Fillable FORM W-9, PAGE 1 of 4: W-9 Request (Damian Landeiro, CPA)

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FORM W-9, PAGE 1 of 4: W-9 Request (Damian Landeiro, CPA)

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INSTRUCTIONS TO PRINTERS

FORM W-9, PAGE 1 of 4

MARGINS: TOP 13mm (

⁄2 "), CENTER SIDES. PRINTS: HEAD to HEAD

PAPER: WHITE WRITING, SUB. 20. INK: BLACK

FLAT SIZE: 216mm (8

⁄2 ") ! 279mm (11")

PERFORATE: (NONE)

Give form to the

requester. Do not

send to the IRS.

Form

W-9

Request for Taxpayer

Identification Number and Certification

(Rev. October 2007)

Department of the Treasury

Internal Revenue Service

Name (as shown on your income tax return)

List account number(s) here (optional)

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

City, state, and ZIP code

Print or type

See Specific Instructions on page 2.

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 your social security number (SSN). However, for a resident

alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is

your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Social security number

Requester’s name and address (optional)

Employer identification number

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose

number to enter.

Certification

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 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

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. See the instructions on page 4.

Sign

Here

Signature of

U.S. person

Date

General Instructions

Form W-9 (Rev. 10-2007)

Part I

Part II

Business name, if different from above

Cat. No. 10231X

Check appropriate box:

Under penalties of perjury, I certify that:

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

TLS, have you

transmitted all R

text files for this

cycle update?

Date

Action

Revised proofs

requested

Date

Signature

O.K. to print

Use Form W-9 only if you are a U.S. person (including a

resident alien), to provide your correct TIN to the person

requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you are

waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S.

exempt payee. If applicable, you are also certifying that as a

U.S. person, your allocable share of any partnership income from

a U.S. trade or business is not subject to the withholding tax on

foreign partners’ share of effectively connected income.

I am a U.S. citizen or other U.S. person (defined below).

A person who is required to file an information return with the

IRS must obtain your correct taxpayer identification number (TIN)

to report, for example, income paid to you, real estate

transactions, mortgage interest you paid, acquisition or

abandonment of secured property, cancellation of debt, or

contributions you made to an IRA.

Individual/Sole proprietor

Corporation

Partnership

Other (see instructions)

Note. If a requester gives you a form other than Form W-9 to

request your TIN, you must use the requester’s form if it is

substantially similar to this Form W-9.

● An individual who is a U.S. citizen or U.S. resident alien,

● A partnership, corporation, company, or association created or

organized in the United States or under the laws of the United

States,

● An estate (other than a foreign estate), or

Definition of a U.S. person. For federal tax purposes, you are

considered a U.S. person if you are:

Special rules for partnerships. Partnerships that conduct a

trade or business in the United States are generally required to

pay a withholding tax on any foreign partners’ share of income

from such business. Further, in certain cases where a Form W-9

has not been received, a partnership is required to presume that

a partner is a foreign person, and pay the withholding tax.

Therefore, if you are a U.S. person that is a partner in a

partnership conducting a trade or business in the United States,

provide Form W-9 to the partnership to establish your U.S.

status and avoid withholding on your share of partnership

income.

The person who gives Form W-9 to the partnership for

purposes of establishing its U.S. status and avoiding withholding

on its allocable share of net income from the partnership

conducting a trade or business in the United States is in the

following cases:

● The U.S. owner of a disregarded entity and not the entity,

Section references are to the Internal Revenue Code unless

otherwise noted.

● A domestic trust (as defined in Regulations section

301.7701-7).

Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership)

Exempt

payee

Purpose of Form

INSTRUCTIONS TO PRINTERS

FORM W-9, PAGE 2 of 4

MARGINS: TOP 13 mm (

⁄2"), CENTER SIDES. PRINTS: HEAD to HEAD

PAPER: WHITE WRITING, SUB. 20. INK: BLACK

FLAT SIZE: 216 mm (8

⁄2") ! 279 mm (11")

PERFORATE: (NONE)

Form W-9 (Rev. 10-2007)

Page 2

Sole proprietor. Enter your individual name as shown on your

income tax return on the “Name” line. You may enter your

business, trade, or “doing business as (DBA)” name on the

“Business name” line.

