Substitute Form

W-9

(Rev. November 2009)

Request for Taxpayer Identification Number and Certification

Give form to the requester. Do not send to the IRS.

Name (as shown on your income tax return)

See Specific Instructions on page 2.P ease print or type

Business name i! "i!!erent !rom above

#orporation *e"ica' &n"ivi"ua'(So'e )roprietor #hec$ appropriate box% 00# !i'ing as 1isregar"e" /ntity (So'e )roprietor +""ress (number street an" apt. or suite no.) +ttorney Regu'ar )artnership ,ther Non )ro!it -overnment .o'unteer Boar" *ember 00# !i'ing as a #orporation *e"ica' +ttorney Re2uester3s name an" a""ress (optiona') Regu'ar 00# !i'ing as )artnership /xempt !rom bac$up withho'"ing

#ity state an" 4&) co"e

0ist account number(s) here (optiona')

Part I Taxpayer Identification Number !TIN"

Socia security number

/nter your 5&N in the appropriate box. 5he 5&N provi"e" must match the name given on 0ine 6 to avoi" bac$up withho'"ing. For in"ivi"ua's this is your socia' security number (SSN). 7owever !or a resi"ent a'ien so'e proprietor or "isregar"e" entity see the )art & instructions on page 8. For other entities it is your emp'oyer i"enti!ication number (/&N). &! you "o not have a number see 7ow to get a 5&N on page 8. Note# If the account is in more than one name, see the chart on page 3 for guidelines on whose number to enter.

or
$mp oyer identification number

Part II
%. &.

Certification

9n"er pena'ties o! per:ury & certi!y that% 5he number shown on this !orm is my correct taxpayer i"enti!ication number (or & am waiting !or a number to be issue" to me) an" & am not sub:ect to bac$up withho'"ing because% (a) & am exempt !rom bac$up withho'"ing or (b) & have not been noti!ie" by the &nterna' Revenue Service (&RS) that & am sub:ect to bac$up withho'"ing as a resu't o! a !ai'ure to report a'' interest or "ivi"en"s or (c) the &RS has noti!ie" me that & am no 'onger sub:ect to bac$up withho'"ing an" & am a 9.S. person (inc'u"ing a 9.S. resi"ent a'ien).

'.

Certification instructions. ;ou must cross out item 2 above i! you have been noti!ie" by the &RS that you are current'y sub:ect to bac$up withho'"ing because you have !ai'e" to report a'' interest an" "ivi"en"s on your tax return. For rea' estate transactions item 2 "oes not app'y. For mortgage interest pai" ac2uisition or aban"onment o! secure" property cance''ation o! "ebt contributions to an in"ivi"ua' retirement arrangement (&R+) an" genera''y payments other than interest an" "ivi"en"s you are not re2uire" to sign the #erti!ication but you must provi"e your correct 5&N. (See the instructions on page 8.)

Si(n )ere

Si(nature of *.S. person

Date