Form W-9
(Rev. January 2002) Request for Taxpayer Give form to the
Department of the Treasury Identification Number and Certification requester. Do NOT
Internal Revenue Service send to the IRS.
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Name
Print or
type --------------------------------------------------------------------------------------------------------------------------
Business name, if different from above. (See Specific Instructions on page 2.)
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 code
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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 your social security
number (SSN). HOWEVER, FOR A RESIDENT ALIEN, ------------------------------
SOLE PROPRIETOR, OR DISREGARDED ENTITY, SEE Social security number
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 HOW TO GET A TIN on page 2. or PART II FOR U.S. PAYEES EXEMPT FROM
------------------------------ BACKUP WITHHOLDING (See the
Note: If the account is in more than one name, Employer identification number instructions on page 2.)
see the chart on page 2 for guidelines on - ----------------------------------------------------
whose number to enter - - - - - - - - -
------------------------------ =
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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 Signature of
Here U.S. person = Date =
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Purpose of Form.
A person who is required to file WHAT IS BACKUP WITHHOLDING? - Persons 5. You do not certify to the
an information with the IRS must making certain payments to you must requester that you are not subject to
get your correct taxpayer withhold and pay to the IRS 31% of backup withholding under 3 above (for
identification number (TIN) to such payments under certain reportable interest and dividend
report, for example, income paid conditions. This is called "backup accounts opened after 1983 only).
to you, real estate transactions, withholding." Payments that may be
mortgage interest you paid, subject to backup withholding include Certain payees and payments are
acquisition or abandonment of interest, dividends, broker and exempt from backup withholding. See
secured property, cancellation of barter exchange transactions, rents, the Part II instructions and the
debt, or contributions you made royalties, nonemployee pay, and separate INSTRUCTIONS FOR THE
to an IRA. certain payments from fishing boat REQUESTER OF FORM W-9.
operators. Real estate transactions
Use Form W-9 only if your are are not subject to backup withholding. PENALTIES
a U.S. person (including a
resident alien), to give your If you give the requester your FAILURE TO FURNISH TIN. -If you fail
correct TIN to the person correct TIN, make the proper to furnish your correct TIN to a
requesting it (the requester) certifications, and report all your requester, you are subject to a
and, when applicable, to: taxable interest and dividends on penalty of $50 for each such failure
your tax return, payments you unless your failure is due to
1. Certify the TIN you are receive will not be subject to backup reasonable cause and not to willful
giving is correct (or you are withholding. PAYMENTS YOU RECEIVE WILL neglect.
waiting for a number to be BE SUBJECT TO BACKUP WITHHOLDING IF:
issued), CIVIL PENALTY FOR FALSE INFORMATION
1. You do not furnish your TIN to WITH RESPECT TO WITHHOLDING. -If you
2. Certify you are not subject the requester, or make a false statement with no
to backup withholding, or reasonable basis that results in no
2. You do not certify your TIN backup withholding, you are subject
3. Claim exemption from backup when required (see the Part III to a $500 penalty.
withholding if you are an exempt instructions on page 2 for details),
payee. or CRIMINAL PENALTY FOR FALSIFYING
INFORMATION. - Willfully falsifying
If you are a foreign person, 3. The IRS tells the requester certifications or affirmations may
use the appropriate Form W-8. See that you furnished an incorrect TIN, subject you to criminal penalties
Pub. 515, Withholding of Tax on or including fines and/or imprisonment.
Nonresident Aliens and Foreign
Corporations. 4. The IRS tells you that you are MISUSE OF TINS. If the requester
subject to backup withholding because discloses or uses TINs in violation
Note: If a requester gives you a you did not report all your interest of Federal law, the requester may be
form other than a W-9 to request and dividends on your tax return (for subject to civil and criminal
your TIN, you must use the reportable interest and dividends penalties.
requester's form if it is only), or
substantially similar to this
Form W-9.
