Give form to the
requester. Do NOT
send to the IRS.
Form
W-9
Request for Taxpayer
Identification Number and Certification
(Rev. December 1996)
Department of the Treasury
Internal Revenue Service
Name (If a joint account or you changed your name, see Specific Instructions on page 2.)
List account number(s) here (optional)
Address (number, street, and apt. or suite no.)
City, state, and ZIP code
Please print or type
For Payees Exempt From Backup
Withholding (See the instructions
on page 2.)
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. For
individuals, this is your social security number
(SSN). However, if you are a resident alien OR a
sole proprietor, see the instructions on page 2.
For other entities, it is your employer
identification number (EIN). If you do not have a
number, see How To Get a TIN on page 2.
Social security number
OR
Requester's name and address (optional)
Employer identification number
Note: If the account is in more than one name,
see the chart on page 2 for guidelines on whose
number to enter.
Certification
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
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.
2.
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 on page 2.)
Sign
Here
Signature
Date
2. The IRS tells the requester that you
furnished an incorrect TIN, or
3. The IRS tells you that you are subject
to backup withholding because you did not
report all your interest and dividends on
your tax return (for reportable interest and
dividends only), or
Purpose of Form.--A person who is
required to file an information return with
the IRS must get your correct taxpayer
identification number (TIN) to report, for
example, income paid to you, real estate
transactions, mortgage interest you paid,
acquisition or abandonment of secured
property, cancellation of debt, or
contributions you made to an IRA.
4. You do not certify to the requester
that you are not subject to backup
withholding under 3 above (for reportable
interest and dividend accounts opened
after 1983 only), or
5. You do not certify your TIN when
required. See the Part III instructions on
page 2 for details.
Note: If a requester gives you a form other
than a W-9 to request your TIN, you must
use the requester's form if it is substantially
similar to this Form W-9.
What Is Backup Withholding?--Persons
making certain payments to you must
withhold and pay to the IRS 31% of such
payments under certain conditions. This is
called "backup withholding." Payments
that may be subject to backup withholding
If you give the requester your correct
TIN, make the proper certifications, and
report all your taxable interest and
dividends on your tax return, payments
you receive will not be subject to backup
withholding. Payments you receive will be
subject to backup withholding if:
1. You do not furnish your TIN to the
requester, or
Form
W-9
(Rev. 12-96)
Part I
Part II
Business name, if different from above. (See Specific Instructions on page 2.)
Cat. No. 10231X
Certain payees and payments are
exempt from backup withholding. See the
Part II instructions and the separate
Instructions for the Requester of Form
W-9.
Check appropriate box:
Individual/Sole proprietor
Corporation
Partnership
Other
Under penalties of perjury, I certify that:
Part III
Use Form W-9 to give your correct TIN
to the person requesting it (the requester)
and, when applicable, to:
1. Certify the TIN you are giving is
correct (or you are waiting for a number to
be issued),
2. Certify you are not subject to backup
withholding, or
3. Claim exemption from backup
withholding if you are an exempt payee.
include interest, dividends, broker and
barter exchange transactions, rents,
royalties, nonemployee pay, and certain
payments from fishing boat operators. Real
estate transactions are not subject to
backup withholding.
Civil Penalty for False Information With
Respect to Withholding.--If you make a
false statement with no reasonable basis
that results in no backup withholding, you
are subject to a $500 penalty.
Criminal Penalty for Falsifying
Information.-- Willfully falsifying
certifications or affirmations may subject
you to criminal penalties including fines
and/or imprisonment.
Penalties
Failure To Furnish TIN.--If you fail to
furnish your correct TIN to a requester, you
are subject to a penalty of $50 for each
such failure unless your failure is due to
reasonable cause and not to willful neglect.
Misuse of TINs.--If the requester
discloses or uses TINs in violation of
Federal law, the requester may be subject
to civil and criminal penalties.
Form W-9 (Rev. 12-96)
Page
2
What Name and Number To
Give the Requester
Give name and SSN of:
For this type of account:
The individual
1. Individual
The actual owner of the
account or, if combined
funds, the first individual
on the account
1
2. Two or more
individuals (joint
account)
Specific Instructions
Name.--If you are an individual, you must
generally enter the name shown on your
social security card. However, if you have
changed your last name, for instance, due
to marriage, without informing the Social
Security Administration of the name
change, enter your first name, the last
name shown on your social security card,
and your new last name.
The minor
2
3. Custodian account of
a minor (Uniform Gift
to Minors Act)
The grantor-trustee
1
4. a. The usual
revocable savings
trust (grantor is
also trustee)
1. Interest, Dividend, and Barter
Exchange Accounts Opened Before 1984
and Broker Accounts Considered Active
During 1983. You must give your correct
TIN, but you do not have to sign the
certification.
The actual owner
1
b. So-called trust
account that is not
a legal or valid trust
under state law
2. Interest, Dividend, Broker, and
Barter Exchange Accounts Opened After
1983 and Broker Accounts Considered
Inactive During 1983. You must sign the
certification or backup withholding will
apply. If you are subject to backup
withholding and you are merely providing
your correct TIN to the requester, you must
cross out item 2 in the certification before
signing the form.
