Applicant Information

Transcription

1 Please return all cmpleted applicatins t: SJVAPCD Strategies and Incentives Department 1990 East Gettysburg Avenue; Fresn, CA SCHOOL BUS INCENTIVES PROGRAM Applicant Infrmatin 1. Applicant Type: Public Schl District 2. Applicant Name: Jint Pwers Authrity (JPA) 3. Address: 4. City: 5. State: 6. ZIP Cde: 7. Mailing Address (if different frm abve): 8. City: 9. State: 10. ZIP Cde: 11. Gegraphic Area Served by Applicant (City r Cunty): 12. Schl District(s) Assciated with this Prject, if applicant is a JPA: Primary Cntact Infrmatin 1. First Name: 2. Last Name: 3. Title: Phne Number: 6. Alternate Cntact Number: 7. Fax Number: Agreement Signing Authrity 1. First Name: 2. Last Name: 3. Title: Page 1 f 5 Apprved January 2014

2 **Cmplete a separate page fr each schl bus t be replaced** Existing Old Schl Bus Infrmatin 1. Schl District Identificatin Number: 2. Schl Bus Strage Address: Vehicle f 3. City, State, Zip Cde: 4. Ttal Mileage: 5. Annual Mileage: 6. Annual Fuel Usage (Gallns): 7. Schl Bus Make: 8. Schl Bus Mdel: 9. Schl Bus Mdel Year: 10. Grss Vehicle Weight Rating (GVWR): 11. Vehicle Identificatin Number (VIN): 12. License Number: 13. Schl Bus Type: C Cnventinal D Transit Special Ed Other, specify: Engine Infrmatin 1. Engine Make: 2. Engine Mdel: 3. Engine Mdel Year: 4. Hrsepwer: 5. Engine Serial Number: 6. EPA-Certified Family Name (e.g., XCEXH0123MAH): 7. Tw Strke Engine: Yes N 8. Displacement: 9. Fuel Type: Diesel Other, specify: Page 2 f 5 Apprved January 2014 Internal use nly GMS Unit:

3 **Cmplete a separate page fr each schl bus t be replaced** Vehicle f Prpsed New Schl Bus Infrmatin 1. Schl Bus Make: 2. Schl Bus Mdel: 3. Schl Bus Mdel Year: 4. GVWR: 5. Schl Bus Type: C Cnventinal D Transit Special Ed Other, specify: 6. Ttal Cst f New Schl Bus: 7. Additinal Optins (check all that apply): Nne Fg Lights Retarder Air Cnditining Other, specify: Prpsed New Engine Infrmatin 1. Engine Make: 2. Engine Mdel: 3. Engine Mdel Year: 4. Hrsepwer: 5. EPA-Certified Family Name (e.g., XCEXH0123MAH): 6. Displacement: 7. Fuel Type: Diesel Other, specify: Internal use nly GMS Unit: Page 3 f 5 Apprved January 2014

4 Signature Frm Signing Authrity t initial and sign in blue ink Certificatins By initialing each f the fllwing sectins, I certify that I have read the Eligibility Criteria and Guidelines and agree t ALL f the fllwing terms and cnditins: The schl bus(es) within this applicatin is/are utilized t service a public schl district. The schl bus(es) within this applicatin is/are based within the gegraphic area f the SJVAPCD and seventy-five percent (75%) r mre f the vehicle miles traveled r fuel cnsumed will be within the bundaries f the SJVAPCD fr at least five (5) years frm the date the new schl bus is purchased. Any funding received, including funding frm ther surces, cmbined with this grant will nt exceed the full cst f the new schl bus. Applicant will nt rder, purchase, make payment, r take delivery f the new schl bus withut an executed agreement with the SJVAPCD. SJVAPCD maintains the right t inspect the schl bus at any time during the agreement perid. I hereby certify that all infrmatin prvided in this applicatin and any attachments are true and crrect t the best f my knwledge. Signing Authrity Signature Date Page 4 f 5 Apprved January 2014

5 Packet Checklist When submitting a prject fr cnsideratin, submit a cmplete applicatin packet. An incmplete applicatin packet will lengthen the applicatin prcessing time and delay pssible incentive funding. A cmplete applicatin packet includes the fllwing items: Cmpleted (Pages 1 thru 3), n required fields blank. Cmpleted Signature Frm (Page 4). First page f IRS Frm W-9. Dated and itemized dealer qute fr the prpsed new schl bus(es). The qute must prvide a breakdwn f the ttal cst f the new schl bus, including additinal ptins. Reslutin frm the schl district s gverning bdy r ther dcumentatin signed by a duly authrized fficial with authrity t make financial decisins, authrizing the submittal f the applicatin and identifying the individual(s) authrized t implement and enter int agreement with the District fr the replacement prject. Cpy f the current Califrnia Highway Patrl Safety Certificatin (CHP frm 292) fr each schl bus n