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Form
<br />1 Name shown on your tax
<br />BillGlarke
<br />entity name, if different from abov€
<br />Bill Clarke Attorney at Law & Government Affairs
<br />General lnstructions
<br />Section references are to the lnternal Revenue Code unless otherwise noted.
<br />Future developments. lnformation about developments affecting Form W-9 (such
<br />as legislation enacted after we release it) is alwww,irs.govlfwg.
<br />Purpose of Form
<br />An individual or entity (Form W-9 requester) who is required to file an information
<br />return with the IRS must obtain your correct taxpayer identitication number IlN)
<br />which may be your social security number (SSN), individual taxpayer identiflcation
<br />number (lTlN), adoption taxpayer identilication number (ATIN), or employer
<br />identification number (ElN), to report on an information r€turn the amount paid to
<br />you, or other amount reportable on an information return. Examples of information
<br />returns include, but ar6 not limited to, the following:
<br />. Form 1099-lNT (interest earned or paid)
<br />o Form 1099-DlV (dividends, including those from stocks or mutual funds)
<br />. Form 1099-MISC (various typ€s of income, prizes, awards, or gross proceeds)
<br />. Form 1 099-8 (stock or mutual fund sales and certain other transactions by
<br />brok€rs)
<br />. Form 1 099-5 (proceeds lrom real estate transactions)
<br />. Form 1 099-K (merchant card and third party network transactions)
<br />Request for Taxpayer
<br />ldentification Number and Geftification
<br />on line; do not leave this line
<br />Requester's name
<br />w-g Give Form to the
<br />requester. Do not
<br />send to the lRS.
<br />4 Exemptions (codes apply only to
<br />certain entities, not individuals; see
<br />instructions on page 3):
<br />Exempt payee code (if any) _
<br />Exemptlon from FATCA reporting
<br />code (if any)
<br />(Apllos to accunts maintalnad @lside the U,S,)
<br />(optional)
<br />(Rev. December 2014)
<br />Department of the Treasury
<br />lnternal Revenue Service
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<br />7 List account numbe(s) here (optional)
<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 generally your social security number (SSN). However, for a
<br />resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
<br />entities, it is your employer identification number (ElN). lf you do not have a number, see How to get a
<br />I/N on page 3.
<br />Note. lf the account is in more than one name, see the instructions for line 1 and the chart on page 4 for
<br />guidelines on whose number to enter.
<br />or
<br />Certification
<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) I am exempt from backup withholding, or (b) I have not been notified by the lnternal Revenue
<br />Service (lRSi that I am sub;ect to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS 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 />Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently
<br />transactions, item 2 does
<br />subject to backup withholding
<br />because you have failed to report all interest and dividends on your tax return. For real estate not apply. For mortgage
<br />interest paid, acquisition or abandonment of secured of debt, contributions to an individual retirement arrangement (lRA), and
<br />generally, payments other d to sign the certification, but you must your correct TlN. See the
<br />instructions on 3.
<br />Here 7.
<br />. Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T
<br />(tuition)
<br />. Form 1099-C (cancoled debt)
<br />. Form 1099-4 (acquisition or abandonment ol secured property)
<br />Use Form W-9 only it you are a U.S. person (including a resident alien), to
<br />provide your correct TlN.
<br />If you do not return Form W-9 to the requester with a TlN, you might be subiect
<br />to backup withholding. See lryhat ls backup withholding? on page 2'
<br />By signing the filled-out form, you:
<br />1. Certi{y that the TIN you are giving is correct (or you are waiting for a number
<br />to be issued),
<br />2. Certily that you are not subject to backup withholding, or
<br />3. Claim exemption from backup withholding if you are a U,S. exempt pay€e' lf
<br />applicable, you are also certifying that as a U.S. person, your allocable share of
<br />any partnership income from a U.S. trade or business is not subject to the
<br />wiihnotding tax on foreign partners' share of effectively connected income' and
<br />4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
<br />exempt from the FATCA reporting, is correct. S€e t/Vhaf is FATCA reporting? on
<br />page 2 for further information.
<br />3 Check appropriate box for federal tax classification; check only one of the lollowing seven box€s:
<br />!lndivlduat/soteproprietoror ! COorporation EsOorporation I Partnersnip !TrusVestate
<br />single-member LLC
<br />! timiteO liability company. Enter the tax classification (C=C corporation, S=S corporaiion, P=partnership) >
<br />Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for
<br />the tax classification of the single-member owner.
<br />! Other lsee instructions) >
<br />5 Address (number, street, and apt. or suite
<br />1501 CapitolWay, Suite 203
<br />6 City, state, and ZIP code
<br />Olympia, WA 98501
<br />ldentification Number
<br />Social security number
<br />Part I
<br />Employer
<br />5 1 2 7 1 4611
<br />Part ll
<br />Date )7Signature of
<br />U,S. person )
<br />cat. No. 10231X rorm W-9 (Rev.12-2014\
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