W-9 — Request for Taxpayer Identification Number

Fill out the form below and download a completed W-9 or email it directly to whoever requested it.

Taxpayer Information

Name (as shown on your income tax return) *

Business name / disregarded entity name (if different)

Federal tax classification *

Address

Street address (number, street, apt/suite) *

City *

State *

ZIP *

Taxpayer Identification Number (TIN)

SSN *

Certification & Signature

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; and
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Printed Name *

Date *

Your Signature *

Draw your signature above

Under penalties of perjury, I certify the statements above are true and correct. I intend this electronic signature to have the same legal effect as a handwritten signature, and I consent to conduct this transaction electronically under the ESIGN Act and UETA.

Delivery

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