the applicatin shwing cntinuus certificatin fr the past tw (2) years. Cpy f the current Department f Mtr Vehicles registratin fr each schl bus n the applicatin. Cpy f the ARB certificatin executive rder fr the engine in the prpsed new schl bus(es). Phtgraphs f the engine and schl bus data tags fr each schl bus n the applicatin that will be replaced. The phtgraphs can be in hard r electrnic frmat. The phtgraphs must be legible t cnfirm the fllwing: Grss Vehicle Weight Rating (GVWR) Vehicle Identificatin Number (VIN) Engine Serial Number Engine Mdel Year Engine Family Name If the engine data plate is missing r illegible, please submit dcumentatin cnfirming the serial number and engine family name. Page 5 f 5 Apprved January 2014

6 Frm W-9 (Rev. August 2013) Department f the Treasury Internal Revenue Service Name (as shwn n yur incme tax return) Request fr Taxpayer Identificatin Number and Certificatin Give Frm t the requester. D nt send t the IRS. Print r type See Specific Instructins n page 2. Business name/disregarded entity name, if different frm abve Check apprpriate bx fr federal tax classificatin: Individual/sle prprietr C Crpratin S Crpratin Partnership Trust/estate Limited liability cmpany. Enter the tax classificatin (C=C crpratin, S=S crpratin, P=partnership) Other (see instructins) Address (number, street, and apt. r suite n.) City, state, and ZIP cde Exemptins (see instructins): Exempt payee cde (if any) Exemptin frm FATCA reprting cde (if any) Requester s name and address (ptinal) List accunt number(s) here (ptinal) Part I Taxpayer Identificatin Number (TIN) Enter yur TIN in the apprpriate bx. The TIN prvided must match the name given n the Name line t avid backup withhlding. Fr individuals, this is yur scial security number (SSN). Hwever, fr a resident alien, sle prprietr, r disregarded entity, see the Part I instructins n page 3. Fr ther entities, it is yur emplyer identificatin number (EIN). If yu d nt have a number, see Hw t get a TIN n page 3. Nte. If the accunt is in mre than ne name, see the chart n page 4 fr guidelines n whse number t enter. Scial security number Emplyer identificatin number Part II Certificatin Under penalties f perjury, I certify that: 1. The number shwn n this frm is my crrect taxpayer identificatin number (r I am waiting fr a number t be issued t me), and 2. I am nt subject t backup withhlding because: (a) I am exempt frm backup withhlding, r (b) I have nt been ntified by the Internal Revenue Service (IRS) that I am subject t backup withhlding as a result f a failure t reprt all interest r dividends, r (c) the IRS has ntified me that I am n lnger subject t backup withhlding, and 3. I am a U.S. citizen r ther U.S. persn (defined belw), and 4. The FATCA cde(s) entered n this frm (if any) indicating that I am exempt frm FATCA reprting is crrect. Certificatin instructins. Yu must crss ut item 2 abve if yu have been ntified by the IRS that yu are currently subject t backup withhlding because yu have failed t reprt all interest and dividends n yur tax return. Fr real estate transactins, item 2 des nt apply. Fr mrtgage interest paid, acquisitin r abandnment f secured prperty, cancellatin f debt, cntributins t an individual retirement arrangement (IRA), and generally, payments ther than interest and dividends, yu are nt required t sign the certificatin, but yu must prvide yur crrect TIN. See the instructins n page 3. Sign Here Signature f U.S. persn General Instructins Sectin references are t the Internal Revenue Cde unless therwise nted. Future develpments. The IRS has created a page n IRS.gv fr infrmatin abut Frm W-9, at Infrmatin abut any future develpments affecting Frm W-9 (such as legislatin enacted after we release it) will be psted n that page. Purpse f Frm A persn wh is required t file an infrmatin return with the IRS must btain yur crrect taxpayer identificatin number (TIN) t reprt, fr example, incme paid t yu, payments made t yu in settlement f payment card and third party netwrk transactins, real estate transactins, mrtgage interest yu paid, acquisitin r abandnment f secured prperty, cancellatin f debt, r cntributins yu made t an IRA. Use Frm W-9 nly if yu are a U.S. persn (including a resident alien), t prvide yur crrect TIN t the persn requesting