Print or type
See Specific Instructions on page 2.
Name (as shown on your income tax return)
Business name, if different from above
Address (number, street, and apt. or suite no.)
Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
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.
(Rev. October 2007)
Department of the
Request for Taxpayer
Identification Number and Certification
Give form to the
requester. Do not
send to the IRS.
¨ Individual/Sole proprietor ¨ Corporation
¨ Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership)
¨ Other (see instructions)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid
backup withholding. 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.