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Form W109 Request for Taxpayer Give Form to the
<br />(Ftov.December heTrea) Identification Number and Certification requester. Do not
<br />fJoparlmont of the Treasury send to the IRS,
<br />Internal Revenue Service
<br />__Ti Name. (aa shown on your Income tax return), Name Is required on this line; do not leave thls line blank,
<br />County of Kittitas
<br />name,
<br />Kittitas
<br />3 Check appropriuto box for federal tax classification; check only one of the following seven boxosi 4 Exampilons (codes apply only to
<br />IndividuaVsole proprietor or C Corporation El S Corporation L partnership Trual/estate certaln entities, not Individuals; see
<br />single-momber LLC instructions on page 3):
<br />is l Limited liability company, Enter the tax classltloatlon (04 corporation, Sr<S corporation, Pr�partnership) ► Exempt payee code Of any) 3
<br />Note. For a single-member,LLC that is disregarded, do not check LLC,, check the appropriate box In the lino above for Exemption from FATCA reporting
<br />the tax classl(toatlon of the single -member owner,; code Of any)
<br />Other (see instructions)flppflostaaaCau fsltldl tGirlodootsldo010U,4f
<br />6 Address (number, street, and apt, or sults no.) I Requester's name and address (onticnalt _-
<br />205 West 5th Ave Suite 105
<br />Ellensburg, WA .90926
<br />Enter your TIN In the appropriate box, The TIN provided must match the name given on line 1 to avoid
<br />backup withholding. Foe Individuals, this Is generally your social security number.(SSN), However, for a
<br />resident alien, sole proprietor, ordisregarded entity, see the Part I instructions on page 9, For other
<br />entities, it Is your employer identification number (CIN), If you do not have a number, see How to got a
<br />TIN on page 3,
<br />Note. If the account Is In more than one name, sae the.)nstruotions for line 1 and the chart on page 4 for
<br />guidelines on whose number (a enter.
<br />Under penalties of perjury, I certify that:
<br />1. The number shown on this form Ig my correct taxpayer identlfioatlon number (or I am waiting for a number to be Issued to me); and
<br />2. 1 am not subject to backup w(thhatding because: (6).1 am exempt from backup withholding, or(b) I have not been notified by the Internal Revenue
<br />Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (6) the IRS has notified me that I am
<br />no longer subject to backup withholding; and
<br />3, 1 am a U,S, citizen or other U.S, person (defined below); and
<br />4, The FATCA codes) entered on this form (If any) indicating that I am exempt from FATCA reporting Is correct,
<br />Certification Instructions. You must oross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
<br />because you have failed to report all Interest and dividends on your tax return, For real estate transactions, Item 2 does not apply. For mortgage
<br />Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and
<br />generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your oorraat TIN, Sea the
<br />veyrr I Signature of ( tr
<br />i'i8r0 U.H, person ► 1,,,, ,
<br />General Instructions
<br />Section references are to the Internal Revenue Code unless otherwise noted,
<br />Future developments, Information about developments affecting Form W-9 (such
<br />as legislation erected after we release It) Is at www.frs.gov/Avg,
<br />Purpose of Dorm
<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 Identification numbor (rlN)
<br />which ma yy be your social security number (SSN), Individual taxpayer Identification
<br />number OM), adoption taxpayer Identification number (ATIN), or employer
<br />Identification number (SIN), to report on an information return the amount paid to
<br />you, or other amount reportable on an Information return. Examples of Information
<br />returns Include, but aro not limited to, the following:
<br />• Form 1000 -INT (Interest earned or paid)
<br />e Form 1099 -DIV (dividends, Including those tram stocks or mutual funds)
<br />• Form 1099-MISC (various types of Income, prizes, awards, or gross pr000eds)
<br />• Form 10998 (stock or mutual fund sales and certain other transactions by
<br />brokers)
<br />• Form 1099-S (proceeds from real estate transactions).
<br />• Form 1099-K (merchant card and third party netwoel( transactions)
<br />Date M /.9`0
<br />Form 1006 (home mortgage Interest), 1099-E (student loan Interest), 1099•T
<br />(tuition)
<br />• Form 1099.0 (canceled debt)
<br />• Form 1009-A (acquisition or abandonment of secured property)
<br />Use Form W-9 only if you are a U.S, person (including a resldont alien), to
<br />provide your correct TIN.
<br />It you do not return Form W-9 to the requester with a TiN, you might be subject
<br />to backup wlthholdtnp. $so What Is backup withholding? on page 2.
<br />By signing the filled -out fdrm, you;
<br />1, Cortify that the TIN you are giving is correct (or you are waiting for a number
<br />to be Issued),
<br />2. Certify that you are not subject to backup withholding, or
<br />3. Claim exemption from backup withholding If you are a U.S, exempt payee, If
<br />applicable, you are also oertifying that as a U.S.pparson, your allocable share of
<br />any partnership income from a U.S. trade or busirtasa Is not subject to the
<br />withholding tax on foreign partners' share of effectively connected Income, and
<br />4. Certify that FATCA oode(s) entered on this form (If any) indicating that you are
<br />exempt from ilia FATCA reporting, Is correct. See What Is FATCA reportrng7 an
<br />page 2 for further Information.
<br />pet. No, 10231X Form W-4 (Rev. 12-2014)
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