it (the requester) and, when applicable, t: 1. Certify that the TIN yu are giving is crrect (r yu are waiting fr a number t be issued), 2. Certify that yu are nt subject t backup withhlding, r 3. Claim exemptin frm backup withhlding if yu are a U.S. exempt payee. If applicable, yu are als certifying that as a U.S. persn, yur allcable share f any partnership incme frm a U.S. trade r business is nt subject t the Date withhlding tax n freign partners share f effectively cnnected incme, and 4. Certify that FATCA cde(s) entered n this frm (if any) indicating that yu are exempt frm the FATCA reprting, is crrect. Nte. If yu are a U.S. persn and a requester gives yu a frm ther than Frm W-9 t request yur TIN, yu must use the requester s frm if it is substantially similar t this Frm W-9. Definitin f a U.S. persn. Fr federal tax purpses, yu are cnsidered a U.S. persn if yu are: An individual wh is a U.S. citizen r U.S. resident alien, A partnership, crpratin, cmpany, r assciatin created r rganized in the United States r under the laws f the United States, An estate (ther than a freign estate), r A dmestic trust (as defined in Regulatins sectin ). Special rules fr partnerships. Partnerships that cnduct a trade r business in the United States are generally required t pay a withhlding tax under sectin 1446 n any freign partners share f effectively cnnected taxable incme frm such business. Further, in certain cases where a Frm W-9 has nt been received, the rules under sectin 1446 require a partnership t presume that a partner is a freign persn, and pay the sectin 1446 withhlding tax. Therefre, if yu are a U.S. persn that is a partner in a partnership cnducting a trade r business in the United States, prvide Frm W-9 t the partnership t establish yur U.S. status and avid sectin 1446 withhlding n yur share f partnership incme. Cat. N X Frm W-9 (Rev )

7 Frm W-9 (Rev ) Page 2 In the cases belw, the fllwing persn must give Frm W-9 t the partnership fr purpses f establishing its U.S. status and aviding withhlding n its allcable share f net incme frm the partnership cnducting a trade r business in the United States: In the case f a disregarded entity with a U.S. wner, the U.S. wner f the disregarded entity and nt the entity, In the case f a grantr trust with a U.S. grantr r ther U.S. wner, generally, the U.S. grantr r ther U.S. wner f the grantr trust and nt the trust, and In the case f a U.S. trust (ther than a grantr trust), the U.S. trust (ther than a grantr trust) and nt the beneficiaries f the trust. Freign persn. If yu are a freign persn r the U.S. branch f a freign bank that has elected t be treated as a U.S. persn, d nt use Frm W-9. Instead, use the apprpriate Frm W-8 r Frm 8233 (see Publicatin 515, Withhlding f Tax n Nnresident Aliens and Freign Entities). Nnresident alien wh becmes a resident alien. Generally, nly a nnresident alien individual may use the terms f a tax treaty t reduce r eliminate U.S. tax n certain types f incme. Hwever, mst tax treaties cntain a prvisin knwn as a saving clause. Exceptins specified in the saving clause may permit an exemptin frm tax t cntinue fr certain types f incme even after the payee has therwise becme a U.S. resident alien fr tax purpses. If yu are a U.S. resident alien wh is relying n an exceptin cntained in the saving clause f a tax treaty t claim an exemptin frm U.S. tax n certain types f incme, yu must attach a statement t Frm W-9 that specifies the fllwing five items: 1. The treaty cuntry. Generally, this must be the same treaty under which yu claimed exemptin frm tax as a nnresident alien. 2. The treaty article addressing the incme. 3. The article number (r lcatin) in the tax treaty that cntains the saving clause and its exceptins. 4. The type and amunt f incme that qualifies fr the exemptin frm tax. 5. Sufficient facts t justify the exemptin frm tax under the terms f the treaty article. Example. Article 20 f the U.S.-China incme tax treaty allws an exemptin frm tax fr schlarship incme received by a Chinese student temprarily present in the United States. Under U.S. law, this student will becme a resident alien fr tax purpses if his r her stay in the United States exceeds 5 calendar years. Hwever, paragraph 2 f the first Prtcl t the U.S.