* Name (as shown on your income tax return):
Business Name, if different from above:
Exempt from Withholding:
Yes No
*Select the appropriate tax type:
*Enter type of LLC:
Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate item above for the tax classification of the single-member owner.
*Select the type of Tax ID Number:
SSN
EIN
*Tax ID Number (without dashes):
*Address:
*City:
*State:
*Postal Code:
Phone:
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. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
(Check to certify)
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