The owner
3
5. Sole proprietorship
Give name and EIN of:
For this type of account:
3. Real Estate Transactions. You must
sign the certification. You may cross out
item 2 of the certification.
A valid trust, estate, or
pension trust
6.
Legal entity
4
4. Other Payments. You must give your
correct TIN, but you do not have to sign
the certification unless you have been
notified that you have previously given an
incorrect TIN. "Other payments" include
payments made in the course of the
requester's trade or business for rents,
royalties, goods (other than bills for
merchandise), medical and health care
services (including payments to
corporations), payments to a nonemployee
for services (including attorney and
accounting fees), and payments to certain
fishing boat crew members.
The corporation
Corporate
7.
The organization
Association, club,
religious, charitable,
educational, or other
tax-exempt
organization
8.
5. Mortgage Interest Paid by You,
Acquisition or Abandonment of Secured
Property, Cancellation of Debt, or IRA
Contributions. You must give your correct
TIN, but you do not have to sign the
certification.
The partnership
Partnership
9.
The broker or nominee
A broker or registered
nominee
10.
The public entity
Account with the
Department of
Agriculture in the name
of a public entity (such
as a state or local
government, school
district, or prison) that
receives agricultural
program payments
11.
Privacy Act Notice
1
List first and circle the name of the person whose
number you furnish. If only one person on a joint
account has an SSN, that person's number must be
furnished.
2
Circle the minor's name and furnish the minor's SSN.
3
You must show your individual name, but you may also
enter your business or "doing business as" name. You
may use either your SSN or EIN (if you have one).
4
List first and circle the name of the legal trust, estate,
or pension trust. (Do not furnish the TIN of the personal
representative or trustee unless the legal entity itself is
not designated in the account title.)
Note: If no name is circled when more than one
name is listed, the number will be considered to
be that of the first name listed.
Sole Proprietor.--You must enter your
individual name as shown on your social
security card. You may enter your
business, trade, or "doing business as"
name on the business name line.
Sole proprietorship
The owner
3
12.
Note: Writing "Applied For" means that
you have already applied for a TIN OR that
you intend to apply for one soon.
Part I--Taxpayer Identification Number
(TIN)
You must enter your TIN in the appropriate
box. If you are a resident alien and you do
not have and are not eligible to get an
SSN, your TIN is your IRS individual
taxpayer identification number (ITIN). Enter
it in the social security number box. If you
do not have an ITIN, see How To Get a
TIN below.
Part II--For Payees Exempt From
Backup Withholding
Individuals (including sole proprietors) are
not exempt from backup withholding.
Corporations are exempt from backup
withholding for certain payments, such as
interest and dividends. For more
information on exempt payees, see the
separate Instructions for the Requester of
Form W-9.
Part III--Certification
For a joint account, only the person whose
TIN is shown in Part I should sign (when
required).
If you are exempt from backup
withholding, you should still complete this
form to avoid possible erroneous backup
withholding. Enter your correct TIN in Part
I, write "Exempt" in Part II, and sign and
date the form.
Section 6109 of the Internal Revenue Code
requires you to give your correct TIN to
persons who must file information returns
with the IRS to report interest, dividends,
If you are a nonresident alien or a foreign
entity not subject to backup withholding,
give the requester a completed Form W-8,
Certificate of Foreign Status.
Other Entities.--Enter the business name
as shown on required Federal tax
documents. This name should match the
name shown on the charter or other legal
document creating the entity. You may
enter any business, trade, or "doing
business as" name on the business name
line.
Note: See the chart on this page for further
clarification of name and TIN combinations.
and certain other income paid to you,
mortgage interest you paid, the acquisition
or abandonment of secured property,
cancellation of debt, or contributions you
made to an IRA. The IRS uses the
numbers for identification purposes and to
help verify the accuracy of your tax return.
The IRS may also provide this information
to the Department of Justice for civil and
criminal litigation and to cities, states, and
the District of Columbia to carry out their
tax laws.
How To Get a TIN.--If you do not have a
TIN, apply for one immediately. To apply
for an SSN, get Form SS-5 from your local
Social Security Administration office. Get
Form W-7 to apply for an ITIN or Form
SS-4 to apply for an EIN. You can get
Forms W-7 and SS-4 from the IRS by
calling 1-800-TAX-FORM
(1-800-829-3676).
If you do not have a TIN, write "Applied
For" in the space for the TIN, sign and
date the form, and give it to the requester.
For interest and dividend payments, and
certain payments made with respect to
readily tradable instruments, you will
generally have 60 days to get a TIN and
give it to the requester. Other payments
are subject to backup withholding.
If the account is in joint names, list first
and then circle the name of the person or
entity whose number you enter in Part I of
the form.
If you are a sole proprietor and you have
an EIN, you may enter either your SSN or
EIN. However, using your EIN may result in
unnecessary notices to the requester.
You must provide your TIN whether or
not you are required to file a tax return.
Payers must generally withhold 31% of
taxable interest, dividend, and certain other
payments to a payee who does not give a
TIN to a payer. Certain penalties may also
apply.