-China treaty (dated April 30, 1984) allws the prvisins f Article 20 t cntinue t apply even after the Chinese student becmes a resident alien f the United States. A Chinese student wh qualifies fr this exceptin (under paragraph 2 f the first prtcl) and is relying n this exceptin t claim an exemptin frm tax n his r her schlarship r fellwship incme wuld attach t Frm W-9 a statement that includes the infrmatin described abve t supprt that exemptin. If yu are a nnresident alien r a freign entity, give the requester the apprpriate cmpleted Frm W-8 r Frm What is backup withhlding? Persns making certain payments t yu must under certain cnditins withhld and pay t the IRS a percentage f such payments. This is called backup withhlding. Payments that may be subject t backup withhlding include interest, tax-exempt interest, dividends, brker and barter exchange transactins, rents, ryalties, nnemplyee pay, payments made in settlement f payment card and third party netwrk transactins, and certain payments frm fishing bat peratrs. Real estate transactins are nt subject t backup withhlding. Yu will nt be subject t backup withhlding n payments yu receive if yu give the requester yur crrect TIN, make the prper certificatins, and reprt all yur taxable interest and dividends n yur tax return. Payments yu receive will be subject t backup withhlding if: 1. Yu d nt furnish yur TIN t the requester, 2. Yu d nt certify yur TIN when required (see the Part II instructins n page 3 fr details), 3. The IRS tells the requester that yu furnished an incrrect TIN, 4. The IRS tells yu that yu are subject t backup withhlding because yu did nt reprt all yur interest and dividends n yur tax return (fr reprtable interest and dividends nly), r 5. Yu d nt certify t the requester that yu are nt subject t backup withhlding under 4 abve (fr reprtable interest and dividend accunts pened after 1983 nly). Certain payees and payments are exempt frm backup withhlding. See Exempt payee cde n page 3 and the separate Instructins fr the Requester f Frm W-9 fr mre infrmatin. Als see Special rules fr partnerships n page 1. What is FATCA reprting? The Freign Accunt Tax Cmpliance Act (FATCA) requires a participating freign financial institutin t reprt all United States accunt hlders that are specified United States persns. Certain payees are exempt frm FATCA reprting. See Exemptin frm FATCA reprting cde n page 3 and the Instructins fr the Requester f Frm W-9 fr mre infrmatin. Updating Yur Infrmatin Yu must prvide updated infrmatin t any persn t whm yu claimed t be an exempt payee if yu are n lnger an exempt payee and anticipate receiving reprtable payments in the future frm this persn. Fr example, yu may need t prvide updated infrmatin if yu are a C crpratin that elects t be an S crpratin, r if yu n lnger are tax exempt. In additin, yu must furnish a new Frm W-9 if the name r TIN changes fr the accunt, fr example, if the grantr f a grantr trust dies. Penalties Failure t furnish TIN. If yu fail t furnish yur crrect TIN t a requester, yu are subject t a penalty f $50 fr each such failure unless yur failure is due t reasnable cause and nt t willful neglect. Civil penalty fr false infrmatin with respect t withhlding. If yu make a false statement with n reasnable basis that results in n backup withhlding, yu are subject t a $500 penalty. Criminal penalty fr falsifying infrmatin. Willfully falsifying certificatins r affirmatins may subject yu t criminal penalties including fines and/r imprisnment. Misuse f TINs. If the requester disclses r uses TINs in vilatin f federal law, the requester may be subject t civil and criminal penalties. Specific Instructins Name If yu are an individual, yu must generally enter the name shwn n yur incme tax return. Hwever, if yu have changed yur last name, fr instance, due t marriage withut infrming the Scial Security Administratin f the name change, enter yur first name, the last name shwn n yur scial security card, and yur new last name. If the accunt is in jint names, list first, and then circle, the name f the persn r entity whse number yu entered in Part I f the frm. Sle prprietr. Enter yur individual name as shwn n yur incme tax return n the Name line. Yu may enter yur business, trade, r ding business as (DBA) name n the Business