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5
<br />Fom !V-3 (R-v- 3'292'r,
<br />Part ll. Certification
<br />7o eelablish b lhe mthhordflg agent thet you are : q : po'="tt o
<br />;;ffi1t';;, -,n. io# w-s.-Yi; 'ntv be requested to 'Yn bv r,'
<br />;rruilff LIXd "ri
<br />i'it rrt"i 1.'t' or 5 below-srdrcat€e oth€'rlre.
<br />no, a toit accgunl. only th' person whose ill'l rs sfiorza 'n Farl i
<br />trl"iro igi'(,'rh";t requid!1. lohe casa o{ a dsegarded enliy lhc
<br />i-l*l 11",!n*o on line t #urt tign. Erernpt pay*ec re€ &etnptlrvee
<br />code. eaAier.
<br />Sronature requiromenl3- Comple!; the cerlifrcatbn as indicated in
<br />ite"ms 1 throuqh 5 belo"v
<br />i. interast. a.livi{ttnd, aatJ bnrlel exchang* acco.utrtr op.erred
<br />?:i{'J:S.t*$.:iro:nl,lmft rit*fd*:#',H.'*
<br />certilication,
<br />2- lnlerest, rlividend, broker. sn<l bader €xchange eccrunts
<br />r['il+;T*'::;at:ul*1,"":t"TH:,fl F*",i"':'ffi ',uii$iljl'
<br />;ruffiil;'u."r."p **rt"roog and vou ra rnerBly providing
<br />lil;;#ffiltf' ,h. t"'qtor"t. yoJrntrst roes out item 2 in lhe
<br />lEailicatton b4lore signing lhe form'
<br />3- Real estate lransactions' You must sign the certifcation' You may
<br />cross out item 2 o( tfie certificatton'
<br />rl. otlter p{yments. vrxJ mugt oiva {out cotrecl TtN' but you do not
<br />h '-o rA qi6 lhe cetl't1c6lon unle& you have b€efl noflfied lhal you
<br />;,:JI ;-"ruy Ju*n "o
<br />in""""tt T[u' 'r}tt'er payments- rncltrda
<br />^1,,-6^re trrr.le rn lfie courv! o-t rite,squ":ret's fade or btgnass for
<br />i;'#l.;iil;:sil; ("il']h* b;rs 6r m*'chandsar' rn?dcar and
<br />;:;]ii';# ;;es fincl'ding pavmenis to corpo(aionsl'.FaFnents tn
<br />;;;;;;;;. rror servicas. #vmetrs n'aoe rn sttilernenl ol pavfirent
<br />;ir5;;;I;,t;ttty n-'r"",r uanJJtrons' oavnents to certajn fish'nq
<br />ffij ;;;;-Gri rnd fshernrer=' and gro$s proceerls pild ts
<br />r ttJrn"yt fncluding payrT!€nts to corpontions)'
<br />q Morldice inlerEsl poid by you. ncqql$iltott or aban<lonntettl ol
<br />...;;;;; o1""o.rav. .an"ill"tio^ ol debt' qtrolified itlilton protlranr
<br />lllili",['rrl,l'? section 529],-iiJG-acc'"ii"ts {t'n<ter seclion S?sAl'
<br />irii.'J.*t.t-rigSA Archer MsA or HsA :onlritrutiorts or
<br />:iil;il;t;.; ;;J pe,,siot di$ittbrilions- v:t1trst ii(* vou( tltffiect
<br />Tltl, brrt you <!o not'have tc sign rhi c€rlncalon'
<br />For this sf
<br />e Oin{trdidtdryGl
<br />individud
<br />'Ust firsi and circle the r'arne
<br />9 . A vsrid trust. esiate- # t#il i!6i
<br />l!|. Ciffir;m s tlC l*:'an7'vgr:c- nffi5fonlfJ?rtm)i*
<br />! I . A$€nfiea. --tub' elilirre- cFlebb
<br />aduationaj. or otft a iai:-xfl gi
<br />orgmiatim
<br />l?. ParrwrhrP ry muti'rchs tl.i
<br />13- A brokertr.eg;wd ildffi
<br />l.r A.wnt rr{h Oa Orlrrng r oi
<br />Agiclare * rtrt r*lt r r:u&f
<br />tridtr 6uctr s I rt:c:cbsrj
<br />gfi.;anst schi,l fEF: 69!'.f:
<br />thal r{ei€ rq.icdhsat P${rF
<br />paymtrb
<br />15 G€nlortlst fif4g Fm 164'l s
<br />under tht OolbnJ fe4 LlcSrd -1'
<br />msint fumr I t4':t l*r na7l}'lca
<br />do*
<br />'ottt16l2YgPo''
<br />Gise nrrs and EIN ot
<br />v.lltelws
<br />legi dditr'
<br />th* f,.:rtt:td
<br />r,hr{€#6$a
<br />Ihdsfiddls
<br />lF.e5re!grffirn-
<br />EEe lr$r gcitY
<br />The 5u*
<br />cf the p.=sr:n Trhase fttrnber '7ou fumsh.