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Form W-9 (Rev. 12-2000)
Form W-9 (Rev. 1-2002)
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SPECIFIC INSTRUCTIONS
such payments until you provide report interest, dividends, and
NAME. If you are an individual, our TIN to the requestor. certain other income paid to you,
you must generally enter the name mortgage interest you paid, the
shown on your social security NOTE: Writing "Applied For" acquisition or abandonment of
card. However, if you have means that you have already secured property, cancellation of
changed your last name, for applied for a TIN or that you debt, or contributions you made
instance, due to marriage, intend to apply for one soon. to an IRA or MSA. The IRS uses
without informing the Social the numbers for identification
Security Administration of the PART II-FOR PAYEES EXEMPT FROM purposes and to help verify the
name change, enter your first BACKUP WITHHOLDING accuracy of your tax return. The
name, the last name shown on your IRS may also provide this
social security card, and your Individuals (including sole information to the Department of
new last name. proprietors) are not exempt from Justice for civil and criminal
backup withholding. Corporations litigation and to cities, states,
If the account is in joint are exempt from backup withholding and the District of Columbia to
names, list first and then circle for certain payments, such as carry out their tax laws.
the name of the person or entity interest and dividends. For more
whose number you enter in Part I information on exempt payees, see You must provide your TIN whether
of the form. the separate Instructions for the or not you are required to file a
Requester of Form W-9. tax return. Payers must generally
SOLE PROPRIETOR. Enter your withhold 31% of taxable interest,
INDIVIDUAL name as shown on your If you are exempt from backup dividend, and certain other
social security card on the withholding, you should still payments to a payee who does not
"Name" line. You may enter your complete this form to avoid give a TIN to a payer. Certain
business, trade, or "doing possible erroneous backup penalties may also apply.
business as (DBA)" name on the withholding. Enter your correct
"Business name" line. TIN in Part I, write "Exempt" in WHAT NAME AND NUMBER TO
Part II, and sign and date the GIVE THE REQUESTER
LIMITED LIABILITY COMPANY form. -------------------------- -----------------------------
(LLC). If you are a single-member FOR THIS TYPE OF ACCOUNT: GIVE NAME AND SSN OF:
LLC (including a foreign LLC with If you are a nonresident alien or -------------------------- -----------------------------
a domestic owner) that is a foreign entity not subject to 1. Individual The individual
disregarded as an entity separate backup withholding, give the 2. Two or more individuals The actual owner of the
from its owner under Treasury requester the appropriate (joint account) account or, if combined
regulations section 301.7701-3, completed Form W-8. funds, the first
ENTER THE OWNER'S NAME ON THE individual on the account 1
"NAME" LINE. Enter the LLC's name PART III-CERTIFICATION 3. Custodian account The minor 2
on the "Business name" line. of a minor (Uniform
To establish to the withholding Gift to Minors Act)
CAUTION: A disregarded domestic agent that you are a U.S. person,
entity that has a foreign owner or resident alien, sign Form W-9. 4. a. The usual revocable The grantor-trustee 1
must use the appropriate Form W-8. You may be requested to sign by savings trust
the withholding agent even if (grantor is also
OTHER ENTITIES. Enter your items 1, 3, and 5 below indicate trustee)
business name as shown on otherwise.
