Form W-9

Request for Taxpayer Identification and Certification

IRS Public Domain Form

Name & Business Information

1. Name (as shown on your income tax return) *

2. Business name / disregarded entity name (if different from above)

3. Federal Tax Classification *

Individual / Sole Proprietor C Corporation S Corporation Partnership Trust / Estate LLC

Address

5. Street Address *

City *

State

ZIP Code *

Requester's Name & Address (optional)

Part I — Taxpayer Identification Number *

Enter your SSN or EIN — not both. For sole proprietors, use your SSN.

Social Security Number (SSN)

Employer Identification Number (EIN)

Part II — Certification

Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number; (2) I am not subject to backup withholding; (3) I am a U.S. citizen or other U.S. person; (4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Printed Name

Date

Signature of U.S. person *

This is a functional W-9 equivalent for use between parties. It is not submitted to the IRS. SubPaperz does not provide tax advice.