Name:
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Business name, if different from above:
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Permanent Residence Address ( street, apt. or suite no., or rural route ). Do not use a P.O. box or in-care-of address.
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City or town, state or province. Include postal code where appropriate.
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Country ( Do Not Abbreviate )
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Mailing address ( if different from above )
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City or town, state or province. Include postal code where appropriate.
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Country ( Do Not Abbreviate )
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Select one of the following:
Individual/Sole proprietor Corporation Partnership Other
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Exempt from backup withholding.
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| Part 1: Taxpayer Identification Number |
| Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). For other entities, it is your employer identification number (EIN). |
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| Part 2: Certification |
| Under penalties of perjury, I certify that: |
- The number shown on this form is my correct taxpayer identification number ( or I am waiting for a number to be 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, and
- I am a U.S. person (including a U.S. resident alien).
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| Check here 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. |
Signature of U.S. person (Typing in your name acts as your signature):
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| The date and time of submission and your computer's IP address will be recorded when you click Submit information. |
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