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Other entities. Enter your business name as shown on required

federal tax documents on the “Name” line. This name should

match the name shown on the charter or other legal document

creating the entity. You may enter any business, trade, or DBA

name on the “Business name” line.

If the account is in joint names, list first, and then circle, the

name of the person or entity whose number you entered in Part I

of the form.

Specific Instructions

Name

Exempt Payee

5. You do not certify to the requester that you are not subject

to backup withholding under 4 above (for reportable interest and

dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup

withholding. See the instructions below and the separate

Instructions for the Requester of Form W-9.

Civil penalty for false information with respect to

withholding. If you make a false statement with no reasonable

basis that results in no backup withholding, you are subject to a

$500 penalty.

Criminal penalty for falsifying information. Willfully falsifying

certifications or affirmations may subject you to criminal

penalties including fines and/or imprisonment.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN to a

requester, you are subject to a penalty of $50 for each such

failure unless your failure is due to reasonable cause and not to

willful neglect.

Misuse of TINs. If the requester discloses or uses TINs in

violation of federal law, the requester may be subject to civil and

criminal penalties.

If you are an individual, you must generally enter the name

shown on your income tax return. However, if you have changed

your last name, for instance, due to marriage without informing

the Social Security Administration of the name change, enter

your first name, the last name shown on your social security

card, and your new last name.

If you are exempt from backup withholding, enter your name as

described above and check the appropriate box for your status,

then check the “Exempt payee” box in the line following the

business name, sign and date the form.

4. The IRS tells you that you are subject to backup

withholding because you did not report all your interest and

dividends on your tax return (for reportable interest and

dividends only), or

3. The IRS tells the requester that you furnished an incorrect

TIN,

2. You do not certify your TIN when required (see the Part II

instructions on page 3 for details),

You will not be subject to backup withholding on payments

you receive if you give the requester your correct TIN, make the

proper certifications, and report all your taxable interest and

dividends on your tax return.

1. You do not furnish your TIN to the requester,

What is backup withholding? Persons making certain payments

to you must under certain conditions withhold and pay to the

IRS 28% of such payments. This is called “backup withholding.”

Payments that may be subject to backup withholding include

interest, tax-exempt interest, dividends, broker and barter

exchange transactions, rents, royalties, nonemployee pay, and

certain payments from fishing boat operators. Real estate

transactions are not subject to backup withholding.

Payments you receive will be subject to backup

withholding if:

If you are a nonresident alien or a foreign entity not subject to

backup withholding, give the requester the appropriate

completed Form W-8.

Example. Article 20 of the U.S.-China income tax treaty allows

an exemption from tax for scholarship income received by a

Chinese student temporarily present in the United States. Under

U.S. law, this student will become a resident alien for tax

purposes if his or her stay in the United States exceeds 5

calendar years. However, paragraph 2 of the first Protocol to the

U.S.-China treaty (dated April 30, 1984) allows the provisions of

Article 20 to continue to apply even after the Chinese student

becomes a resident alien of the United States. A Chinese

student who qualifies for this exception (under paragraph 2 of

the first protocol) and is relying on this exception to claim an

exemption from tax on his or her scholarship or fellowship

income would attach to Form W-9 a statement that includes the

information described above to support that exemption.

Note. You are requested to check the appropriate box for your

status (individual/sole proprietor, corporation, etc.).

4. The type and amount of income that qualifies for the

exemption from tax.

5. Sufficient facts to justify the exemption from tax under the

terms of the treaty article.

Nonresident alien who becomes a resident alien. Generally,

only a nonresident alien individual may use the terms of a tax

treaty to reduce or eliminate U.S. tax on certain types of income.

