Federal Deposit Insurance Corporation
Division of Finance
Substitute Form W-9
REQUEST FOR TAXPAYER
IDENTIFICATION NUMBER AND CERTIFICATION
PRIVACY ACT STATEMENT
Section 6109 of the Internal Revenue Code requires you to give your correct Taxpayer Identification Number (TIN) to persons who must file information
returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of
secured property, cancellation of debt, or contributions you made to an IRA. The IRS will use the numbers for identification purposes and to help verify
the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation and to cities,
states, and the District of Columbia to carry out their tax laws. You must provide your TIN whether or not you are required to file a tax return. Payers
must generally withhold 30% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties
may also apply.
Name
Business Name
Exempt From Backup Withholding
Address (Number, Street, Apt. or Suite No.)
City, State, and ZIP Code
List Account Number(s) (Optional)
SECTION I
TAXPAYER ID NUMBER
PAYEE TYPE
AND BUSINESS OWNERSHIP TYPE
TAXPAYER ID NUMBER
Enter your Taxpayer Identification Number (TIN) in the appropriate box. For individuals, this is your Social Security Number
(SSN). For other entities, it is your Employer Identification Number (EIN).
Employer Identification Number (EIN) -
OR
Social Security Number (SSN) - -
(Please check one box in each column)
PAYEE TYPE BUSINESS OWNERSHIP TYPE
Individual Sole Proprietorship
Federal Government A
enc
Partnership
State, Local Government A
enc
Corporation
Law Firm or Practice Government A
enc
Le
al Service Provide
Trust
Forei
n/Non-resident
Provide the appropriate Form W
8
Tax Exempt/Non-Profit
Other
Please explain
Other
Please explain
CERTIFICATION INSTRUCTIONS - You must cross out item 2, below if you have been notified by the IRS that you are currently
subject to backup withholding because of underreporting of interest or dividends on your tax return. For real estate transactions, item 2
does not apply. For mortgage interest paid, the acquisition or abandonment of secured property, cancellation of debt, contributions to
an individual retirement account (IRA), and generally, payments other than interest and dividends, you are not required to sign the
Certification, but you must provide your correct TIN.
SECTION 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
IRS that I am subject to backup withholding as a result of failure to report all interest and dividends, or (c) the IRS has notified me
that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications
required to avoid backup withholding.
Signature of U.S. Person Date
Name (Please print) Title Telephone Number Fax Number
( ) - ( ) -
FDIC 4531/10 (10-03)
