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Form V{-9 iFt!,. 3-20211 Fage 5
<br />Part ll. Certification
<br />Io estabiish to lhe wrthholdrng sgefit that you ate a U-5- person. nr
<br />resident alien. sign Fernn $J-S- Y,ru may be request€d to sign by the
<br />lt'ithholding agent even if ilern 1. '1, *r 5 belolu irrrdirates alhen.tise.
<br />For a ioint accounl, onk the perscn lrh,:se T1FJ is sholvn in Pgrt I
<br />shnuld sign {',uhen requiredi, llr tie cas* of a disregarded entily. lhe
<br />per=nn ldentified on fine I must s;EF. Eterpt pay*es. see !trsfirpf ,oayee
<br />ccde, +adier.
<br />Signature requir+nrents. r:smplat'e the c*riificgtioll as indicated in
<br />ilems 1 frrough 5 beio'".'.
<br />1. lnlerest, diviclend, an<J harter exehatrge account$ opener-l
<br />before l9B4 ancl broker accounle considered active dtrritrg l9&3'
<br />You must give your ccrrect TiN" L'ut 1'ou db nol har,'s to sign the
<br />certiflcation.
<br />2. krterest, tliviclend, brr:ker, and barter exchange iccotlnts
<br />ooenerl after 1983 arr<l broker accounts ccnsidered inactive during-;
<br />l$93. You nrust sign tite cerlificalion or backup r',rithholding '+ill apply. lf
<br />yor: are sublect to backup vrithholding and 1au are merely providing
<br />vour conecl TIN lo the requester. yt,u m{rst 6ra5s out itenr ! in ihe
<br />certification before signing the form.
<br />3, Real e*t*te lransaction$. You must sigir th4 cert*icaiion. You may
<br />cross out itenr 2 of the certification.
<br />4, Ottrer paynrents,, You milst give yottr ronect TiN. but )'r:u do not
<br />have tD sign the certificati{rn unlees you have been nc'lilied lhat you
<br />huve previously given an incorrect Tiltl. "Otherpayrnents" iticiude
<br />paynr'ents mad-eln the course of the requ€ster's trade or business for
<br />rents, ro1'alties. goods (other lhan bjlls fcr nrerchandisei. m€dical and
<br />health csre sen'ices iincluding pa}rynents to corporaticns!. Pa''rrnents t'l
<br />a nonemployee lor seryice,s. Payments nrade in lettlement of paymenl
<br />card andthiid-parFy netu/trk lrEnsactions, paynents to certain fishirrg
<br />boat crew nrenrbers and fishermen- and grc,ss proceeds paid to
<br />atto m€vs iincluding payments lo corFnrralrons i.
<br />5, Mcrtgage interest paitl by yotr" *cqtrisilicn or abandcrnnrent af
<br />securetl propertt , csllcellatiotr af elebt, qtralifiecl tttiti,rn pr-ograjT-
<br />- -
<br />paynrenti {u'nclei secti*rr 529}, ABLE acc*rrnte {ltn,efer section 5294}'
<br />iBA. Coverdell ESA, Areher MSA rrr HSA corltribtdioils or
<br />cliatributians, antl pnsicr <fistributions. You muat gite yDLrr corsct
<br />Tll'J. but ycr-r do n':t have le *ign the certifir:alion.
<br />What Name and Number To Give the Requester
<br />TFr* tn'rst
<br />' List first and circle the narn* *f th'* p'el:an vuhcse nurnber you fumish'
<br />lf only orre Ferson on alointr atc*urrt has ;a 3'3i!l' that pers+n's trumber
<br />must be fumished.
<br />I Circie the n:inur's name ard furnisf! the rrninor's SSN"
<br />rYou must sho'.'r your irrdiuiCuai name c'rl line '1. erid enter your business
<br />or. DBA nanre.,l ahy c,rr fi ns 2. Yc{,t ma'i use erthet y.ur SSI'I or Elt'l ii
<br />y'ru have onej, bi:t tie IRS encourage* i'eu t* use yot.lr 3Sl'l
<br />I List first and ;iffle the name ,lf tfrs trust" *stat*. 3r Pensron lrust- (DO
<br />nc,t funriah the TllJ +f the personal r*pre;entatiite ct truetee uniess '.he
<br />legal *ntitv ils€ll i5 nnt desigl.rate"J in the eccaunt tltle j
<br />' Hote: The grarttr musi aJs. pr'r:i,i* a F,:rrn i'T-9 tr tiB ti '.-slee Df lh'r
<br />trust.
<br />" For more inf*nrration ,tir'$pti,lfial lllifig nr*thejs {l]t grantlr lruBts, 3te
<br />lh+ lnslructionE l+r Fr,rm 1DJ1
<br />N+te: lf nr: ner,'re i= cirrl*d..lhen ra+r* thanr ane fianr* is li:ted- tfie
<br />number will be t'lnsi'Jere.d t+ b'e Lh.drt ,lf .lhe iirBt narns listed.
