|
UD5
<br />Form llll-g
<br />{Rsv. November 201 7)
<br />Doparlm€nt of the lreasury
<br />lntemal Rflenue Seruice
<br />on your tax Name is on
<br />above
<br />not lsavo thiB blank.
<br />Give Form to the
<br />requester, Do not
<br />send to the lRS.
<br />4 Exemptions (codes apply onlv to
<br />certain entities, not individuals: see
<br />instructions on page 3):
<br />Exempt payee code (if any)
<br />Exemplion from FATCA reporiing
<br />code (if any)
<br />Request for Taxpayer
<br />ldentification Number and Gertification
<br />> Go to www,irs.govlFormWg lor instructions and the latest information.
<br />2
<br />1 Name
<br />Signature of
<br />U.S. person )
<br />BRU
<br />account numb€{(s} hers {optione0
<br />name,
<br />c'i
<br />c)
<br />O)do-
<br />Eo,6OEcto>'ll'a)oi16
<br />O- .o
<br />=(,
<br />o,o.U'
<br />0)oa
<br />{Apptes to accounts tnaialriltd autside lhe U S)
<br />Bequester's nam6
<br />Enter your TIN in the appropriate box, The TIN provided must match the name given on
<br />backup withholding. For individuals, this is generally your social security numuer lsstrt;.resident alien, sole proprieior, or disregarded entity, see the jnstructions for part l, later.
<br />ontilies, il is your employer identilication number (ElN). lf you do not have a number, see
<br />TtN, later.
<br />line 1 to avoid
<br />However, for a
<br />For other
<br />How to get a
<br />Note: lf the account is in more than one name, see the inslructions for line 1. Also see What Name and
<br />Number To Give the Requesler for guidelines on whose number to enter.
<br />Under penalties of perjury, I cerlify that:
<br />'1. The number shown on this form is my correct taxpayer identlfication number (or I am waiting for a number to be issued to me); and2. I am not subject to backup withholding because: (a) I am exempt from backup withholdlng, or (b) I have not been notified by the lnternal RevenueService (lRS) that I am subject to backup withholding as a result of a failure to report all interesi or dividends, or (c) the IRS has notified me that I amno longer sub.ject to backup wilhholding; 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 repoding is correct.
<br />Certilication instructions. You must cross ou1 item 2 above if you have been notified by the IRS that you are currsntly subject to backup withholding becauseyou have failed to reporl all inierest and dividends on your tax return. For real estate transactions, item2 does not appiy. For mortgage interest paid,-
<br />acquisition or abandonmenl of secured propeny, cancellation of debt, contributions to an individual retirement arrangement (lR4,;"d generally, payments
<br />other than interest and dividends, you are not requires[g16i7g;$hgggddisdjpn, but you musl provide your correct Tlti. See the instructi6ns for Fah i, later.&DNt cn=John Dr! E.nst,
<br />o=Dru BrU ou,Here
<br />General I ns
<br />T4JS
<br />Dat€r 2018-01.17 13r0!-):14
<br />-08'00'
<br />Dare > 01117119
<br />. Form 1099-DlV (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 from real estatetransactions)
<br />r Form 1 099-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 (canceled debt)
<br />. Forrn 1 099-4 (acquisition or abandonment of secured property)
<br />Use Form W-9 only it you are a U.S. person (including a resident
<br />alien), to provide your correct TlN.
<br />If you do not return Fom W-9 to the raqueste( with a TlN, you might
<br />be subject to backup withholding. See What is backup withholding,
<br />later.
<br />Section references are to the lnternal Rovenue Code unless otherwise
<br />noted.
<br />Future developments. For the latest informalion about developments
<br />related to Form W-9 and its instruciions, such as legislation enacted
<br />after th€y were published, go to www.irs.govlFormWg.
<br />Purpose of Form
<br />An individual or entity (Form W-9 requester) who is required to file an
<br />information return wilh the IRS must obtain your correct taxpayer
<br />identification number [lN) which may be your social security number
<br />(SSN), individual taxpayer identification number (lTtN), adopiion
<br />taxpayer ldentification number (ATIN), or employer identification number
<br />(ElN), to report on an information return the amount paid to you, or other
<br />amount reportable on an information return. Examples of information
<br />returns include, but are not limited to, the following.. Form 1 099-lNT (interest earned or paid)
<br />3 Check appropriate box for federal tax classification of lhe person whose name is entered on line 1. Check only one of the
<br />following seven boxes.
<br />I lndividualaole proprietor or n c corporation n s corporation n rartnership f] TrusVestate
<br />single-member LLC
<br />E] fimiteO liability company. Enter the lax classification {C=C corporation, S=S corporation, p=parlnership) t !
<br />Not€: Check the appropriate box rn tha line above for lhe til classitication of ih€ single-membor owngr, Do not check
<br />LLC if the LLC is classifi€d as a single-member LLC that is disregaided from the owner unless the owner of the LLC is
<br />ano,ther LLC that ls not disregarded from the owner for U.S, federal tax purposes. Otherwise, a single-member LLC
<br />ls disregarded llom the owner should check lhe appropriate box for the tax classitication of its own-er.
<br />Other
<br />apt. or suite no.) See instructions.5 Address {numbor, street,
<br />PO
<br />SN 98068E
<br />state, and ZIP code
<br />NumberPart I
<br />Part ll
<br />Cat. No. 10231X FormW-9(R6v. 11-2017)
|