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