<br />$ecure Your Tax Fecsrds Frorn ldentity Theft
<br />Iden?itv th+ft xcurs '.'rh*n s,rme{'n€ uses lrraur persctral in{crmation,
<br />BuL-h is !'sr,irni*n.le. 5Sl',1. or*ti,er;denliFlir*; infc'rmatir-rn-'.vithcut !i+ur
<br />permissi.:n te cc'rnr-'lrit Jraud ,:r tt.fiet *-irqe:- Fr' ider,lily ifiief ma? use
<br />yr:ur SSIiJ to get a. l,!tr ,:r may file a t;au r*turn r'l+ing ycur 5Sl"l tf re*eive
<br />a refund.
<br />Til rrduae ir{iilr flgk:
<br />. Prot+ct your BSltl'
<br />. Ensure y,]ur ernpi'l:jef b. F,ttlectifi'f, 'f-*ur SSll' ard
<br />. B* car*firl rruh+n ch*;sirr3 a t*d r*1t.,-I'l Fr€'parEr.
<br />If ycur tax re"lrrds are atfected ty lclcrfrtg theft and you tecEtv4 a
<br />rrotiie from thE itrS. resp,rnd righl a'r,;11 tc' Ll-e n,lme and phcne number
<br />prrnted on lhe IFS n':tlce *r lette,,r.
<br />ll vDilr tan rst,lrtls are n:]l cLl.rlsr,llli Effs:ted b'i; idsrility tl-:efl hr-rl you
<br />ihrn( you are a! risk du+ to a los'l or it,rlien purse ar wallet. qu*tionabl+
<br />cre,lii carrj ecrtitillt. *r a qrr,restc,nabie ,:r*df report- contaci ihe !FS
<br />Identity Thett F{otlifte at 8trfl-'M+{.1gq Dr rub'mit F'5rm 14't39.
<br />Fqr rtr:re informati+rr- see P,-rb' 50i?. ldsflit,j Thelt lnfr:rnraticil ior
<br />Taxpayers.
<br />For lhi,s of account:
<br />8- Disegardad *rtit? n{t !sn*C b} r,
<br />indntdval
<br />$- A valirj kust. esttrle. Br fff$riufl itrFt
<br />1o. l:lrpe€tisn a LLtr decHfl,g '3Fq'=t€
<br />stalus sn Fcm SJriZ ,w Frym l55J
<br />11 . As:triaticr- €{ub. religiw*s. lhrirh{'/-
<br />eCucatian.rl. t('3thir tax-*x"spi
<br />organialion,
<br />1:?. P3rtner3hiF qr rruLl-nrtrrt*r LLC
<br />13, A brrkEtr 0r G,jistared ncmit*
<br />1i. A;munt :vith th+ f,tpatr're' t li
<br />Ag.iculhtrts in the sme r{ r P:llic
<br />+ntiin isu,rti s a altt* cr !o;sl
<br />'f,ovemmtrr?. :cl-s:'l di:tnct. 0r siin:fii
<br />that r*eives aqricultiril F{i'E tr
<br />payments
<br />'15. t:itrttr lrust liling Farr' iC-ll or
<br />urder the Optional Filirrg idelir.d 3.
<br />requirirq Fom 1c69 i3# RBgillatiEfls
<br />s+ctica 1.6i1 -4rlill!{ii(EJr'-
<br />Give rnaulre and €lN ef:
<br />The olrlrer
<br />Leqra mtQ'l
<br />Tle r.:epcralim
<br />n:e tr,.i:r,iafcr
<br />The Frlnersfiip
<br />The hrrt-v sr narrnee
<br />Thr pui:lic rrtit'1
<br />For this type of acer:unt:Give narne alrtl SSFI of;
<br />l.lndividual
<br />i. Twc cr mle indrui,iuals tlornt :rctunti
<br />otler than sn &efunl maiiltsine,: t:.{
<br />an FFI
<br />3. Two cr nore U S- persons
<br />l,;nint rccolnt maintirintd b:; an FFll
<br />-t fustrdial acrcrnt +J a nins
<br />IJnif+ffi '3i+t to lrlincrs Actt
<br />5 :. The usual Electble svirgs 'ttust
<br />igrantor iE dss tru:teei
<br />b. Src.rlle'l trr:i aicsnt thei i6 flot
<br />a l:gal r:r lalid rr,:t lnitr siattr ls!'j
<br />6. $ole propietr:hip or Ci:regafeo
<br />eniity sr':ned bi' n indiridrnl
<br />7. Granlcr trusl fi{ing rn'Jer l}ptior,:l
<br />Filing ileihd 1 {see Fegulaliors
<br />:€ctisn 1.871 --lrbli?liilr,Ali' "
<br />Th* i:.diviCu;l
<br />Thd sstuil ':.vrrtr ti ihe scc+ffil ryr.
<br />il crmb'ined funds" th* firet irdividral
<br />3n lhe !r,:ctun11
<br />Earh rcicer rf fre accourt
<br />The mins:
<br />The grd,tor-iiristie'
<br />Thi ai1u3l "1Hrsr
<br />Th* q*'n*f
<br />Thr gmt,ri
<br />Kittitas County Agreement for Services (rev.5/M/251
<br />Page 2l of 22
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