PAYER’S NAME: U.S. Bank National Association
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Name (as shown on your income tax return) |
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Business Name, if different from above |
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Check appropriate box: | | o Individual/Sole proprietor | | o Corporation | | |
| | o Partnership | | o Other | | |
| | o Limited liability company. Enter the tax classification (D= disregarded entity, C=corporation, P=partnership è | | |
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Address |
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City, State, and ZIP Code |
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SUBSTITUTE Form W-9 | | | Part 1— Taxpayer Identification Number — Please provide your TIN in the box at right and certify by signing and dating below. If awaiting TIN, write “Applied For.” | | |
Social Security Number
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Employer Identification Number |
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Department of the Treasury Internal Revenue Service | | | PART 2 — For Exempt Payees — Check the box if you are exempt from backup withholding.o |
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Payer’s Request for Taxpayer Identification Number (“TIN”) and Certification | | | PART 3 — Certification — Under penalties of perjury, I certify that:
(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),
(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 Internal Revenue Service (IRS) that I am subject 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 no longer subject to backup withholding, and
(3) I am a U.S. person (including a U.S. resident alien). |
| | | Certification Instructions. — You must cross 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. |
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| | | The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. |
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| | | SIGNATURE | | | DATE |
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CERTIFICATE OF AWAITING TAXPAYER IDENTIFICATION NUMBER
I certify under penalties of perjury that a taxpayer identification number has not been issued to me, and either (1) I have mailed or delivered an application to receive a taxpayer identification number to the appropriate Internal Revenue Service Center or Social Security Administration Office, or (2) I intend to mail or deliver an application in the near future. I understand that if I do not provide a taxpayer identification number by the time of payment, 28% of all reportable payments made to me will be withheld.
Signature Date , 20
GUIDELINES FOR CERTIFICATION OF TAXPAYER IDENTIFICATION
NUMBER ON SUBSTITUTEFORM W-9
Guidelines For Determining the Proper Identification Number to Give the Payer— Social Security Numbers (“SSNs”) have nine digits separated by two hyphens: i.e.,000-00-000. Employer Identification Numbers (“EINs”) have nine digits separated by only one hyphen: i.e.,00-0000000. The table below will help determine the number to give the payer. All “section” references are to the Internal Revenue Code of 1986, as amended. “IRS” is the Internal Revenue Service.
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| | Give the Name
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| | and SOCIAL SECURITY
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| | number or Employer
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| | Identification
| | | | | | IDENTIFICATION
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For this type of account: | | number of — | | | | For this type of account: | | number of — |
1. | | Individual | | The individual | | | | 6. | | Disregarded entity not owned by an individual | | The owner |
2. | | Two or more individuals (joint account) | | The actual owner of the account or, if combined funds, the first individual on the account(1) | | | | 7. | | A valid trust, estate, or pension trust | | The legal entity(4) |
3. | | Custodian account of a minor (Uniform Gift to Minors Act) | | The minor(2) | | | | 8. | | Corporation or LLC electing corporate status on Form 8832 | | The corporation |
4. | | a. The usual revocable savings trust (grantor is also trustee) | | The grantor-trustee(1) | | | | 9. | | Association, club, religious, charitable, educational or other tax-exempt organization | | The organization |
| | b. So-called trust account that is not a legal or valid trust under State law | | The actual owner(1) | | | | | | | | |
5. | | Sole proprietorship or disregarded entity owned by and individual | | The owner(3) | | | | 10. | | Partnership or multi-member LLC | | The partnership or LLC |
| | | | | | | | 11. | | A broker or registered nominee | | The broker or nominee |
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(1) | | List first and circle the name of the person whose SSN you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished. |
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(2) | | Circle the minor’s name and furnish the minor’s SSN. |
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(3) | | You must show your individual name and you may also enter your business or “doing business as” name on the second line. You may use either your SSN or EIN (if you have one), but the Internal Revenue Service encourages you to use your SSN. |
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(4) | | List first and circle the name of the legal trust, estate or pension trust. (Do not furnish the Taxpayer Identification Number of the personal representative or trustee unless the legal entity itself is not designated in the account title). |
NOTE: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.
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GUIDELINES FOR CERTIFICATION OF TAXPAYER IDENTIFICATION NUMBER
ON SUBSTITUTEFORM W-9
Purpose of Form
A person who is required to file an information return with the IRS must get your correct Taxpayer Identification Number (“TIN”) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an individual retirement account. Use SubstituteForm W-9 only if you are a U.S. person (including a resident alien) to give your correct TIN to the requester (the person requesting your TIN) and, when applicable, (1) to certify the TIN you are giving is correct (or you are waiting for a number to be issued), (2) to certify you are not subject to backup withholding, or (3) to claim exemption from backup withholding if you are an exempt payee. The TIN provided must match the name given on the SubstituteForm W-9.