<br />S.St{. {fiat Patson's number
<br />lf ody or€ p€.nofl on d iont ac{:ounl h.3s an
<br />mu:t-be ftrnbhed'
<br />What Name and Nurnbe r To Give the Requester
<br />For lhis of eccottnt:Give narne rnd lSl\d cf:
<br />lh"
<br />r Circle the minor's name and frtrdslt tie rilftols SSN
<br />;:*rgyr"n:'##",H:":",il*l#i'?g#T'Hfr F-
<br />yr" ia* ot"f. brrl Ge iFS rrroJt3*:s'taf ig use ycut Jlr'
<br />t !9t first and crrcl,g ihe na..ne tf itl. 1}rr9- esEl]It' or perl-lisn |tusl {Oo
<br />rlot fumrsi! tle nN al lhs p"t=uJrep"*t*ttad"; s/ $Js&l+ 'rnhss |ie
<br />;#;;tq ,ttdi'" *rt *iqiIa?;drn +r F?unt due I
<br />' No!e: ibe ganlos sggl 3ts$ 9'E tdg e F:rm U/-9 {a $'1* r&'sii€ oi ih:
<br />trust.
<br />-- Fof mote ,nfbtmat'qn tn ;p{rorel niit* 'rit'E.(ls
<br />if t gr'inldt itt-isls' 9t:
<br />the lnstuctions fior Fd'rfi lojl
<br />llole: lf nc nama :3 :rctid'{t'}*r r'3r' tlan "* nttn* Ls lt€!*d' the
<br />nornhsr i"fi c* l:f'a{i<*' {* b{ tt}3n ti t1a liGt :aarQ' n{€'J
<br />Secure Your Tax Records Frorn ldentify Thett
<br />ld?nirl.,' lh*f cccuc -'r-'!g1 io{'+'s'c -*s ;ut g+r'otd 'nlolnr0on
<br />;.;;"';;t;;* ssil t rf*'":*-rrhie q 'rdcrraino' aril''rut laj
<br />;;;# ; ;;; Jr*6 5;.^r ;a : ffi +5'b r't-Y *i !F!i'i {Fr' "*
<br />;;;Tsl'i ;;;ir;ob c' r'a''fii+; -:4 -'t!s 6rr€ /ndr ssFl ta t;f,e1''q
<br />a r:nrnd-
<br />To rzdt*z Yav( i{r;
<br />" Frotat your SS|I-
<br />. Enstsg yflJr tqpic'1er t= p<er:cnrrg v>l 56lt ' :rd
<br />- Sa .:arEful {h:n rhc{1stg a'-&\'{-r'tFf,49'alt"'
<br />li rorrr ia .43{lttt uts #t-al{ UI4anii" tea t14';c't '2')t!+ a
<br />""n. il*'',it--, in -,'ry'l 4ht L'3 !' rhe nan+ ]'rt tf'rr; rtJr: ber
<br />tnnred cn ht ,FS eott€* lr iJfi;t-
<br />ll ,raut rar r+cardr sra :r t =En+r[l,
<br />'4f':.{:zrt 1'" dJ1t'ty- fi''it bul -u
<br />,h ;; i ;; ; ; Jlr*''u u *''
<br />=
<br />J' ! * ?6e'lr' rdlsr''?sestrondtt+
<br />i',"*r' i] J''*rr.tt n t * *.G-"e* s&'egl, r' t -ta"1';' e : f€
<br />ffi;';i;ffi ;;i'' 1 fri ne s:o :' rr'aq'r icrrr r'rtjel
<br />ftr iq,)t? ,ni{}rsrif q" ye tab yi13 lt:"ta|]r Jt'{tl-' 'r-}nna!+fi ttr
<br />frtp*1ers-
<br />r 1*,o o{ mcre ndeJdurb ion( Jcc'Mt!- ort':r ths rn rcsrrnt rurirhrrn:d irt
<br />vFfl
<br />J.fwo q moct U $ P+s*
<br />;lornl iccount majntrn:d b'l o FFI
<br />j Custcdial JcEolnl o{ a mrrq
<br />lljnri,Ft G;fl io irlitq; 'Actl
<br />5 r Th" wlt re!ffit{e -vi(gs b'6t
<br />Igrntor is Jls tr6tEl
<br />b. S+aEed fwt rcqunt iJEl {s mr
<br />,tleoal qr vdltd tral '$d"r itatl krv;
<br />o. SolJ propnetwhip tr ii'a*gsdgl
<br />mtitv ovrned bY m indi"iduaj
<br />; 4rantor l-,st ilrng ud€r CtPo9flai
<br />F lht trt'n(4 'ea. Fi'Jfit'd :
<br />:e-- "c^ t,; i I -'trt: :("'tArt-'
<br />Th€ nct€l lranf l:'Jh- s'L-f,rtt r''
<br />ii smf'1 *. i rrr€ rh- ia: roJD'rl'':l
<br />,$ d-* !:;ffi1
<br />Each hqids {i'}.e Eit@t
<br />ihz mmc+l
<br />ih" lrzrtq-rgi-
<br />lh* ci:sl cvrr:r'
<br />Tir: aT.t.{I
<br />Tht ivaioi-
<br />Kittitas County Agreement for Services (rev ' 5/14/25)
<br />Page 2l of 24
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