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.. . ;� . <br /> TAXPAYER IDENTIFICATION NUMBER <br /> I certify that: <br /> 1. The number shown on this form is my correct taxpayer identification number(or I am <br /> waiting for a number to be issued to me),and <br /> . 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, <br /> or(b) I have not been notified by the Internal Revenue Service (IRS)that I am subject to <br /> backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS <br /> has notified me that I am no longer subject to backup withholding, and <br /> 3. I am a U.S. person(including a U.S. resident alien). <br /> Name: ` <br /> Taxpayer ldentification Number: <br /> • Social Security Number <br /> or <br /> Employer ldentification Number 3 7 - (fl �Q �.3p� <br /> (If you are an individual, enter your name and SSN as it appears on your Social Security <br /> Card. If completing this certification for a sole proprietorship, enter the owner's name <br /> followed by the name of the business and the owner's SSN or EIN. For all other entities, <br /> enter the name of the entity as used to apply for the entity s EIN and the EIN.) <br /> Legal Status(check one): <br /> Individual ✓Governmental <br /> _Sole Proprietor _Nonresident alien I <br /> _Partnership/Legal Corporation _Estate or trust �, <br /> _Tax-exempt _Pharmacy(Non-Corp.) 'i <br /> _Corporation providing or billing _Pharmacy/Funeral Home/Cemetery <br /> medical and/or health care services (Corp.) <br /> _Corparation NOT providing or billing _Limited Liability Company(select <br /> medical and/or health care services applicable tax classification.) <br /> ❑ D=disregarded entity <br /> _Other: ❑ C=corporation <br /> ❑ P=partnership <br /> Signature: � Date: /6 �� /v� <br />