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SubstituteForm W-9 Request for Taxpayer

Identification Number and Certification

Give form to therequester. Do not

(Rev. November 2009)

Pease

printortype

See

Specific

Instructions

on

page

2.

Name (as shown on your income tax return)

Business name i! "i!!erent !rom above

#hec$

appropriate

box%

&n"ivi"ua'So'e roprietor

#orporation

*e"ica' Regu'ar

+ttorney

artnership ,ther

Non ro!it

-overnment

o'unteer

Boar" *ember /xempt !rombac$up

withho'"ing

# !i'ing as 1isregar"e"/ntity So'e roprietor

# !i'ing as a #orporation

*e"ica' Regu'ar

+ttorney# !i'ing as artnership

+""ress (number street an" apt. or suite no.) Reuester3s name an" a""ress (optiona')#ity state an" 4& co"eist account number(s) here (optiona')

Part I Taxpayer Identification Number !TIN"

/nter your 5&N in the appropriate box. 5he 5&N provi"e" must match the name given on ine 6 to avoi" bac$upwithho'"ing. For in"ivi"ua's this is your socia' security number (SSN). 7owever !or a resi"ent a'ien so'e proprietoror "isregar"e" entity see the art & instructions on page 8. For other entities it is your emp'oyer i"enti!icationnumber (/&N). &! you "o not have a number see 7ow to get a 5&N on page 8.

Note# If the account is in more than one name, see the chart on page 3 for guidelines on whose numberto enter.

Socia security numberor

$mpoyer identification numberPart II Certification

n"er pena'ties o! per:ury & certi!y that%

%. 5he number shown on this !orm is my correct taxpayer i"enti!ication number (or & am waiting !or a number to be issue" to me) an"

&. & am not sub:ect to bac$up withho'"ing because% (a) & am exempt !rom bac$up withho'"ing or (b) & have not been noti!ie" by the &nterna' RevenueService (&RS) that & am sub:ect to bac$up withho'"ing as a resu't o! a !ai'ure to report a'' interest or "ivi"en"s or (c) the &RS has noti!ie" me that & amno 'onger sub:ect to bac$up withho'"ing an"

'. & am a .S. person (inc'u"ing a .S. resi"ent a'ien).Certification instructions. ;ou must cross out item 2 above i! you have been noti!ie" by the &RS that you are current'y sub:ect to bac$up withho'"ingbecause you have !ai'e" to report a'' interest an" "ivi"en"s on your tax return. For rea' estate transactions item 2 "oes not app'y.For mortgage interest pai" acuisition or aban"onment o! secure" property cance''ation o! "ebt contributions to an in"ivi"ua' retirement arrangement(&R+) an" genera''y payments other than interest an" "ivi"en"s you are not reuire" to sign the #erti!ication but you must

provi"e your correct 5&N. (See the instructions on page 8.)

Si(n )ereSi(nature of*.S. person Date

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