W-9 Form

Taxpayer Identification Number/ Social Security number *

Name: *

I have reviewed the terms of the W-9 form provided on the button below *

Yes

No

Business/ Entity Name

Date and time *

Full Address (Pay checks will be mailed here) *

Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes. *

Individual/sole proprietor

single-member LLC

C Corporation

S Corporation

Partnership

Trust/estate

Under penalties of perjury, I certify that: 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 2. 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; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. *

Yes

No

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