name/disregarded entity name line. Partnership, C Crpratin, r S Crpratin. Enter the entity's name n the Name line and any business, trade, r ding business as (DBA) name n the Business name/disregarded entity name line. Disregarded entity. Fr U.S. federal tax purpses, an entity that is disregarded as an entity separate frm its wner is treated as a disregarded entity. See Regulatin sectin (c)(2)(iii). Enter the wner's name n the Name line. The name f the entity entered n the Name line shuld never be a disregarded entity. The name n the Name line must be the name shwn n the incme tax return n which the incme shuld be reprted. Fr example, if a freign LLC that is treated as a disregarded entity fr U.S. federal tax purpses has a single wner that is a U.S. persn, the U.S. wner's name is required t be prvided n the Name line. If the direct wner f the entity is als a disregarded entity, enter the first wner that is nt disregarded fr federal tax purpses. Enter the disregarded entity's name n the Business name/disregarded entity name line. If the wner f the disregarded entity is a freign persn, the wner must cmplete an apprpriate Frm W-8 instead f a Frm W-9. This is the case even if the freign persn has a U.S. TIN. Nte. Check the apprpriate bx fr the U.S. federal tax classificatin f the persn whse name is entered n the Name line (Individual/sle prprietr, Partnership, C Crpratin, S Crpratin, Trust/estate). Limited Liability Cmpany (LLC). If the persn identified n the Name line is an LLC, check the Limited liability cmpany bx nly and enter the apprpriate cde fr the U.S. federal tax classificatin in the space prvided. If yu are an LLC that is treated as a partnership fr U.S. federal tax purpses, enter P fr partnership. If yu are an LLC that has filed a Frm 8832 r a Frm 2553 t be taxed as a crpratin, enter C fr C crpratin r S fr S crpratin, as apprpriate. If yu are an LLC that is disregarded as an entity separate frm its wner under Regulatin sectin (except fr emplyment and excise tax), d nt check the LLC bx unless the wner f the LLC (required t be identified n the Name line) is anther LLC that is nt disregarded fr U.S. federal tax purpses. If the LLC is disregarded as an entity separate frm its wner, enter the apprpriate tax classificatin f the wner identified n the Name line. Other entities. Enter yur business name as shwn n required U.S. federal tax dcuments n the Name line. This name shuld match the name shwn n the charter r ther legal dcument creating the entity. Yu may enter any business, trade, r DBA name n the Business name/disregarded entity name line. Exemptins If yu are exempt frm backup withhlding and/r FATCA reprting, enter in the Exemptins bx, any cde(s) that may apply t yu. See Exempt payee cde and Exemptin frm FATCA reprting cde n page 3.

8 Frm W-9 (Rev ) Page 3 Exempt payee cde. Generally, individuals (including sle prprietrs) are nt exempt frm backup withhlding. Crpratins are exempt frm backup withhlding fr certain payments, such as interest and dividends. Crpratins are nt exempt frm backup withhlding fr payments made in settlement f payment card r third party netwrk transactins. Nte. If yu are exempt frm backup withhlding, yu shuld still cmplete this frm t avid pssible errneus backup withhlding. The fllwing cdes identify payees that are exempt frm backup withhlding: 1 An rganizatin exempt frm tax under sectin 501(a), any IRA, r a custdial accunt under sectin 403(b)(7) if the accunt satisfies the requirements f sectin 401(f)(2) 2 The United States r any f its agencies r instrumentalities 3 A state, the District f Clumbia, a pssessin f the United States, r any f their plitical subdivisins r instrumentalities 4 A freign gvernment r any f its plitical subdivisins, agencies, r instrumentalities 5 A crpratin 6 A dealer in securities r cmmdities required t register in the United States, the District f Clumbia, r a pssessin f the United States 7 A futures cmmissin merchant registered with the Cmmdity Futures Trading Cmmissin 8 A real estate investment trust 9 An entity registered at all times during the tax year under the Investment Cmpany Act f A cmmn trust fund perated by a bank under sectin 584(a) 11 A financial institutin 12 A middleman knwn in the investment cmmunity as a nminee r custdian 13 A