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Form W-9 Request for Taxpayer Give Form to the
<br />requester. Do not (Rav. Oeoo~er 2014)
<br />Dtportlnenl of tho Trejuury Identification Number and Certification send to the IRS.
<br />lnlarnal .RalltnUO SJIMce
<br />1 N11me,(H shown on yourlnc omo lQ)notum}. Namo _ls·requlrelf on 1h11 Rne; do not 1911111 lhla U110 blank.
<br />county of Kittitas
<br />t.J 2 Busjrit1111 mmv/dlsn!gardod entll)' nama, If dlllonmt from abo1111
<br />f l<lttl!as County
<br />0. 3 Check appropriate box for federal tax classiffcallon: check only one of Iha foUowfng seven boxes: 4 E-xo111ptlo~ (oodas lft'~ qnfy ~-g certa11\enlllles, not Ind v dliml,; uil ! ., 0 lridlvllfual/10le proprietor or D C Corporation O S Corporation O Partnership
<br />slngle-momber Llo
<br />0 TrusVastate !Mtruc Joni on page a):
<br />Exempt payee code 01 .1111y) 3 ii O Limited Uablllly company. Enter the tax classlllcaUon (C•C corporatlon, S•S corporation, p .. partnarshlp) II>
<br />Exemption from FATCA reporting Noto. Fora l!lngltM'nember LLC that Is dlsr~gard.od, do not check LLC: check the appropriate box In Iha llna above for
<br />. lh11lax olaaslffcatlon of the sing le-mambo~ owoer. coda ~f any)
<br />0 Other (1M lnstructlOJ1s} JI,, f'il,pllolfollH:IUll/1--..,..,...i.i. h lJ.IJ
<br />I S AddteS'S (IIUmbar, litr~t. and apt. or eulta no .) 'R0<iuo.atar'• name and addreas (opt!o"'°
<br />205 West 5th Ave Suite 105
<br />! 8 Olty, tiel•, lllld ZIP c:pdo
<br />Ellens~rg, WA 98926
<br />7 Uat account number(9) hero (opl!on·lll)
<br />.!Sil •• Taxr:>~ver Identification Nutnber (TIN)
<br />Enter your TIN In ltio el)p~~Jra!_e pox, Thi, 'flN p,:ovlded must matQh the nome git/en on line 1 to avoid Soolaf ,aourlly hllmher
<br />backup withholding, For I lv(dual11, this Is gen&rally your aa~al security numbet (SSN). However, font I I l-[D -1 I I I resldent al!en, 1ole p,:oprletor, or dlsregordad enllty, see the Part I lnslruo.tlons on page 3. For o{her
<br />8flll(fes, 11 Is your employer ldenUfleatk>n number &JN). Ir you do not have a nUl11ber, soo How to QGI "
<br />TIN on page 3. F.o::-r-,..--..,..,......,,.,:--:-:---..,.-..-----.
<br />Note. If the account Is In more than one name, see the Instructions for Rne 1 and the chart on page 4 for I flmpioyor ldtntlfl011llon nwnt,er
<br />guldellnes oo Whose number to enter.
<br />'l 1
<br />Certification
<br />Under penalties of pe~ury, I certify that:
<br />1. The number shown on this form Is my correct taxpayer ldentlflcatlon number (or I am waiting for a number to be Issued to me); and
<br />2. I am not subfect to baokup wlthholdlnQ because: {a) I am exempt from backup wlthlloldlng, or (b) I have not been notified by the Internal Revenue
<br />Service .OBS) that I am subJact to baokup Wlthhold;lng as a result of a failure to report all Interest or dividend!!, or (c) the IRS has notified me .that I am
<br />no longer aubJe.ot lo blioKUp wllhholqlng; and
<br />3. I am a U.S.,oltlzen or other U.S. person (clefln-ed below); 11nd
<br />4. Tha FATOA coda(s) entered oo this form Or any) lndlc~tlng that I am exempt from FATCA reporting Is correct.
<br />Certlfloatlon Instructions. You must cross out Item 2 abova If yoµ have been noll/led by the I~ that you ,re currently auJ:>)eot to backup wltl'lholdlog •
<br />be_causa Yol.l have falled to report Qff Interest and dlvlde)'lds on your tax .return , For real ,eslate tre,nsac.tloo&, Item 2 dO&S not apply. For mQrtgage
<br />lnterqsti pold, acquisition or abandonment o,f sewred proper1y, cancellatlon of debt, conl(lpuUo.ns to an Individual retirement ~~ngernoot QRA), and
<br />generally, payments other th~n Interest and dividends, you IU'& not required t9 etgn tho certmoation. but you must provide your correct TIN. See the
<br />lhstruo11o~on p~gi, 3.