However, most tax treaties contain a provision known as a

“saving clause.” Exceptions specified in the saving clause may

permit an exemption from tax to continue for certain types of

income even after the payee has otherwise become a U.S.

resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception

contained in the saving clause of a tax treaty to claim an

exemption from U.S. tax on certain types of income, you must

attach a statement to Form W-9 that specifies the following five

items:

1. The treaty country. Generally, this must be the same treaty

under which you claimed exemption from tax as a nonresident

alien.

2. The treaty article addressing the income.

3. The article number (or location) in the tax treaty that

contains the saving clause and its exceptions.

Also see Special rules for partnerships on page 1.

Foreign person. If you are a foreign person, do not use Form

W-9. Instead, use the appropriate Form W-8 (see Publication

515, Withholding of Tax on Nonresident Aliens and Foreign

Entities).

● The U.S. grantor or other owner of a grantor trust and not the

trust, and

● The U.S. trust (other than a grantor trust) and not the

beneficiaries of the trust.

Limited liability company (LLC). Check the “Limited liability

company” box only and enter the appropriate code for the tax

classification (“D” for disregarded entity, “C” for corporation, “P”

for partnership) in the space provided.

For a single-member LLC (including a foreign LLC with a

domestic owner) that is disregarded as an entity separate from

its owner under Regulations section 301.7701-3, enter the

owner’s name on the “Name” line. Enter the LLC’s name on the

“Business name” line.

For an LLC classified as a partnership or a corporation, enter

the LLC’s name on the “Name” line and any business, trade, or

DBA name on the “Business name” line.

INSTRUCTIONS TO PRINTERS

FORM W-9, PAGE 3 of 4

MARGINS: TOP 13 mm (

⁄2"), CENTER SIDES. PRINTS: HEAD to HEAD

PAPER: WHITE WRITING, SUB. 20. INK: BLACK

FLAT SIZE: 216 mm (8

⁄2") ! 279 mm (11")

PERFORATE: (NONE)

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form W-9 (Rev. 10-2007)

Page 3

Part I. Taxpayer Identification

Number (TIN)

Enter your TIN in the appropriate box. 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 do not

have an ITIN, see How to get a TIN below.

How to get a TIN. If you do not have a TIN, apply for one

immediately. To apply for an SSN, get Form SS-5, Application

for a Social Security Card, from your local Social Security

Administration office or get this form online at www.ssa.gov. You

may also get this form by calling 1-800-772-1213. Use Form

W-7, Application for IRS Individual Taxpayer Identification

Number, to apply for an ITIN, or Form SS-4, Application for

Employer Identification Number, to apply for an EIN. You can

apply for an EIN online by accessing the IRS website at

www.irs.gov/businesses and clicking on Employer Identification

Number (EIN) under Starting a Business. You can get Forms W-7

and SS-4 from the IRS by visiting www.irs.gov or by calling

1-800-TAX-FORM (1-800-829-3676).

If you are asked to complete Form W-9 but do not have a TIN,

write “Applied For” in the space for the TIN, sign and date the

form, and give it to the requester. For interest and dividend

payments, and certain payments made with respect to readily

tradable instruments, generally you will have 60 days to get a

TIN and give it to the requester before you are subject to backup

withholding on payments. The 60-day rule does not apply to

other types of payments. You will be subject to backup

withholding on all such payments until you provide your TIN to

the requester.

If you are a sole proprietor and you have an EIN, you may

enter either your SSN or EIN. However, the IRS prefers that you

use your SSN.

If you are a single-member LLC that is disregarded as an

entity separate from its owner (see Limited liability company

(LLC) on page 2), 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.

Note. See the chart on page 4 for further clarification of name

and TIN combinations.

Note. Entering “Applied For” means that you have already

applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded domestic entity that has a foreign owner

must use the appropriate Form W-8.

9. A futures commission merchant registered with the

Commodity Futures Trading Commission,

10. A real estate investment trust,

11. An entity registered at all times during the tax year under

the Investment Company Act of 1940,

12. A common trust fund operated by a bank under section

584(a),

13. A financial institution,

14. A middleman known in the investment community as a

nominee or custodian, or

15. A trust exempt from tax under section 664 or described in

section 4947.

