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llll-9Form
<br />(Rev. October20'18)
<br />Deparlment of the Treasury
<br />lnternal Revenue Ssruice
<br />Request for Taxpayer
<br />ldentification Number and Certification
<br />I
<br />rc€-
<br />Give Form to the
<br />requester, Do not
<br />send to the lRS.
<br />Dale >0t- 0 -)0L
<br />(dividends, including those from stocks or mutual
<br />funds)
<br />. Form 1099-MISC (various types of income, prizes, awards, or gross
<br />proceeds)
<br />. Form 1099-8 {stock or mutual fund sales and certain other
<br />transactions by brokers)
<br />. Form 1099-5 (proceeds lrom real estate transactions)
<br />o Form 1099-K {merchant card and third party network transactions)
<br />. Form 1098 (home mortgage interest), 1098-E (student loan interest),
<br />1098-T (tuition)
<br />. Form 1099-C (canceied debt)
<br />. Form 1 099-A (acquisition or abandonment of secured property)
<br />Use Form W-9 only if you are a U.S. person (including a resident
<br />alien), to provide your correct TlN.
<br />lf you do not return Form W-9 to the requester with a TIN, you might
<br />be subject to backup withholding. See What is backup withholding,
<br />later.
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<br />I Name (as shown on your income on do not leave
<br />2 Businoss name/disregardod entity name, if ditferent from above
<br />4 Exemptions (codes apply only to
<br />certain enlities, not individuals; see
<br />instructions on page 3):
<br />Exempt payee code (if any) 3
<br />Exemption trom FATCA reporting
<br />code (if any)
<br />Wpties lo eccounls ma'nlainedoulsldBthc U S)
<br />name
<br />7 List account
<br />Enter your TIN in the appropriate box. The TIN provided must maich 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 alien, sole proprietor, or disregarded entity, see the instructions for Part l, later. For other
<br />entities, it is your employer identification number (ElN). lf you do not have a number, see How to get a
<br />t/V, later.
<br />Note: lf the account is in more than one name, see the instructions for line 1, Also see What Name and
<br />Number To Give the Fequester for guidelines on whose number to enter.
<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) | am exempt from backup withholding, or (b) I have not been notified by the lnternal Revenue
<br />Service (lRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IFS has notified me that I am
<br />no longer subject to backup withholding; 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 />Cerlification instructions. You must cross out it€m 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
<br />you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
<br />acquisition or abandonment of secured property, cancellation of debt, conhibutions to an individual retirement arrangement (lRA), and generally, payments
<br />other than intsrest and dividends, you are not required to sign the certification, but you must provide your correct TlN. See the instructions for Part ll, later.
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<br />Sign
<br />Here
<br />General ln s
<br />Section reJerences are to the lnternal Revenue Code unless otherwise
<br />noted.
<br />Future developmonts. For the latest information about developments
<br />related to Form W-9 and its instructions, such as legislation enacted
<br />after they were published, go to www.irs.gov/FormW9.
<br />Purpose of Form
<br />An individual or entity (Form W-9 requester) who is required to file an
<br />information return with the IRS must obtain your correct taxpayer
<br />identlfication number [IlN) which may be your social securily number
<br />(SSN), individual taxpayer identification number (lTlN), adoption
<br />taxpayer identification numb€r (ATIN), or employer identification number
<br />(ElN), to report on an information return the amount paid to you, or othor
<br />amount reportable on an inlormation return. Examples of information
<br />returns include, but are not limited to, the following.
<br />. Form 1099-lNT (interest earned or paid)
<br />3 Check appropriata box for federal tax classification of the person whose name is entered on line 1 . Check only one ol the
<br />following seven boxes.
<br />fl lndividual/sole proprietor or fl C Corporation n s Corporation E Partnership n Trusl/estate
<br />singl6-member LLC
<br />fl t-imiteO liabillty company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ) _
<br />Note: Check the appropriats box in thB llns abov€ tor lho lax classification o, tho single.mgolb€r owner. Do nol ch€ck
<br />LLC if the LLC is classilied as a singls-mEmbsr LLC lhat is disregardgd from tho own6r u*lo6s thg owl€r ol the LLC is
<br />another LLC that is not disregorded from thB ov/ner for U,S. lgdetal lax purposeg. Othorwiso. a singlo-mombor LLC
<br />is disregarded from lhe owner should check the appropriate box for the tax classification of its owner,
<br />Other Political Subdivision
<br />apt. or
<br />utt"
<br />(numbsr,
<br />Suite 1
<br />6 City, state, and ZIP
<br />wA 98926
<br />numbor
<br />Part I
<br />numbsr
<br />9 1 6 0 0 1 3 4 I
<br />Part ll
<br />U.S, person
<br />Signature of
<br />Cat. No. 10231X Form W-9 {Fev. 10-2018}
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