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w-g Request for Taxpayer
<br />ldentification Number and Certification
<br />) Go to www,irs.govlFormW9lor instructions and the latest information.
<br />Give Form to the
<br />requester. Do not
<br />send to the lRS.
<br />Form
<br />(Rev. October 2018)
<br />Deparlment of the Treasury
<br />lnternal Revenue Service
<br />1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
<br />2 Business name/disregarded entiiy name, if diflerent from above
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<br />General ln ons
<br />Section references are to the lnternal Revenue Code unless otherwise
<br />noted.
<br />Future developments. For the latest inforrnation about developments
<br />related to Form W-9 and its instructions, such as legislation enacted
<br />atter they were published, go lo www.irs.govlFormW9.
<br />Purpose of Form
<br />An individual or entity (Form W-9 requester) who is required to file an
<br />inlormation return with the IRS musl obtain your correct taxpayer
<br />identification number [lN) which may be your social security number
<br />(SSN), individual taxpayer identification number (lTlN), adoption
<br />taxpayer identification number (ATIN), or employer identification number
<br />(ElN), to report on an information return the amount paid to you, or oiher
<br />amount reportable on an information return. Examples of information
<br />returns include, but are not limited to, the following.
<br />r Form 1099-lNT (interest earned or paid)
<br />4 Exemptions (codes apply only to
<br />certain entities, noi individuals: see
<br />instructions on pago 3):
<br />Exempt payee code {if any) 3
<br />Exemption from FATCA reporting
<br />code (if any)
<br />(Applies lo Bcc@nls mainlained ouLide lhe U S.)
<br />Requester's name and address {optional)
<br />Date >0P0 --tuA
<br />099-DlV {dividends, including those from stocks or mutual
<br />funds)
<br />. Form 1099-MISC (various types ol income, prizes, awards, or gross
<br />proceeds)
<br />. Form 1099-8 (stock or mulual fund sales and certain other
<br />transactions by brokers)
<br />. Form 1 099-5 (proceeds from real estate transactions)
<br />. Form 1 099-K (merchant card and third pafty network transactions)
<br />. Form 1098 (home mortgage interest), 1098-E (student loan interest),
<br />1098-T (tuition)
<br />. Form 1099-C (canceled 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 TlN, you might
<br />be subject to backup withholding. See What is backup withholding,
<br />later.
<br />account
<br />Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
<br />backup withholding. For individuals, this is generaliy 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 />IlN, 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 Requester tor guidelines on whose number to enter.
<br />Certification
<br />Under penalties of perjury, I certify that:
<br />1. The number shown on this form is my corect taxpayer identification number (or I am waiting for a number to be issued to me); and
<br />2. I am not subject to backup wiihholding because: (a) I am exempt from backup withholdlng, 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 repod all inierest or dividends, or (c) the IRS has noti{ied 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 />Certilication instructions, You must cross oui item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
<br />you have failed to reporl all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
<br />acquisition or abandonmont of secured propedy, cancellation of debt, contributions to an individual reiirement arrangement (lRA), and generally, payments
<br />othel than interesi and dividends, you are not required to sign the corlification, but you must provide your correct TlN. See the instructions for Part ll, later.
<br />7
<br />or
<br />Sign
<br />Here
<br />I
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<br />3 Check appropriale box for federal tax classi{ication of the person whose name is entered on line 1 . Check only one of the
<br />following sevon boxes.
<br />f] lndividual/sole proprietor or fl C Corporation I s Corporation n Padnership f] Trust/estate
<br />single-member LLC
<br />I timiteO liabillty company. Enter the tax classitication (C=C corporation, S-S corporation, P=Partnership) ]
<br />Note: Check the appropriaie box in tlre llne above lor the tax classiliEation ot Lha single-rrenrber owner. Clo nol check
<br />LLC ii the LLC rs classiliod Bs a singlernenrbor l-LC that is disregarded from the orvner unless the olvnor ct lh€ LLC is
<br />another LLC that i$ not disfegarded from lho o'rrner for U.S, federal tax purposss, Otherwi$e, a singlo-m€mb6r LLC lhat
<br />is disregarded lrom the owner should check the appropriate box for the tax classjfication of its owner,
<br />Other {se6 instnrctions} >
<br />5 Address {numbsr, street, and apt. or suile no.} Ser: inslruc!io|rg.
<br />w.5 Suite 105
<br />6 stale, and
<br />WA 98326
<br />cation Number
<br />Social numbor
<br />Part I
<br />id€nlification flumber
<br />9 1 6 0 0 ,|3 4 I
<br />Part ll
<br />Signature of
<br />U.S. person
<br />Cat. No. 10231X rorm W-9 (R6v. 10-2018)
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