How to Get a TIN
If you do not have a TIN, apply for one immediately. To apply for an SSN, obtainForm SS-5, Application for a Social Security Card, at the local office of the Social Security Administration or get this form on-line at www.ssa.gov. UseForm W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, orForm SS-4, Application for Employer Identification Number, to apply for an EIN. You may also get this form by calling1-800-772-1213. You can apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can getForms W-7 and SS-4 from the IRS by calling 1-800-TAX-FORM(1-800-829-3676) or from the IRS web site at www.irs.gov.
If you do not have a TIN, write “Applied For” in Part 1, sign and date the form, and give it to the payer. For interest and dividend payments and certain payments made with respect to readily tradable instruments, you will generally have 60 days to get a TIN and give it to the requester. If the requester does not receive your TIN within 60 days, backup withholding, if applicable, will begin and continue until you furnish your TIN.
Note: Writing “Applied For” on the form means that you have already applied for a TIN or that you intend to apply for one soon. As soon as you receive your TIN, complete anotherForm W-9, include your TIN, sign and date the form, and give it to the requester.
CAUTION: A disregarded domestic entity that has a foreign owner must use the appropriateForm W-8.
Payees Exempt from Backup Withholding
Individuals (including sole proprietors) are NOT exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends.
Note: If you are exempt from backup withholding, you should still complete SubstituteForm W-9 to avoid possible erroneous backup withholding. If you are exempt, enter your correct TIN in Part 1, check the “Exempt” box in Part 2, and sign and date the form. If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester the appropriate completedForm W-8, Certificate of Foreign Status.
The following is a list of payees that may be exempt from backup withholding and for which no information reporting is required. For interest and dividends, all listed payees are exempt except for those listed in item (9). For broker transactions, payees listed in (1) through (13) and any person registered under the Investment Advisers Act of 1940 who regularly acts as a broker are exempt. Payments over $600 required to be reported and direct sales over $5,000 (seeForm 1099-MISC and its instructions) are generally exempt from backup withholding only if made to payees described in items (1) through (7). However, the following payments made to a corporation (including gross proceeds paid to an attorney under section 6045(f), even if the attorney is a corporation) and reportable onForm 1099-MISC are not exempt from backup withholding: (i) medical and health care payments, (ii) attorneys’ fees, and (iii) payments for services paid by a federal executive agency. Only payees described in items (1) through (5) are exempt from backup withholding for barter exchange transactions and patronage dividends.
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(1) | | An organization exempt from tax under section 501(a), any individual retirement plan (“IRA”), or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2). |
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(2) | | The United States or any of its agencies or instrumentalities. |
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(3) | | A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities. |
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(4) | | A foreign government, a political subdivision of a foreign government, or any of their agencies or instrumentalities. |
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(5) | | An international organization or any of its agencies or instrumentalities. |
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(6) | | A corporation. |
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(7) | | A foreign central bank of issue. |
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(8) | | A dealer in securities or commodities registered in the United States, the District of Columbia, or a possession of the United States. |
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(9) | | A futures commission merchant registered with the Commodity Futures Trading Commission. |
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(10) | | A real estate investment trust. |
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(11) | | An entity registered at all times during the tax year under the Investment Company Act of 1940. |
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(12) | | A common trust fund operated by a bank under section 584(a). |
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(13) | | A financial institution. |
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(14) | | A middleman known in the investment community as a nominee or custodian. |
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(15) | | An exempt charitable remainder trust, or a non-exempt trust described in section 4947. |
Exempt payees described above should fileForm W-9 to avoid possible erroneous backup withholding.FILE THIS FORM WITH THE REQUESTER, FURNISH YOUR TAXPAYER IDENTIFICATION NUMBER, CHECK THE “EXEMPT” BOX IN PART 2 ON THE FACE OF THE FORM IN THE SPACE PROVIDED, SIGN AND DATE THE FORM AND RETURN IT TO THE REQUESTER.
Certain payments that are not subject to information reporting are also not subject to backup withholding. For details, see sections 6041, 6041A, 6042, 6044, 6045, 6049, 6050A and 6050N, and their regulations.
Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to give your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. possessions to carry out their tax laws. The IRS may also disclose this information to other countries under a tax treaty, or to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividends, and certain other payments to a payee who does not give a TIN to a payer. The penalties described below may also apply.
Penalties
Failure to Furnish TIN. If you fail to furnish your correct TIN to a payer, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.
Civil Penalty for False Information With Respect to Withholding. If you make a false statement with no reasonable basis which results in no imposition of backup withholding, you are subject to a penalty of $500.
Criminal Penalty for Falsifying Information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including finesand/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.
FOR ADDITIONAL INFORMATION, CONTACT YOUR TAX ADVISOR OR THE INTERNAL REVENUE SERVICE.
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