Request for Taxpayer
Identification Numberand Certification
Give form to the
requester. Do not
send to the IRS.
Department of the Treasuy
Business name. if different fiom above
box: D Sole proprietor
Address (number. street. and apt. ()('suite no.)
City. state. and ZIP code
List account number(s) here (optional}
'er Identification Number (TIN)
o Partnership 0 Other ~
O Exempt from backup
Requester's name and address
Enter your TIN in the appropriate box. For individuals. this is your social security number (SSN).
However. for a resident alien. sole proprietor. or disregarded entity. see the Part I instructions on
page 3. For other entities. it is your employer identification number (EIN).If you do not have a number.
see How to get a TIN on page 3.
Note: If the account is in more than one name. see the chart on page 4 forguidelineson whose number
Under penalties of peljury.
I certify that:
1. The number shown on this form is my correct
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 ORS)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,
I am a U.S. person (including a U.S. resident arlel1).
instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently su~ect
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions,
item 2 does not apply.
interest paid, acquisition or abandonment of secured property. cancellation of