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TAXPAYER IDENTIFICATION NUMBER <br /> I certify that: <br /> 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 <br /> 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal <br /> 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 <br /> notified me that I am no longer subject to backup withholding,and <br /> 3. 1 am a U.S.person(including a U.S.resident alien). <br /> • If you are an individual,enter your name and SSN as it appears on your Social Security Card. <br /> • If you are a sole proprietor, enter the owner's name on the name line followed by the name of the business and the owner's <br /> SSN or EIN. <br /> • If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner's name on the name <br /> line and the d/b/a on the business name line and enter the owner's SSN or EIN. <br /> • If the LLC is a corporation or partnership, enter the entity's business name and EIN and for corporations, attach IRS <br /> acceptance letter(CP261 or CP277). <br /> • For all other entities, enter the name of the entity as used to apply for the entity's EIN and the EIN. <br /> Name: <br /> or <br /> Business Name: City of Decatur <br /> Taxpayer Identification Number: <br /> Social Security Number <br /> or <br /> Employer Identification Number 376-001 -30,9 <br /> Legal Status (check one): <br /> ❑ Individual ® Governmental <br /> ❑ Sole Proprietor ❑ Nonresident alien <br /> ❑ Partnership ❑ Estate or trust <br /> ❑ Legal Services Corporation ❑ Pharmacy(Non-Corp.) <br /> ❑ Tax-exempt ❑ Pharmacy/Funeral Home/Cemetery(Corp.) <br /> ❑ Corporation providing or billing ❑ Limited Liability Company (select applicable tax <br /> medical and/or health care services classification) <br /> ❑ D = disregarded entity <br /> ❑ Corporation NOT providing or billing ❑ C = corporation <br /> medical and/or health care services ❑ P = partnership <br /> r <br /> Signature: Dater .)o Z. <br /> Revision 6-10-09 <br />