trust exempt frm tax under sectin 664 r described in sectin 4947 The fllwing chart shws types f payments that may be exempt frm backup withhlding. The chart applies t the exempt payees listed abve, 1 thrugh 13. IF the payment is fr... THEN the payment is exempt fr... Interest and dividend payments All exempt payees except fr 7 Brker transactins Exempt payees 1 thrugh 4 and 6 thrugh 11 and all C crpratins. S crpratins must nt enter an exempt payee cde because they are exempt nly fr sales f nncvered securities acquired prir t Barter exchange transactins and patrnage dividends Payments ver $600 required t be reprted and direct sales ver $5,000 1 Payments made in settlement f payment card r third party netwrk transactins Exempt payees 1 thrugh 4 Generally, exempt payees 1 thrugh 5 2 Exempt payees 1 thrugh 4 1 See Frm 1099-MISC, Miscellaneus Incme, and its instructins. 2 Hwever, the fllwing payments made t a crpratin and reprtable n Frm 1099-MISC are nt exempt frm backup withhlding: medical and health care payments, attrneys' fees, grss prceeds paid t an attrney, and payments fr services paid by a federal executive agency. Exemptin frm FATCA reprting cde. The fllwing cdes identify payees that are exempt frm reprting under FATCA. These cdes apply t persns submitting this frm fr accunts maintained utside f the United States by certain freign financial institutins. Therefre, if yu are nly submitting this frm fr an accunt yu hld in the United States, yu may leave this field blank. Cnsult with the persn requesting this frm if yu are uncertain if the financial institutin is subject t these requirements. A An rganizatin exempt frm tax under sectin 501(a) r any individual retirement plan as defined in sectin 7701(a)(37) B The United States r any f its agencies r instrumentalities C A state, the District f Clumbia, a pssessin f the United States, r any f their plitical subdivisins r instrumentalities D A crpratin the stck f which is regularly traded n ne r mre established securities markets, as described in Reg. sectin (c)(1)(i) E A crpratin that is a member f the same expanded affiliated grup as a crpratin described in Reg. sectin (c)(1)(i) F A dealer in securities, cmmdities, r derivative financial instruments (including ntinal principal cntracts, futures, frwards, and ptins) that is registered as such under the laws f the United States r any state G A real estate investment trust H A regulated investment cmpany as defined in sectin 851 r an entity registered at all times during the tax year under the Investment Cmpany Act f 1940 I A cmmn trust fund as defined in sectin 584(a) J A bank as defined in sectin 581 K A brker L A trust exempt frm tax under sectin 664 r described in sectin 4947(a)(1) M A tax exempt trust under a sectin 403(b) plan r sectin 457(g) plan Part I. Taxpayer Identificatin Number (TIN) Enter yur TIN in the apprpriate bx. If yu are a resident alien and yu d nt have and are nt eligible t get an SSN, yur TIN is yur IRS individual taxpayer identificatin number (ITIN). Enter it in the scial security number bx. If yu d nt have an ITIN, see Hw t get a TIN belw. If yu are a sle prprietr and yu have an EIN, yu may enter either yur SSN r EIN. Hwever, the IRS prefers that yu use yur SSN. If yu are a single-member LLC that is disregarded as an entity separate frm its wner (see Limited Liability Cmpany (LLC) n page 2), enter the wner s SSN (r EIN, if the wner has ne). D nt enter the disregarded entity s EIN. If the LLC is classified as a crpratin r partnership, enter the entity s EIN. Nte. See the chart n page 4 fr further clarificatin f name and TIN cmbinatins. Hw t get a TIN. If yu d nt have a TIN, apply fr ne immediately. T apply fr an SSN, get Frm SS-5, fr a Scial Security Card, frm yur lcal Scial Security Administratin ffice r get this frm nline at Yu may als get this frm by calling Use Frm W-7, fr IRS Individual Taxpayer Identificatin Number, t apply fr an ITIN, r Frm SS-4, fr Emplyer Identificatin Number, t apply fr an EIN. Yu can apply fr an EIN nline by accessing the IRS website at and clicking n Emplyer Identificatin Number (EIN) under Starting a Business. Yu can get Frms W-7 and SS-4 frm the IRS by visiting IRS.gv r by calling TAX-FORM ( ). If yu are asked t cmplete Frm W-9 but d nt have