Form W-9, (Rev. December 2000), Department of the Treasury, Internal Revenue
Service
Request for Taxpayer Identification Number and Certification
Give form to the requester. Do not send to the IRS.
Please print or type:
Name (See Specific Instructions on page 2.)
_______________________________________________________________________
Business name, if different from above. (See Specific Instructions on page
2.)
_______________________________________________________________________
Check appropriate box [ ] Individual/Sole proprietor [ ] Corporation
[ ] Partnership [ ] Other - _______________
_______________________________________________________________________
Address (number, street, and apt. or suite no.)
City, state, and ZIP code
Requester's name and address (optional)
List account number(s) here (optional)
_______________________________________________________________________
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. For individuals, this is your social
security number (SSN). However, for a resident alien, sole proprietor, or
disregarded entity, see the Part 1 instructions on page 2. For other
entities, it is your employer identification number (EIN). If you do not
have a number, see How to get a TIN on page 2.
Note: If the account is in more than one name, see the chart on page 2 for
guidelines on whose number to enter.
Social security number [___-__-____]
or
Employer identification number [__-_______]
Part II For U.S. Payees Exempt From Backup Withholding (See the
instructions on page 2.)
- -
_______________________________________________________________________
Part III 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), and
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. 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 correct
TIN. (See the instructions on page 2.)
Sign Here
Signature of U.S. person - ______________________Date - _______________
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 IRA.
Use Form W-9 only if you are a U.S. person (including a resident alien), to
give your correct TIN to the person requesting it (the requester) and, when
applicable, to:
1. Certify the TIN you are giving is correct (or you are waiting for a
number to be issued),
2. Certify you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt
payee.
If you are a foreign person, use the appropriate Form W-8. See Pub. 515,
Withholding of Tax on Nonresident Aliens and Foreign Corporations:
Note: If a requester gives you a form other than Form W-9 to request your
TIN, you must use the requester's form if it is substantially similar to
this Form W-9.
What is backup withholding? Persons making certain payments to you must
withhold and pay to the IRS 31% of such payments under certain conditions.
This is called "backup withholding." Payments that may be subject to backup
withholding include interest, dividends, broker and barter exchange
transactions, rents, royalties, nonemployee pay, and certain payments form
fishing boat operators. Real estate transactions are not subject to backup
withholding.
If you give the requester your correct TIN, make the proper certifications,
and report all your taxable intrest and dividends on your tax return,
payments you receive will not be subject to backup withholding. Payments
you receive will be subject to backup withholding if:
1. You do not furnish your TIN to the requester, or
2. You do not certify your TIN when required (see the Part III
instructions on page 2 for details), or
3. The IRS tells the requester that you furnished an incorrect TIN, or
4. The IRS tells you that you are subject to backup withholding
because you did not report all your interest and dividends on your tax
return (for reportable interest and dividends only), or
5. You do not certify to the requester that you are not subject to
backup withholding under 4 above (for reportable interest and dividend
accounts opened after 1983 only).
Certain payees and payments are exempt from backup withholding. See
the Part II instructions and the separate Instructions for the Requester of
Form W-9.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, 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 that results in no backup
withholding, you are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal penalties
including fines and/or imprisonment.
Misuse if TINs. If the requester discloses or uses TINs in violation of
Federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Name. If you are an individual, you must generally enter the name shown on
your social security card. However, if you have changed your last name, for
instance, due to marriage without informing the Social Security
Administration of the name change, enter your first name, the last name
shown on your social security card, and your new last name.
If the account is in joint names, list first and then circle the name of the
person or entity whose number you enter in Part 1 of the form.
Sole proprietor. Enter your individual name as shown on your social
security card on the "Name" line. You may enter your business, trade, or
"doing business as (DBA)" name on the "Business name" line.
Limited liability company (LLC). If you are a single-member LLC (including
a foreign LLC with a domestic owner) that is disregarded as an entity
separate from its owner under Treasury regulations section 301.7701-3, enter
the owner's name on the "Name" line. Enter the LLC's name on the "Business
name" line.
Caution: A disregarded domestic entity that has a foreign owner must use
the appropriate Form W-8.
Other entities. Enter your business name as shown on required Federal tax
documents on the "Name" line. This name should match the name shown on the
charter or other legal document creating the entity. You may enter any
business, trade, or DBA name on the "Business name" line.
Part 1 - Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box.
If you are a resident alien and you do not have and are not eligible to get
an SSN, your TIN is your IRS individual taxpayer identification number
(ITIN). Enter it in the social security number box. If you do not have an
ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may enter either your
SSN or EIN. However, the IRS prefers that you use your SSN.
