Form W-9
LCL similar agreed Form
Rev. October 2018
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
1 Name (as shown on your income tax return) :
KROUCH VICTORIA JEAN
2 Business name/disregarded entity name, if different from above :
3 Check appropriate box for federal tax classification :
☐ Individual/sole proprietor or single member LLC
☐ C Corporation ☐ S Corporation ☐ Partnership ☐ Trust/estate
☐ Limited liability company.
Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ► _______________
☐ Other ►_________________
4 Exemptions :
Exempt payee code (if any) _________
Exemption from FATCA reporting code
(if any) __________________________
(applies to acconts maintained outside the
U.S.)
5 Address (number, street, and apt. or suite no.) :
4551 MONACO LAKE DRIVE
33956-2702 SAINT JAMES CITY
6 City, state and ZIP code :
ETATS-UNIS
Requester's name and address (optional) :
7 List account number(s) here (optional) :
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the
“Name” line to avoid backup withholding. For individuals, this is your social security number (SSN).
If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your
IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If
you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. If you are a
single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s
SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is
classified as a corporation or partnership, enter the entity’s EIN. For other entities, it is your
employer identification number (EIN).
Social security number
463941750
or
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 below), and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above 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.
Sign
Here
Signature of
U.S. person ►
Date ►
Id :
CN=LCL,OU=Emissio-
n de propositions
commerciales,OU=Em-
is par LCL,OU=0002
954509741,O=CRED-
IT LYONNAIS,C=FR
Date/heure :
2020-03-23 14:04:01
(en référence à la
France métropolitaine)
click to sign
signature
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click to sign
signature
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