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Request for Taxpayer Identification Number and Certification

IMPORTANT TAX INFORMATION - PLEASE READ THIS NOTICE CAREFULLY

This form was developed to comply with Internal Revenue Service (IRS) regulations to permit us to file an information return with the IRS. You are required by law to provide us your correct Taxpayer Identification Number (TIN). This information will only be shared with the IRS. If you have questions completing this page in the form, please call: (888) 536-6463

General Information

Legal name

Business name (if different from above)

Federal tax classification Individual / sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/estateLimited liability company - C CorporationLimited liability company - S CorporationLimited liability company - PartnershipOther

Street address

City, state, and ZIP code

Exemptions (only apply to certain entities, not individuals). Refer to instructions

Exempt payee code (if any)
Exempt FATCA reporting code (if any)

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given above to avoid 28% backup withholding. For individuals, this is generally your social security number (SSN). For other entities, it is your employer identification number (EIN).

Social security numberEmployer identification number

SSN/EIN

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 issued to me); and
I
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. citizen or other U.S. person (defined below); and
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must select "am" above in item 2 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.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

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May 27, 2022 12:27 pm EDT

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