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<br />and dir€ct selss o|/lsr 1 throubh s2
<br />mpt
<br />orlhird pery
<br />M- A ax exempt vust undsr a gdcriolr 4.(ll tb) plan or ssctkln 4€ ? bl
<br />plan
<br />tlqte;'Vou may wl*h to consult wlth ths llnenchl institutbn r€qu€€ting
<br />this fofm to d€tertnine lehfth€r th€ FATtiA s€ds encilorsi€ ln pt paysi
<br />iods should ba complBted.
<br />Line 5
<br />Enldr ltoureddrsss (ftumbst str€€t, and epenm€nt or suit€ nunber!,
<br />This is whsre th€ requs$i€r of this Form l r,g will meil your irrtotmAtion
<br />Et! tns" lt t h ls addre-rs differs f 1pm th€ on€ ih€ r.€qu€.st€r eksaih he^s on
<br />file, writ€ l.lEWet lh€ top; lf e n€v/ addrsss is provijed, lh€r€ is stille
<br />chanc€ ths. old eddrdss will bq u$sd uirtil ths pewi changss your
<br />addr€iie in th€ir l€cord.E.
<br />Llne d
<br />Enur your.city, srali. and ZIF ccde.
<br />Part l. Taxpalrer ldentifieation ttlumber fIlN|
<br />Enrer your TIN ln th* epproprlate box. fi you ere a r€siJsnt ells n and
<br />you do nor have and eid not €llgible to g€r an $SN, rcurTlN is your lR$
<br />individuelte{pey€r idsntificatton number I,ItlNt, Entsi ir in th€ scchl
<br />securlty number lnx. lf !i3! do not hatB'an lTlN, ssilHri,r/ togste lff{
<br />b€low.
<br />ll you ere a sole Fro$htor arld you hew gn El N, yo! rnay snt€ r €ith€r
<br />youiSSN or ElN"
<br />lf liou ers a slngls -tne mb€ r LLC fiet ls disr€osrdsd A.s an € ntity
<br />.s€parale ffom ils oi.v[sfi €nt€r ths or,./n€r's SSN [or ElN. if th€ own€r hes
<br />enbl, qo not€nt€ithd disrdgarded€ntity's ElN. llthb LLC iscla^$,silkdeE
<br />4corporathn or Fannsrship. €nt€r the entiry's EIN;
<br />l.lote; $ee l,Ifiaf /{afl,s and Nilfibar Io Gffe the f;squsshr, ht€ r, lor
<br />ilnh€r chriflcAlion of nsm€ and TIN combinstlons,
<br />Howto 0€taTlH, li you do not haw a TlN, epfV lor on€ imm€diat€V.
<br />To eppv foran SSN. g€t Form S$.5, Application bre StrhlS€curity
<br />Cerd, lrom your localSSA otflcs or g€t thb form onlln€ et
<br />pu,u. $S,4. gnrr. You ffrarr elso gsuhG form Uy ca! iinO 1 -80fl . ? ?2. I i tl,
<br />Use Form W.7; Appllcstlon for IRS thdiviCuelTaxpayqr idenrithetion
<br />NUffb€r, to aFply for en lTlN, or Form S$.4, Appliiation for EmFldr,r\€r
<br />ld€ntilication Number. toapptyforan ElN. Yo! can apij!{oren EIN
<br />anlin€ by ac*€.gsing ths lRg.vl,sheit€ et 1{4t,u.A"s.gov/&Jsi,'ress€s and
<br />clhking on Enploysr ldsntiticetion Nrimber (BNl und€tgHnihg e
<br />Businsss..Go 1o.u^vl,u-,rsgEy/F6rfis to vh!'i. downloed, or print Form
<br />W.l Ard/6i Fom SS-+, Or, liQu can go ro *vnv,i'3.gEv/6iderForinr to
<br />Fbo€ an orclsr snd hs,!i€ Fbrm W-? endf.or Sg-+ meiledto Vou within 10
<br />business days.
<br />It you aie a.ek€d ro complel€ Fotm W.9 But do nrit haW e TlN. eppv
<br />ftr a TIN and wriis "AFpliad Far" in tis $Face for lh€ JIN; sign end dat€
<br />ths torm, End giv€ it to thd ldqu€s1€i. Fof. int€resl arid dlviCa nd
<br />paym€nE, endc€rlain psymsnts mads \.iith rssp€cl to rqadily tradable
<br />in,E{iumant$, oiifi€rally },oii Will haw S.0 deys lo gst a TIN and giw it ro
<br />ths r€qu€st€r befon you er€ subFct.to backuplrrithholding on
<br />paym€nls. The 6{.day ruh do€s not apply to cther typss ol Faymsil,E.
<br />You will be sublrct to beckup withholdifiq on 4ll.such payiilsnts until
<br />you proviJe yourTlN 10 tis r€qu€stsr.
<br />l.loto; Ent€ring .ApFli€d For" me anb that you haue akaady applied lor a
<br />1lN or that you int€nd to epplv tor on€ s{lpn.
