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EXHIBIT 99.5
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Form W-9 REQUEST FOR TAXPAYER GIVE FORM TO THE
(Rev. December 2000) IDENTIFICATION NUMBER AND CERTIFICATION REQUESTER. DO NOT
Department of the Treasury SEND TO THE IRS.
Internal Revenue Service
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PLEASE PRINT OR TYPE
Name (See SPECIFIC INSTRUCTIONS on page 2.)
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Business name, if different from above. (See SPECIFIC INSTRUCTIONS on page 2.)
Check appropriate box: / / Individual/Sole proprietor / / Corporation / / Partnership / / Other ____________________
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Address (number, street, and apt. or suite no.) Requester's name and address (optional)
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City, state and zip
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PART I TAXPAYER IDENTIFICATION NUMBER (TIN) List account number(s) here (optional)
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Enter your TIN in the appropriate box. For individuals, this is SOCIAL SECURITY NUMBER
your social security number (SSN). HOWEVER, FOR A RESIDENT
ALIEN, SOLE PROPRIETOR, OR DISREGARDED ENTITY, SEE THE PART I
INSTRUCTIONS ON PAGE 2. For other entities, it is your employer -------------------------------
identification number (EIN). If you do not have a number, see OR
HOW TO GET A TIN on page 2. -------------------------------
EMPLOYER IDENTIFICATION NUMBER
NOTE: IF THE ACCOUNT IS IN MORE THAN ONE NAME, SEE
CHART ON PAGE 2 FOR GUIDELINES ON WHOSE NUMBER TO ENTER.
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PART II FOR U.S. PAYEES EXEMPT FROM
BACKUP WITHHOLDING (See the
instructions on page 2.)
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PART III CERTIFICATION
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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.)
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SIGN HERE SIGNATURE OF
U.S. PERSON DATE
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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 from 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 interest 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 OF 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.
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Form W-9 (Rev. 12-2000) Page 2
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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 I 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 I -- 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 (LL C) above), and are owned by an individual,
enter your SSN (or "pre-LLC" E IN, 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 Requester 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 I, 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.
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 The actual owner of the
individuals (joint account or, if combined
account) funds, the first individual
on the account(1)
3. Custodian account The minor(2)
a minor (Uniform Gift
to Minors Act)
4. a. The usual The grantor-trustee(1)
revocable savings
trust (grantor is
also trustee)
b. So-called trust The actual owner(1)
account that is 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 Legal entity(4)
pension trust
8. Corporate The corporation
9. Association, club, The organization
religious, charitable,
educational, or other
tax-exempt
organization
10. Partnership The partnership
11. A broker or registered The broker or nominee
nominee
12. Account with the The public entity
Department of
Agriculture in the
name of a public entity
(such as a state or
local government,
school district, or
prison) that receives
agricultural 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.