THEN the payment is exempt

for . . .

IF the payment is for . . .

All exempt payees except

for 9

Interest and dividend payments

Exempt payees 1 through 13.

Also, a person registered under

the Investment Advisers Act of

1940 who regularly acts as a

broker

Broker transactions

Exempt payees 1 through 5

Barter exchange transactions

and patronage dividends

Generally, exempt payees

1 through 7

Payments over $600 required

to be reported and direct

sales over $5,000

See Form 1099-MISC, Miscellaneous Income, and its instructions.

However, the following payments made to a corporation (including gross

proceeds paid to an attorney under section 6045(f), even if the attorney is a

corporation) and reportable on Form 1099-MISC are not exempt from

backup withholding: medical and health care payments, attorneys’ fees, and

payments for services paid by a federal executive agency.

The chart below shows types of payments that may be

exempt from backup withholding. The chart applies to the

exempt payees listed above, 1 through 15.

7. A foreign central bank of issue,

8. A dealer in securities or commodities required to register in

the United States, the District of Columbia, or a possession of

the United States,

The following payees are exempt from backup withholding:

1. An organization exempt from tax under section 501(a), any

IRA, or a custodial account under section 403(b)(7) if the account

satisfies the requirements of section 401(f)(2),

2. The United States or any of its agencies or

instrumentalities,

3. A state, the District of Columbia, a possession of the United

States, or any of their political subdivisions or instrumentalities,

4. A foreign government or any of its political subdivisions,

agencies, or instrumentalities, or

5. An international organization or any of its agencies or

instrumentalities.

Other payees that may be exempt from backup withholding

include:

6. A corporation,

Generally, individuals (including sole proprietors) are not exempt

from backup withholding. Corporations are exempt from backup

withholding for certain payments, such as interest and dividends.

Note. If you are exempt from backup withholding, you should

still complete this form to avoid possible erroneous backup

withholding.

1. Interest, dividend, and barter exchange accounts

opened before 1984 and broker accounts considered active

during 1983. You must give your correct TIN, but you do not

have to sign the certification.

2. Interest, dividend, broker, and barter exchange

accounts opened after 1983 and broker accounts considered

inactive during 1983. You must sign the certification or backup

withholding will apply. If you are subject to backup withholding

and you are merely providing your correct TIN to the requester,

you must cross out item 2 in the certification before signing the

form.

Part II. Certification

For a joint account, only the person whose TIN is shown in

Part I should sign (when required). Exempt payees, see Exempt

Payee on page 2.

To establish to the withholding agent that you are a U.S. person,

or resident alien, sign Form W-9. You may be requested to sign

by the withholding agent even if items 1, 4, and 5 below indicate

otherwise.

Signature requirements. Complete the certification as indicated

in 1 through 5 below.

INSTRUCTIONS TO PRINTERS

FORM W-9, PAGE 4 of 4

MARGINS: TOP 13 mm (

⁄2"), CENTER SIDES. PRINTS: HEAD to HEAD

PAPER: WHITE WRITING, SUB. 20. INK: BLACK

FLAT SIZE: 216 mm (8

⁄2") ! 279 mm (11")

PERFORATE: (NONE)

Form W-9 (Rev. 10-2007)

Page 4

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Give name and EIN of:

For this type of account:

3. Real estate transactions. You must sign the certification.

You may cross out item 2 of the certification.

A valid trust, estate, or pension trust

Legal entity

4. Other payments. You must give your correct TIN, but you

do not have to sign the certification unless you have been

notified that you have previously given an incorrect TIN. “Other

payments” include payments made in the course of the

requester’s trade or business for rents, royalties, goods (other

than bills for merchandise), medical and health care services

(including payments to corporations), payments to a

nonemployee for services, payments to certain fishing boat crew

members and fishermen, and gross proceeds paid to attorneys

(including payments to corporations).

