Request for Taxpayer Identification Number and Certification

Request for Taxpayer Identification Number and Certification
Go to www.irs.gov/FormW9 for instructions and the latest information.
1. Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner’s name on line 1, and enter the business/disregarded entity’s name on line 2.)*
2. Business name/disregarded entity name, if different from above.
3a. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.*

Individual/sole proprietorC CorporationS CorporationPartnershipTrust/estateLLCOther
Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
3b. If on line 3a you checked “Partnership” or “Trust/estate,” or checked “LLC” and entered “P” as its tax classification, and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check this box if you have any foreign partners, owners, or beneficiaries.
4. Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
Exempt payee code (if any)
Exemption from Foreign Account Tax Compliance Act (FATCA) reporting code (if any)
5. Address*

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code
Requester's name (optional)

First NameLast Name
Requester's address (optional)

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code
List account number(s) here (optional)
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 generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.
Social security number
A
A
A
X
G
G
X
S
S
S
S
Employer identification number
X
X
X
X
X
X
X
X
X
X
Part II - Certification
Under penalties of perjury, I certify that:

1. 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

2. 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

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

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 for Part II, later.
Signature*

Clear
Date*

MonthDayYear
Date
Disclaimer
These tax forms are provided as a courtesy to our Jotform users. It is up to you to make sure you are filing the right form with the IRS and to fill out the form correctly. Jotform does not file tax forms for you - that is your responsibility. If you have any questions or need any legal or tax advice about which form is appropriate or how to fill in the form, or whether the form is required by the IRS, consult your tax preparer, adviser, and/or attorney.
Should be Empty:

Part I - Taxpayer Identification Number (TIN)

Social security number

Employer identification number

Part II - Certification