a TIN, apply fr a TIN and write Applied Fr in the space fr the TIN, sign and date the frm, and give it t the requester. Fr interest and dividend payments, and certain payments made with respect t readily tradable instruments, generally yu will have 60 days t get a TIN and give it t the requester befre yu are subject t backup withhlding n payments. The 60-day rule des nt apply t ther types f payments. Yu will be subject t backup withhlding n all such payments until yu prvide yur TIN t the requester. Nte. Entering Applied Fr means that yu have already applied fr a TIN r that yu intend t apply fr ne sn. Cautin: A disregarded U.S. entity that has a freign wner must use the apprpriate Frm W-8. Part II. Certificatin T establish t the withhlding agent that yu are a U.S. persn, r resident alien, sign Frm W-9. Yu may be requested t sign by the withhlding agent even if items 1, 4, r 5 belw indicate therwise. Fr a jint accunt, nly the persn whse TIN is shwn in Part I shuld sign (when required). In the case f a disregarded entity, the persn identified n the Name line must sign. Exempt payees, see Exempt payee cde earlier. Signature requirements. Cmplete the certificatin as indicated in items 1 thrugh 5 belw. 1. Interest, dividend, and barter exchange accunts pened befre 1984 and brker accunts cnsidered active during Yu must give yur crrect TIN, but yu d nt have t sign the certificatin. 2. Interest, dividend, brker, and barter exchange accunts pened after 1983 and brker accunts cnsidered inactive during Yu must sign the certificatin r backup withhlding will apply. If yu are subject t backup withhlding and yu are merely prviding yur crrect TIN t the requester, yu must crss ut item 2 in the certificatin befre signing the frm. 3. Real estate transactins. Yu must sign the certificatin. Yu may crss ut item 2 f the certificatin. 4. Other payments. Yu must give yur crrect TIN, but yu d nt have t sign the certificatin unless yu have been ntified that yu have previusly given an incrrect TIN. Other payments include payments made in the curse f the requester s trade r business fr rents, ryalties, gds (ther than bills fr merchandise), medical and health care services (including payments t crpratins), payments t a nnemplyee fr services, payments made in settlement f payment card and third party netwrk transactins, payments t certain fishing bat crew members and fishermen, and grss prceeds paid t attrneys (including payments t crpratins). 5. Mrtgage interest paid by yu, acquisitin r abandnment f secured prperty, cancellatin f debt, qualified tuitin prgram payments (under sectin 529), IRA, Cverdell ESA, Archer MSA r HSA cntributins r distributins, and pensin distributins. Yu must give yur crrect TIN, but yu d nt have t sign the certificatin.

9 Frm W-9 (Rev ) Page 4 What Name and Number T Give the Requester Fr this type f accunt: Give name and SSN f: 1. Individual The individual 2. Tw r mre individuals (jint The actual wner f the accunt r, accunt) if cmbined funds, the first individual n the accunt 1 3. Custdian accunt f a minr The minr 2 (Unifrm Gift t Minrs Act) 4. a. The usual revcable savings The grantr-trustee 1 trust (grantr is als trustee) b. S-called trust accunt that is The actual wner 1 nt a legal r valid trust under state law 5. Sle prprietrship r disregarded The wner 3 entity wned by an individual 6. Grantr trust filing under Optinal The grantr* Frm 1099 Filing Methd 1 (see Regulatin sectin (b)(2)(i)(A)) Fr this type f accunt: Give name and EIN f: 7. Disregarded entity nt wned by an The wner individual 8. A valid trust, estate, r pensin trust Legal entity 4 9. Crpratin r LLC electing The crpratin crprate status n Frm 8832 r Frm Assciatin, club, religius, The rganizatin charitable, educatinal, r ther tax-exempt rganizatin 11. Partnership r multi-member LLC The partnership 12. A brker r registered nminee The brker r nminee 13. Accunt with the Department f The public entity Agriculture in the name f a public entity (such as a state r lcal gvernment, schl district, r prisn) that receives agricultural prgram payments 14. Grantr trust filing under the Frm The trust 1041 Filing Methd r the Optinal Frm 1099 Filing Methd 2 (see Regulatin sectin (b)(2)(i)(B)) Nte. If n name is circled when mre than ne name is listed, the