The corporation

Corporate or LLC electing

corporate status on Form 8832

The organization

Association, club, religious,

charitable, educational, or other

tax-exempt organization

5. Mortgage interest paid by you, acquisition or

abandonment of secured property, cancellation of debt,

qualified tuition program payments (under section 529), IRA,

Coverdell ESA, Archer MSA or HSA contributions or

distributions, and pension distributions. You must give your

correct TIN, but you do not have to sign the certification.

The partnership

Partnership or multi-member LLC

The broker or nominee

A broker or registered nominee

10.

The public entity

Account with the Department of

Agriculture in the name of a public

entity (such as a state or local

government, school district, or

prison) that receives agricultural

program payments

11.

Privacy Act Notice

List first and circle the name of the person whose number you furnish. If only one person

on a joint account has an SSN, that person’s number must be furnished.

Circle the minor’s name and furnish the minor’s SSN.

You must show your individual name and you may also enter your business or “DBA”

name on the second name line. You may use either your SSN or EIN (if you have one),

but the IRS encourages you to use your SSN.

List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN

of the personal representative or trustee unless the legal entity itself is not designated in

the account title.) Also see Special rules for partnerships on page 1.

Note. If no name is circled when more than one name is listed,

the number will be considered to be that of the first name listed.

Disregarded entity not owned by an

individual

The owner

12.

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% 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.

Section 6109 of the Internal Revenue Code requires you to provide your correct 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, or Archer MSA or HSA. The IRS uses 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, the District of Columbia, and U.S.

possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal

nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

Secure Your Tax Records from Identity Theft

Identity theft occurs when someone uses your personal

information such as your name, social security number (SSN), or

other identifying information, without your permission, to commit

fraud or other crimes. An identity thief may use your SSN to get

a job or may file a tax return using your SSN to receive a refund.

What Name and Number To Give the Requester

Give name and SSN of:

For this type of account:

The individual

Individual

The actual owner of the account or,

if combined funds, the first

individual on the account

Two or more individuals (joint

account)

The minor

Custodian account of a minor

(Uniform Gift to Minors Act)

The grantor-trustee

a. The usual revocable savings

trust (grantor is also trustee)

The actual owner

b. So-called trust account that is

not a legal or valid trust under

state law

The owner

Sole proprietorship or disregarded

entity owned by an individual

Call the IRS at 1-800-829-1040 if you think your identity has

been used inappropriately for tax purposes.

To reduce your risk:

● Protect your SSN,

● Ensure your employer is protecting your SSN, and

● Be careful when choosing a tax preparer.

Victims of identity theft who are experiencing economic harm

or a system problem, or are seeking help in resolving tax

problems that have not been resolved through normal channels,

may be eligible for Taxpayer Advocate Service (TAS) assistance.

You can reach TAS by calling the TAS toll-free case intake line

at 1-877-777-4778 or TTY/TDD 1-800-829-4059.

Protect yourself from suspicious emails or phishing

schemes. Phishing is the creation and use of email and

websites designed to mimic legitimate business emails and

websites. The most common act is sending an email to a user

falsely claiming to be an established legitimate enterprise in an

attempt to scam the user into surrendering private information

that will be used for identity theft.

The IRS does not initiate contacts with taxpayers via emails.

Also, the IRS does not request personal detailed information

through email or ask taxpayers for the PIN numbers, passwords,

or similar secret access information for their credit card, bank, or

other financial accounts.

If you receive an unsolicited email claiming to be from the IRS,

forward this message to phishing@irs.gov. You may also report

misuse of the IRS name, logo, or other IRS personal property to

the Treasury Inspector General for Tax Administration at

1-800-366-4484. You can forward suspicious emails to the

Federal Trade Commission at: spam@uce.gov or contact them at

www.consumer.gov/idtheft or 1-877-IDTHEFT(438-4338).

Visit the IRS website at www.irs.gov to learn more about

identity theft and how to reduce your risk.

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