If you are an LLC that is disregarded as an entity separate from its owner
(see Limited liability company (LLC) above), and are owned by an individual,
enter your SSN (or "pre-LLC" EIN, if desired). If the owner of a
disregarded LLC is a corporation, partnership, etc., enter the owner's EIN.
Note: See the chart on this page for further clarification of name and TIN
combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately. To
apply for an SSN, get Form SS-5, Application for a Social Security Card,
from your local Social Security Administration office. Get Form W-7,
Application for IRS Individual Taxpayer Identification Number, to apply for
an ITIN or Form SS-4, Application for Employer Identification Number, to
apply for an EIN. You can get Forms W-7 and SS-4 from the IRS by calling 1-
800-TAX-FORM (1-800-829-3676) or from the IRS's Internet Web Site at
www.irs.gov.
If you do not have a TIN, write "Applied For" in the space for the TIN, sign
and date the form, and give it to the requester. For interest and dividend
payments, and certain payments made with respect to readily tradable
instruments, generally you will have 60 days to get a TIN and give it to the
requester before you are subject to backup withholding on payments. The 60-
day rule does not apply to other types of payments. You will be subject to
backup withholding on all such payments until you provide your TIN to the
requester.
Note: Writing "Applied For" means that you have already applied for a TIN
or that you intend to apply for one soon.
Part II - For U.S. 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. For more information on exempt
payees, see the separate instructions for the Requestor of Form W-9.
If you are exempt from backup withholding, you should still complete this
form to avoid possible erroneous backup withholding. Enter your correct TIN
in Part 1, write "Exempt" in Part II, 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 completed Form W-8.
Part III - Certification
To establish to the withholding agent that you are a U.S. person, or
resident alien, sign Form W-9. You may be requested to sign by the
withholding agent even if items 1, 3, and 5 below indicate otherwise.
For a joint account, only the person whose TIN is shown in Part I should
sign (when required).
1. Interest, dividend, and barter exchange accounts opened before 1984
and broker accounts considered active during 1983. You must give your
correct TIN, but you do not have to sign the certification.
2. Interest, dividend, broker, and barter exchange accounts opened
after 1983 and broker accounts considered inactive during 1983. You must
sign the certification or backup withholding will apply. If you are subject
to backup withholding and you are merely providing your correct TIN to the
requester, you must cross out item 2 in the certification before signing the
form.
3. Real estate transactions. You must sign the certification. You
may cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but you do not
have to sign the certification unless you have been notified that you have
previously given an incorrect TIN. "Other payments" include payments made
in the course of the requester's trade or business for rents, royalties,
goods (other than bills for merchandise), medical and health care services
(including payments to corporations), payments to a nonemployee for
services, payments to certain fishing boat crew members and fishermen, and
gross proceeds paid to attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified state tuition program
payments, IRA or MSA contributions or distributions, and pension
distributions. You must give your correct TIN, but you do not have to sign
the certification.
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 MSA. 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, and the
District of Columbia to carry out their tax laws.
You must provide your TIN whether or not you are required to file a tax
return. Payers must generally withhold 31% of taxable interest, dividend,
and certain other payments to a payee who does not give a TIN to a payer.
Certain penalties may also apply.
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What Name and Number to Give the Requester
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For this type of account: Give name and SSN of:
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1. Individual The individual
2. Two or more individuals (joint The actual owner of the account
account) or, if combined funds, the first
individual on the account(1)
3. Custodian account of a minor The minor(2)
(Uniform Gift to Minors Act)
4. a. The usual revocable savings The grantor-trustee(1)
trust (grantor is also trustee)
b. So-called trust account that is The actual owner(1)
not a legal or valid trust under
state law
5. Sole proprietorship The owner(3)
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For this type of account: Give name and EIN of:
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6. Sole proprietorship The owner(3)
7. A valid trust, estate, or pension Legal entity (4)
trust
8. Corporate The corporation
9. Association, club, religious, The organization
charitable, educational, or other
tax-exempt organization
10. Partnership The partnership
11. A broker or registered nominee The broker or nominee
12. Account with the Department of The public entity
Agriculture in the name of a
public entity (such as a state or
local government, school district,
or prison) that receives
agricultural program payments
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(1) List first and circle the name of the person whose number you furnish.
If only one person on a joint account has an SSN, that person's number must
be furnished.
(2) Circle the minor's name and furnish the minor's SSN.
(3) You must show your individual name, but you may also enter your
business or "DBA" name. You may use either your SSN or EIN (if you have
one).
(4) List first and circle the name of the legal trust, estate, or pension
trust. (Do not furnish the TIN 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.