STATE OF FLORIDA

SUBSTITUTE FORM W-9

PART #: $en%or Information
IRS *a+e &as s!o,n on -our inco+e ta. return(

Mail or fax to: Chief Financial Officer Department of Financial Services Bureau of Accounting, 200 East Gaines Street Ta a!assee, F" #2#99-0#$% P O!E: &'$0( %)#-$$)9 FA": &'$0( %)#-$$$0

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Business *a+e/ 0oing Business As &0BA( Primar& A%%ress 'A%%ress (here Form #)** sho+l% ,e maile%Attention of In 1are of

Street A22ress

34O4 Bo. State53ro6ince

1ountr- ; 3osta 1o2e, if ot!er t!an U4S4

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PART .: Taxpa&er I%entification !+m,er 'TI!Enter -our TI* !ere/ (DO NOT USE DASHES)

Ta.8a-er I2entification T-8e &c!ec: a88ro8riate <o.(/

Fe2era E+8 o-er I2entification *u+<er &FEI*(

OR

Socia Securit- *u+<er &SS*(

PART /: 0+siness Desi1nations 'Select onl& oneIf 0+siness Desi1nation (ith Asteris2s ' 3- is selecte%4 please ans(er 5+estion ,elo(:

S 1or8oration = Go6ern+enta EntitIn2i6i2ua *onresi2ent A ien

3artners!i8 = Foreign 1or8oration or EntitSo e 3ro8rietor *ot for 3rofit

1 1or8oration Trust or Estate *on-cor8orate Renta Agent In2ian Tri<a Go6ern+ent

"i+ite2 "ia<i it- 1o+8an- &""1(/ 0isregar2e2 Entit1or8oration S 1or8oration = 3artners!i8 = 1

PART 6: Certification Statement

Un2er 8ena ties of 8er>ur-, I certif- t!at/ )4 T!e nu+<er s!o,n on t!is for+ is +- correct ta.8a-er infor+ation &or I a+ ,aiting for a nu+<er to <e issue2 to +e( A!D 24 OR I a+ su<>ect to <ac:u8 ,it!!o 2ing I a+ not su<>ect to <ac:u8 ,it!!o 2ing <ecause/ a( I a+ e.e+8t fro+ <ac:u8 ,it!!o 2ing <( I !a6e not <een notifie2 <- t!e Interna Re6enue Ser6ice &IRS( t!at I a+ su<>ect to <ac:u8 ,it!!o 2ing as a resu t of fai ure to re8ort a interest or 2i6i2en2s, OR c( t!e IRS !as notifie2 +e t!at I a+ no onger su<>ect to <ac:u8 ,it!!o 2ing A!D I a+ a U4S4 citi?en or ot!er U4S4 8erson &inc u2ing U4S4 resi2ent a ien(

#4

Certification Instr+ctions: To certif& the statement a,ove4 si1n an% complete &o+r information ,elo( as preparer 7 Preparer8s !ame 'Please PrintPreparer8s Title 're5+ire% for ,+siness entities 9 Please PrintSi1nat+re Email 'if availa,leDate Telephone !+m,er

Florida Substitu t e Form W- 9 Instructions

Rev. 12/2011

T!e State of F ori2a +ust o<tain -our correct ta.8a-er infor+ation t!at ,i <e use2 to 2eter+ine ,!et!er -ou ,i recei6e a For+ )099 for 8a-+ents +a2e to -ou <- an agenc- of t!e State of F ori2a4 T!is ta.8a-er infor+ation is co ecte2 on t!e F ori2a Su<stitute For+ W-9, an2 inc u2es a Ta.8a-er I2entification *u+<er &TI*(, IRS *a+e, an2 ot!er re ate2 infor+ation4 T!e infor+ation 8ro6i2e2 on t!is for+ +ust +atc! t!e infor+ation on fi e ,it! t!e Interna Re6enue Ser6ice &IRS( for Fe2era inco+e ta. re8orting an2 ,i <e 6erifie2 t!roug! t!e IRS TI* Matc!ing 3rogra+4 IRS regu ations re@uire t!e State of F ori2a to ta:e <ac:u8 ,it!!o 2ing fro+ future 8a-+ents +a2e to -ou if -ou fai to 8ro6i2e t!e infor+ation re@ueste24 All vendors doing business with the State of Florida must complete the Substitute Form W !. "ue to specific re#uirements on Florida$s Substitute Form W !% an &RS Form W ! will not be accepted. 'endors located outside the (nited States that do not have a )&* issued b+ the (.S. ,overnment should contact the 'endor -anagement Section at ./001 213 001!. NOTE This form can only be used if you do not have intern e t or e- mail access. Other than this excep tion, all Substitu t e Form - !s should be filed electronically by visitin" the #endor $ortal %ebsite at https4//flvendor.m+floridacfo.com . $art &' #endor (nform a t ion 1. IRS Name: )his should be the name as it appears on +our Federal income ta5 return% and ma+ be either an individual name or a business name. Do not abbre vi a t e names unless the+ are registered that wa+ with the &RS. 2. Business Name: Doing Business s !DB ": 6ist an+ 7"oing 8usiness As9 names that will be doing business with the State of Florida. &f +ou do not have "8As% leave this field blan:. #. $rimar% ddress: )his is the address where Form 10!!s and an+ other related correspondence should be mailed. $art )' Taxpay e r (dentifica tion Numbe r *T(N+ and Type 1. &nter 'our (IN: ;nter either +our Social Securit+ *umber .individuals1 or +our Federal ;mplo+er &dentification *umber .F;&*1. Do Not include dashes. 2. (a)*a%e r Identi+ica tion (%*e: Select the appropriate bo5 to indicate whether the )&* +ou have provided is +our SS* or F;&*. $art ,' -usiness .esi"na tions 1. Business Designa tion: Select the appropriate bo5. &f +ou are unsure of which bo5 to chec:% contact +our income ta5 preparer for assistance. $art /' 0ertifica tion Stat e m e n t 1. ,erti+ication State m e n t : Select the appropriate bo5 regarding bac:up withholding. <ou should chec: 7& am sub=ect to bac:up withholding 9 onl% if +ou have been notified b+ the &RS that +ou are sub=ect to bac:up withholding or +ou have been notified b+ the State of Florida that +our )&* on file is incorrect and the State will perform bac:up withholding on future pa+ments. >a+ers must generall+ withhold 2/? of ta5able interest% dividends and certain other pa+ments to a pa+ee that is sub=ect to bac:up withholding. &f +ou are unsure of +our bac:up withholding status% contact +our ta5 advisor for assistance. 2. $re*ar e r -s Nam e: Fill in the preparer$s name% title% signature% email address .if available1% date and phone number. )he preparer should be an e5ecutive of the organi@ation and someone who can answer #uestions that ma+ arise relating to the Substitute Form W !. -ail or fa5 the completed form to4 Ahief Financial Bfficer Florida "epartment of Financial Services 8ureau of Accounting / 'endor -anagement Section 200 ;ast ,aines Street )allahassee% F6 323!! 0302 >hone4 ./001 213 001! Fa54 ./001 213 0000 Rev. 12/2011