<br />Ceutlonr.A disrqgerded U€. snlity thst has a.lorelgn or*n€r must us€
<br />th€ apFropr6ts Form W-€.
<br />Fart ll. Cerlilication
<br />To€6leblish toth€ wlthholding aqintthatl(DU €r€ aLl..s. psr$on. or
<br />r€sidsntali€n, stgtt Form'W.6. You may bs rsqu€stsdlostln byth€
<br />withholdinE eg€-nt s,ush il itsfi 1 . +, or s bslc)r# ifldketss.oth€rwis€,
<br />tui.e ioirit eccounl cinly th€ person whos€ TIN ie ehc,\rin in Pen I
<br />.shsuld.si!n lwh€n r€quirsq, ln th€ ces of e di.slggeided€nt ity, th€
<br />psrson identilh'd on line t must sblr. Exdmpt fegs€6 .Eds E'refiFr psye€
<br />codg serhor.
<br />Slf,nelulg lEqullsmoms, ComFlst€ ths a€fiificetbn as indicatsd in
<br />it€nc 1 through 5 bsleil/,
<br />lrom
<br />abo,!ta
<br />Frymem ht
<br />an.d divids
<br />El-I p{yment Alsnipt(or,,,
<br />AllsiBm s*cspt
<br />Ih h+
<br />an
<br />th€y
<br />.s;ils.s of
<br />l rn..s Forr,l 10Sg-MISe, i,lieceltaneous lficorils, and its instruetions.
<br />2 tlov,'ewr. the followino Blvm€nts mad€ to e corooration end
<br />rsportebl€ on Form 10So-lilSC srs not €x€mpr tiom beckup
<br />withholding: mediceland heehh cerc payirr€nts. attorn€ys' f€€s,. gtoss
<br />pcceeds pad to an sttorn€y r€portabls undsr ssction 6.045(4, end
<br />paym€nts lor.g€rviiss Fad by a fcdsrel€xscuti\i€ ag€ncy.
<br />&don f rom FATCA rcpordng code, The lolbvring ccdes iCentify
<br />FeJr's€s thet ar€ €x€mF! from r€poning undsi FATCA. Th€ss codsE
<br />eFply to psrsons submittin's this form fi3r eccounts meintAinsd outsids
<br />qf th€'lJnit€d Slel€e bV c€rtain tordign linanchl in,slitution$. Th€r€for€, if
<br />you ers onV submin.ing thb torrn.for en account lou hold in.rh€ Unh€d
<br />Stat€s, lr,ou ff'ay leer/€.lhiilisld blenk. Cdnsultwilh th€ p€rson
<br />l€qu€sting thi.sform if you.ate unc€rtein if th€ fiBencht irciitution is
<br />su bjsct to th€s€ r€qu irs rrr€ ntE. A rsqu€st€ r mey indicet€ that a code is
<br />not r€quirsd bV FroviCing ) cu wirh e Form W.g luith "Not Applicabl€" lor
<br />eny similAr indicet'ron) writtsn or print€d ctn th€ lins fcir e FATCA
<br />oeemption code.
<br />A-An orgenizetion exempt from iax under ssction sOJ (al or any
<br />individual r€tir€m€nt Flan a.e dstin€d in section t i01 htt3 ?l
<br />B-Th€ Unh€d Stet€s or any of its agenc i€s qr instrumsntelitiss
<br />q -A .s{At€. th€ Sbtr'tcr of Cal0nbh, + U..$. commonwbalth dr
<br />pos€sgrion: or eny $1 thsir political subdiv isions or instrum€nleliti€s
<br />D-A corporetion the sto{k of r#hich b reguhrtyrraded on on€ or
<br />ltDrs €steblish€d securitiss merk€ts, aE.d€€cribsd in Fie{uletbns
<br />seiticn t.t+rz-t1c;p11i1
<br />E-A corporation that is a msmb€r ol the same expanded ettiliet€d
<br />glou p q.s a corpsretion d€sc rib€d in Fsg u t4lions .psction 1, 1a?2. 1 Fl [1] tl
<br />F-A d€aler in s€cuillis,s. comtn€diti€s. or d€rivativ€ flnenciel
<br />instrume nts {including not ionel Frinc ipal coniracts. f utu r€s, folMerds tiild 6ptions]lhit i! r€gisr€rCd e"s$u{h und€r th€.lalus of'the United
<br />Stat€s or eny .gtet€
<br />G -A reale$ate in,iestment trust
<br />H-A requhte{ in\.sstm€nt com Fe.ny es dsilned in s€ction 8sl or en
<br />€nrty'r€gists r€d sl 4lltim€s durin{ th€ t€x.y€sr u ndsi th€ lnwistment
<br />Compeny Acr of 194.fl
<br />l-A common trust,ftnd as dsfined in ssction S8+{el
<br />J-A bank es d€finad in secticn s8i
<br />K-A b'roker
<br />L- A trust exempt frorr tex under s€ction SS4 or d€.sc ribed in s€ction
<br />{a+{e}[1)
<br />Professional Services Agreement
<br />Page24
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