Form W-9
Request for Taxpayer Identification Number and Certification
Give form to the requester. Do not send to the IRS.
1 Name (as shown on your income tax return)
2 Business name/disregarded entity name
3 Federal tax classification
Individual/sole proprietor
4 Exemptions
Exempt payee: — · FATCA: —
Address
Account number(s)
—
Requester’s name and address
—
Part I · Taxpayer Identification Number
Social security number
—
The taxpayer identification number is hidden in this preview. The full number appears in the downloaded or printed PDF only.
Part II · Certification
Under penalties of perjury, I certify that:
- 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
- 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
- I am a U.S. citizen or other U.S. person (defined below).
Signature of U.S. person
Date