IRS Form W-9 InformationBy law, we are required to collect this information.Name(Required)Full name as shown on your income tax return Business nameOr disregarded entity name, if different from above. IRS Classification(Required) Individual/sole proprietor/single-member LLC C Corporation S Corporation Partnership Trust/estate Limited Liability Company (LLC) Other (see instructions) LLC Type(Required)Note: Check the appropriate item for the tax classification of the single-member owner. Do not check LLC above if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. C Corporation S Corporation Partnership IRS Classification Other(Required) ExemptionsCodes apply only to certain entities, usually outside the United States, and not individuals; see W-9 instructions. Include exempt payee code and/or exemption from FATCHA reporting code as applicable. Address(Required)This should be your current address, and where we will mail checks. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address Change?(Required)Is this a change of address within the past year? No Yes Taxpayer Identification Type(Required) Social Security Number (SSN) Employer Identification Number (EIN) Taxpayer Identification Number(Required)Input SSN as xxx-xx-xxxx Input EIN as xx-xxxxxxx Contact and ConsentName(Required)Person completing this form First Last Title/position Email(Required) Phone(Required)Daytime phonePhone ExtDaytime phone extension Mobile PhoneCertification(Required)Under penalties of perjury, I certify that: 1. I am authorized to complete this form on behalf of the named entity above; and 2. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 3. 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 (IRS) 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; and 4. I am a U.S. citizen or other U.S. person (defined in the IRS Form W-9 Instructions); and 5. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. I certify the above as an agent authorized on behalf of the entity named on this formEmailThis field is for validation purposes and should be left unchanged. Δ