<br />Sign Sign ature of
<br />HQre U.S. petaon
<br />Section references ara to the In! ·al Revenue Coda unless otherwise noted.
<br />Futlll'e diivelopm.-n\a. lnfo«natlon about davelopmen\a affecting Fonn W-9 (such
<br />as leglalatlo11 •l'.lacled alterW• rete•s• It) la at www./,a;gov/fW9.
<br />Purpose of Form
<br />kl ·JndlvJ:l!tlll or entity (F<ll'fl1 W·9 requ,~t~ .who JI required to flla1111 lnformi1Uon
<br />relum ,l#lih th• ~s mu,t obtain your correct ~y,r ldorilllloatlon n~mbot (rlN)
<br />which m•i, b,11 YoiAI' aoolal aiitrurky number (SSN), tn.dMd~·taxpayer kl1nt1nca.tlon
<br />oumbe'r(ITIN),edoplkln laxpay,r ldan!IIIClltlQn number (ATIN)l,cr amployer
<br />1&n11ilaQtlon n11mbff (EiN), lo·r"pott on an ln(llf1TlaUon rolllfl) he amount paid to
<br />, you, or oth'or amolll\l ~pOttehla on an lnformaUon NII.um. Ei<J!mplas of, ln(ormaU@
<br />riltuma lnr;lud&. b!Jt-aye not llmltod to, lhl lollowlng :
<br />• Fonn 1099-INT Onterast earned or paid)
<br />• Form 1()99.01\f (dMdendt, lncfudlno lhoao from lilocks 011rnut11al I\Jl)dil)
<br />, form 1099•MISO,(vatlova typu or Income. prlzoir; 11w1rds1 or grou fftoaoad s)
<br />, F«m 1099-B (ato~ or mutu41 ru™natea and cer1aip ottt,ir tra~clfons by
<br />brokllto}
<br />• Fonn 1099-S fproceeds from real estate transactions)
<br />• Form 1099-K (merchant ca<d and third party network transactions)
<br />• Form 1098 (home mortgage Interest), 1098-E (student loan Interest}, 1098-T
<br />(tuition)
<br />• Fonn 1099-C (canceled debt)
<br />• Fonn 1099-A (acqll!efllon or lbll\dOl)m.1~1 of 1Gc11rad proper\Y)
<br />Uie Form W-9 only rr .vau are a lJ,S. p~aon QIICludl,:ig a Aslden l alien). to
<br />provide vour comiot TIN.
<br />If you do not t11Um Form W,9 to tho requH/er with• TIN, you might be sub/act
<br />to baclttlp wlthholdlll1J., Sile W,,1t 'ls ber:Avp wl//lholdlng? on page 2.
<br />By ,l1,J11lrig th• tllllld·out ror:m, you :
<br />1, Certlty that Iha TIN you are giving ls correct (or you 11ra waiting for a number
<br />lo ~ luufd\',
<br />2 . Certify 1h11 yw 1ra-not aUbfeot to backup wltt,lioldfng, or
<br />3. Olalm exemption from baoliup withholdl.,g If y~IJ ara it lJ,S. e)lempt payH. II
<br />app1Jcabl11,, yo~ ore 1!~i> ~wtll'lfog I.ha\ ~ a U.S. person, yriur aKocablo fflaro ol
<br />any partt1erst1lp ~a,ne kon1 1 u,a, trade or b1.111inoss It! not •ublecl lo !ht
<br />wlthhold1ng (al( on foreign pannoni' 1h11n1 o! e(feoUvely connected ln~omi, and
<br />4. Cef11fy Uiat FATCA code(sl tnllf'9CI on lllls foll!l Of lfly) lr,dloatlnQ tt1a.l you ll'e
<br />ex~mpt f,om the FATCA rciportfno, ls cotrect, Se,Whal.1£ FATCA 111ponlnr,'! on
<br />pago ,2 IOI' rUrth&r lnlom'utitlon.
<br />Cat. No. 10231X Form W-9(Rev. 12-2014)
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