required Federal tax documents on b. So-called trust The actual owner 1
the "Name" line. This name should For a joint account, only the account that is not
match the name shown on the person whose TIN is shown in Part a legal or valid
charter or other legal document I should sign (when required). trust under state
creating the entity. You may law
enter any business, trade, or DBA 1. INTEREST, DIVIDEND, AND 5. Sole proprietorship The owner 3
name on the "Business name" line. BARTER EXCHANGE ACCOUNTS OPENED
BEFORE 1984 AND BROKER ACCOUNTS -------------------------- -----------------------------
PART I-TAXPAYER IDENTIFICATION CONSIDERED ACTIVE DURING 1983. FOR THIS TYPE OF ACCOUNT: GIVE NAME AND EIN OF:
NUMBER (TIN) You must give your correct TIN, -------------------------- -----------------------------
but you do not have to sign the 6. Sole proprietorship The owner 3
ENTER YOUR TIN IN THE APPROPRIATE certification. 7. A valid trust, estate, Legal entity 4
BOX. or pension trust
2. INTEREST, DIVIDEND, BROKER, 8. Corporate The corporation
If you are a RESIDENT ALIEN and AND BARTER EXCHANGE ACCOUNTS 9. Association, club, The organization
you do not have and are not OPENED AFTER 1983 AND BROKER religious, charitable,
eligible to get an SSN, your TIN ACCOUNTS CONSIDERED INACTIVE educational, or other
is your IRS individual taxpayer DURING 1983. You must sign the tax-exempt organization
identification number (ITIN). certification or backup 10. Partnership The partnership
Enter it in the social security withholding will apply. If you 11. A broker or registered The broker or nominee
number box. If you do not have an are subject to backup withholding nominee
ITIN, see HOW TO GET A TIN below. and you are merely providing your 12. Account with the The public entity
correct TIN to the requester, you Department of
If you are a SOLE PROPRIETOR must cross out item 2 in the Agriculture in the name
and you have an EIN, you may certification before signing the of a public entity
enter either your SSN or EIN. form. (such as a state or
However, the IRS prefers that you local government, school
use your SSN. 3. REAL ESTATE TRANSACTIONS. district, or prison)
You must sign the certification. that receives
If you are an LLC that is You may cross out item 2 of the agricultural program
DISREGARDED AS AN ENTITY separate certification. payments
from its owner (see LIMITED
LIABILITY COMPANY (LLC) above), 4. OTHER PAYMENTS. You must -------------------------- -----------------------------
and are owned by an individual, give your correct TIN, but you do 1 List first and circle the name of the person whose
enter your SSN (or "pre-LLC" EIN, not have to sign the certification number you furnish. If only one person on a joint
if desired). If the owner of a unless you have been notified that account has an SSN, that person's number must be
disregarded LLC is a corporation, you have previously given an furnished.
partnership, etc., enter the incorrect TIN. "Other payments"
owner's EIN. include payments made in the 2 Circle the minor's name and furnish the minor's SSN.
course of the requester's trade
NOTE: See the chart on this page or business for rents, royalties, 3 You must show your individual name, but you may also
for further clarification of name goods (other than bills for enter your business or "DBA" name. You may use either
and TIN combinations. merchandise), medical and health your SSN or EIN (if you have one).
care services (including payments
HOW TO GET A TIN. -If you do not to corporations), payments to a 4 List first and circle the name of the legal trust,
have a TIN, apply for one nonemployee for services, payments estate, or pension trust. (Do not furnish the TIN of
immediately. To apply for an SSN, to certain fishing boat crew the personal representative or trustee unless the
get FORM SS-5 from your local members and fishermen, and gross legal entity itself is not designated in the account
Social Security Administration proceeds paid to attorneys title.)
office. Get FORM W-7, Application (including payments to
for IRS Individual Taxpayer corporations). NOTE: IF NO NAME IS CIRCLED WHEN MORE THAN ONE NAME
Identification Number, to apply IS LISTED, THE NUMBER WILL BE CONSIDERED TO BE THAT OF
for an ITIN or FORM SS-4, 5. MORTGAGE INTEREST PAID BY THE FIRST NAME LISTED.
Application for Employer YOU, ACQUISITION OR ABANDONMENT
Identification Number, to apply OF SECURED PROPERTY, CANCELLATION
for an EIN. You can get Forms W-7 OF DEBT, QUALIFIED STATE TUITION
and SS-4 from the IRS by calling PROGRAM PAYMENTS, IRA OR MSA
1-800-TAX-FORM (1-800-829-3676) CONTRIBUTIONS OR DISTRIBUTIONS,
or from the IRS's Internet Web AND PENSION DISTRIBUTIONS. You
Site at WWW.IRS.GOV. must give your correct TIN, but
you do not have to sign the
If you do not have a TIN, certification.
write "Applied For" in the space
for the TIN, sign and date the PRIVACY ACT NOTICE
form, and give it to the
requester. For interest and Section 6109 of the Internal
dividend payments, and certain Revenue Code requires you to give
payments made with respect to your correct TIN to persons who
readily tradable instruments, you must file information returns with
will generally have 60 days to the IRS 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