IRS Form W-9

Request for Taxpayer Identification and Certification

1. Name (as shown on your income tax return)*

2. Business name (only if different from above)

Enter the LLC tax classification (C=C corporation, S=S corporation, P=Partnership)*

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

5. Address (number, street, and apt. or suite no.)*

6. City, state, and ZIP code*

Example: New York, NY 10024

7. Email*

Part I: Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I. For other entities, it is your employer identification number (EIN). If you do not have a number, see instructions "How to get a TIN."

Social security number*

Employer identification number*

Part II: Certification

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 in Instructions); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Date

Signature

Please sign below

Email

This field is for validation purposes and should be left unchanged.