine 1 to avoid
<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 How to get a
<br />TIN on page 3.
<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 />Social security number
<br />or
<br />tification number
<br />Certification
<br />b010t `t
<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. 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 t 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 />Sign Signature of
<br />Here U.S. person ► _' Date 10 -
<br />General
<br />>
<br />s
<br />General Instructions �
<br />Section references are to the Inlemal 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./rs.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 (ATW), 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 sates and certain other transactions by
<br />brokers)
<br />• Farm 1099-S (proceeds from real estate transactions)
<br />• Form 1099-K (merchant card and third party network transactions)
<br />• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T
<br />(tuition)
<br />• Form 1099-C (canceled debt)
<br />• Form 1099-A (acquisition or abandonment of secured property)
<br />Use Form W-9 only it 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. Certify 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 an 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 gni-9 (Rev. 12-2014)
<br />
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