Print or type
See Specific Instructions on page 2.
Taxpayer Identification Number (TIN)
Under penalties of perjury, I certify that:
Certification instructions. You must cross out item 2 above if you have been notified by the
IRS that you are currently subject to backup withholding because you have failed to report all
interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For
mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt,
contributions to an individual retirement arrangement (IRA), and generally, payments other than
interest and dividends, you are not required to sign the Certification, but you must provide your
correct TIN. See the instructions on page 4.
Section references are to the Internal Revenue Code unless otherwise noted.
(Rev. October 2007)
Department of the Treasury
Internal Revenue Service
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)
Business name, if different from above
Check appropriate box: o Individual/Sole proprietor o Corporation o
liability company. Enter the tax classification (D=disregarded entity, C=corporation,
Other (see instructions) ►
o Exempt payee
Address (number, street, and apt. or suite no.)
Requester’s name and address
City, state, and ZIP