number will be cnsidered t be that f the first name listed. Secure Yur Tax Recrds frm Identity Theft Identity theft ccurs when smene uses yur persnal infrmatin such as yur name, scial security number (SSN), r ther identifying infrmatin, withut yur permissin, t cmmit fraud r ther crimes. An identity thief may use yur SSN t get a jb r may file a tax return using yur SSN t receive a refund. T reduce yur risk: Prtect yur SSN, Ensure yur emplyer is prtecting yur SSN, and Be careful when chsing a tax preparer. If yur tax recrds are affected by identity theft and yu receive a ntice frm the IRS, respnd right away t the name and phne number printed n the IRS ntice r letter. If yur tax recrds are nt currently affected by identity theft but yu think yu are at risk due t a lst r stlen purse r wallet, questinable credit card activity r credit reprt, cntact the IRS Identity Theft Htline at r submit Frm Fr mre infrmatin, see Publicatin 4535, Identity Theft Preventin and Victim Assistance. Victims f identity theft wh are experiencing ecnmic harm r a system prblem, r are seeking help in reslving tax prblems that have nt been reslved thrugh nrmal channels, may be eligible fr Taxpayer Advcate Service (TAS) assistance. Yu can reach TAS by calling the TAS tll-free case intake line at r TTY/TDD Prtect yurself frm suspicius s r phishing schemes. Phishing is the creatin and use f and websites designed t mimic legitimate business s and websites. The mst cmmn act is sending an t a user falsely claiming t be an established legitimate enterprise in an attempt t scam the user int surrendering private infrmatin that will be used fr identity theft. The IRS des nt initiate cntacts with taxpayers via s. Als, the IRS des nt request persnal detailed infrmatin thrugh r ask taxpayers fr the PIN numbers, passwrds, r similar secret access infrmatin fr their credit card, bank, r ther financial accunts. If yu receive an unslicited claiming t be frm the IRS, frward this message t phishing@irs.gv. Yu may als reprt misuse f the IRS name, lg, r ther IRS prperty t the Treasury Inspectr General fr Tax Administratin at Yu can frward suspicius s t the Federal Trade Cmmissin at: spam@uce.gv r cntact them at r IDTHEFT ( ). Visit IRS.gv t learn mre abut identity theft and hw t reduce yur risk. 1 List first and circle the name f the persn whse number yu furnish. If nly ne persn n a jint accunt has an SSN, that persn s number must be furnished. 2 Circle the minr s name and furnish the minr s SSN. 3 Yu must shw yur individual name and yu may als enter yur business r DBA name n the Business name/disregarded entity name line. Yu may use either yur SSN r EIN (if yu have ne), but the IRS encurages yu t use yur SSN. 4 List first and circle the name f the trust, estate, r pensin trust. (D nt furnish the TIN f the persnal representative r trustee unless the legal entity itself is nt designated in the accunt title.) Als see Special rules fr partnerships n page 1. *Nte. Grantr als must prvide a Frm W-9 t trustee f trust. Privacy Act Ntice Sectin 6109 f the Internal Revenue Cde requires yu t prvide yur crrect TIN t persns (including federal agencies) wh are required t file infrmatin returns with the IRS t reprt interest, dividends, r certain ther incme paid t yu; mrtgage interest yu paid; the acquisitin r abandnment f secured prperty; the cancellatin f debt; r cntributins yu made t an IRA, Archer MSA, r HSA. The persn cllecting this frm uses the infrmatin n the frm t file infrmatin returns with the IRS, reprting the abve infrmatin. Rutine uses f this infrmatin include giving it t the Department f Justice fr civil and criminal litigatin and t cities, states, the District f Clumbia, and U.S. cmmnwealths and pssessins fr use in administering their laws. The infrmatin als may be disclsed t ther cuntries under a treaty, t federal and state agencies t enfrce civil and criminal laws, r t federal law enfrcement and intelligence agencies t cmbat terrrism. Yu must prvide yur TIN whether r nt yu are required t file a tax return. Under sectin 3406, payers must generally withhld a percentage f taxable interest, dividend, and certain ther payments t a payee wh des nt give a TIN t the payer. Certain penalties may als apply fr prviding false r fraudulent infrmatin.