|
� Fo�, W•9 Request for Taxpayer Give Form to the
<br /> �a�,,.No�,e�,t�2o�� tdentifrcation Number and Certification requester.Do not
<br /> Deparfinentofthe7�easury send to the tRS.
<br /> Intemal Revernre Se�vtee h Go to wsvw.trs.gov/FormW9 tor insiructions and the latest info►mation.
<br /> 1 Narne(aa slwNm on your(ncoma tax retixn).Nama is required on this 8ne;do not leave thfs Rne biank
<br /> ,leremy Szczelaszczyk
<br /> 2 8�uinans namddtssreflazded entity name,N ddterent fmm above
<br /> m 3 Check eppropriata box for federal tax ciasstRcatlon of the person whoae name is en�on Ifns 1.Check w�y ons oi 1he 4 Exempt�na(eodes apply ony to
<br /> �+ followinp sevan boues. eartatn errtlties,not individuals;see
<br /> G instnictions on page 3):
<br /> g p rnar�a�v���c�� ❑ C Corporatbn D s c«p�a«, ❑ Parinarshtp ❑Tnist/eslate
<br /> m c singte-m�nb�LLC Fxempt Psyee coda(ft anY)
<br /> �� ❑ Umited liability comparry.Entar the taz dsssiticetlon{C•G corporallon,Sw corporatbn.P=Partnership)►
<br /> p� Note:Cher�c the apptopriate box In the�Ina abova iw the tax dasaMicatlon oE lhe s(ngle-member owner, po not check Exemptton from FATCA repo�ting
<br /> � LLC H the LLC(s elassHkd as a singfe-memb�LLC ihat is dtsroparded from tha ow�er unless the owner ot ll�llC is
<br /> a� anolher lLC that is not�aregarded from the owner for U.S.t�ferel tax Purposes.Othenvise.a singie-member LLC that coda pt artiy)
<br /> � is dEsregarcled trom ttre owner should check thc appropriate box ta tlie tax classification of Rs owner.
<br /> � ❑ Othe►(see�structtons}♦ f•aoa.e ro xowna�+r.h.e wwe.n»u.sJ
<br /> �
<br /> y 6 Address number street a�d a t.or wite no.)See�stn�cqons, Re4ueatera name end address(optionaQ
<br /> m
<br /> N
<br /> s e,s e
<br /> �_
<br /> � Ust account number(s)here(optfa�ary �
<br /> Tax a er ldentification Number[flt� �
<br /> Enter your TIN in the appropriate box.The T!N provided must match the name given on tine 1 to avofd Socta!secuHty number �
<br /> backup withholding.Fw indivfduals,this Is generally ydur sociai securily number(SSNj.However,tor a
<br /> resident alien,sole proprietor,o�disregarded entky,see the instructfons for Part i,later.Fo�other
<br /> entities,k is your employer identification number(EI►�,if you do not hava a number,see How to get a
<br /> TIN,later.
<br /> Note:if the account is In more than one name,see the instructioris for Iine 1.Also see Whai lVame and Employer identtfieatton number
<br /> Number To Give fhe Requester for guidelines on whose number to enter.
<br /> Certiftca#ion
<br /> Under per�aldes ot perJury,i certffy that:
<br /> 1.The number shown on this form is my correot taxpayer ideMit{catta►number(or i am waiting for a number to be issued ta me);and
<br /> 2.!am not subject to backup withholding because:(aj 1 am exempt irom backup withhotdtnp,or(bj I have r�ot been notihed by the Intemai Revenue
<br /> Service pRS)that I am subject to backup withhoiding as a resutt of a failure ta raport ali Interest or dividends,o�(c)the IAS has notiNed me that I am
<br /> no Ionger subject to backup wlthhofding;and
<br /> 3.1 am a U.S.citizen or other U.S.person(defined be}ow};and
<br /> 4.The FA7CA codejs}entered on this form(if attyj indicating that I am exempt from FATCA reporting is correct.
<br /> CertNication instrucHons.You must cross out kem 2 a6ove if you have been notlfted by the IRS that you are cunent�y subject to backup withhoiding becausa
<br /> you have tailed to repat aH interest and dividends on you�tsx retum.For real estate trensactlons,item 2 does not apply.For mortgage inierest pafd,
<br /> aoquisition or abandonment of secured property,canceilatlon of debt,contrlbutions to an individual retirement arrengement(IRA},and gen�alty,payments
<br /> other than interasi and divldends,you are not requhed to sign the ce�tification,but you must provlde your cortect TIN.See the Instructfons tor Part 11,later.
<br /> Sign SigeelU►e Of ' /^�r l�� /�
<br /> Here u.s.p«so�+► uec�► / � f
<br /> Genera l !n C�1 S �Fonn'f 098-DIV(div(dends,lnciuding those from stocks or mutual
<br /> funds)
<br /> 5ectlon references ere to the intemal Revenue Code unless otherroise .Fwm�099-MISC(varlous types of income,prizes,awards,or grass
<br /> noted. proceedsj -
<br /> future developmants.For the latest infortttatian about developmants .Form 1099-B(stock of mutual fund sales and certain othar
<br /> related to Form W-9 and its instructions,such es legislation enected transactfons by brokers)
<br /> after they were pUblished,go io www.irs.govlFormW9. •Fotm 1099-S(proceeds from real estate transactipns)
<br /> Purpose of Form . •Form 1099-K(merchant card and third party network transaotfons)
<br /> M Individuat or endty(Farm W-9 requesterj who is required to file an 'FO�1098(home mortgage interest�,109&E(student toan interest),
<br /> Information retum wffh the IRS must obtain your correct taxpayer 1098•T(tuition)
<br /> identiflcation r►umber(Tlt�which may be your socfal aseudty number •Form 1099-C{canceled debt) i '
<br /> (SSh!),3ndividual texpayer tdentliication n�unber(IT'it�,adoptbn •Form 1099-A(acquisition or abandonment of secured propertyj �
<br /> texpayer identificatbn rnanber(AT1Nj,or emptoyer identifkatlon numbar Use Form W-9 onty if you are a U.S.person(indudfng a resident �
<br /> (E t�,to report on en infwma8on r�um the amouM pald to you,or other alian),to provide your coRect TIN.
<br /> amount reportable on an information reium.Exampies ot information
<br /> retums Inciude,but are not iimited to,the ipllow(n8. !t you do not retum Forrtt W-9 to the requester wlth a T1N,you might
<br /> •Farm 1099-1NT(interest eamed or paidj be subJect to backup withhoJding.See What is backup wtthhotding,
<br /> � later. I
<br /> Cat.No.10231X Fortn W-9{Rev.11-2017) i
<br /> i '
<br /> ! �
<br /> I ,
<br /> ! �
<br />
|