Form W-9
(Rev. January 2003)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give form to the
requester. Do not
send to the IRS.
Print or type
See
Specific Instructions
on page 2.
Name
Business name, if different from above
Individual/
Check appropriate box: Sole proprietor Corporation Partnership Other
Exempt from backup
withholding
Address (number, street, and apt. or suite no.) Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. 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,
Social security number
or
see How to get a TIN on page 3.
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
Part II
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. person (including a U.S. resident alien).
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
Signature of
Here
U.S. person
Date
Purpose of Form
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.
U.S. person. 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.
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.
Foreign person. If you are a foreign person, use the
appropriate Form W-8 (see Pub. 515, Withholding of Tax on
Nonresident Aliens and Foreign Entities).
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 recipient
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 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.
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.
Cat. No. 10231X
Form
W-9 (Rev. 1-2003)
Form W-9 (Rev. 1-2003) Page 2
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.
If you are a nonresident alien or a foreign entity not
subject to backup withholding, give the requester the
appropriate completed Form W-8.
What is backup withholding? Persons making certain
payments to you must under certain conditions withhold and
pay to the IRS 30% of such payments (29% after December
31, 2003; 28% after December 31, 2005). This is called
backup withholding.Payments that may be subject to
backup withholding include 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.
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.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TIN to the requester, or
2.
Y
ou do not certify your TIN when requir
ed (see the Part
II instructions on page 4 for details), or
3.
The IRS te
lls the requester that you fur
nished an
incorr
ect TIN, or
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
5. Y
ou do not certify to the requester that you ar
e not
subject to backup withholding unde
r 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.
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.
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.
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.
Specific Instructions
Name
If you are an individual, you must generally enter the name
shown on your social security card. 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 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.
Sole proprietor. Enter your individual name as shown on
your social security card on the Nameline. You may enter
your business, trade, or doing business as (DBA)name on
the Business nameline.
Limited liability company (LLC). If you are a single-member
LLC (including a foreign LLC with a domestic owner) that is
disregarded as an entity separate from its owner under
Treasury regulations section 301.7701-3, enter the owners
name on the Nameline. Enter the LLCs name on the
Business nameline.
Other entities. Enter your business name as shown on
required Federal tax documents on the Nameline. 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 nameline.
Note: You are requested to check the appropriate box for
your status (individual/sole proprietor, corporation, etc.).
Exempt From Backup Withholding
If you are exempt, enter your name as described above and
check the appropriate box for your status, then check the
Exempt from backup withholdingbox in the line following
the business name, sign and date the form.
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.
Exempt payees. Backup withholding is not required on any
payments made to the following payees:
1. An or
ganization exempt from tax unde
r section 501(a),
any IRA, or a custodial account unde
r 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 State
s, or any of their political subdivisions or
instrumentalities;
4. A for
eign gover
nment or any of its political subdivisions,
agencie
s, or instrumentalities; or
5. An inte
rnational organization or any of its agencie
s or
instrumentalitie
s.
Other payees that may be exempt from backup
withholding include:
6. A corporation;
7.
A foreign central bank of issue;
8.
A de
aler in securities or commodities required to registe
r
in the United State
s, the District of Columbia, or a
possession of the United States;
Form W-9 (Rev. 1-2003) Page 3
9. A futures commission merchant registered with the
Commodity Futures Trading Commission;
10. A r
eal estate inve
stment trust;
11. An entity r
egistered at all times during the tax ye
ar
unde
r the Investment Company Act of 1940;
12. A common trust fund ope
rated by a bank unde
r
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 fr
om tax unde
r section 664 or
de
scribed in section 4947.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt recipients listed above, 1 through 15.
If the payment is for . . . THEN the payment is exempt
for . . .
Interest and dividend payments All exempt recipients except
for 9
Broker transactions Exempt recipients 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Barter exchange transactions
and patronage dividends
Exempt recipients 1 through 5
Payments over $600 required
to be reported and direct
sales over $5,000
1
Generally, exempt recipients
1 through 7
2
1
See Form 1099-MISC, Miscellaneous Income, and its instructions.
2
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.
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.
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-owner LLC that is disregarded as an
entity separate from its owner (see Limited liability
company (LLC) on page 2), enter your SSN (or EIN, if you
have one). If the LLC is a corporation, partnership, etc., enter
the entitys EIN.
Note: See the chart on page 4 for further clarification of
name and TIN combinations.
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 on-line at
www.ssa.gov/online/ss5.html. 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 get Forms W-7 and
SS-4 from the IRS by calling 1-800-TAX-FORM
(1-800-829-3676) or from the IRS Web Site at www.irs.gov.
If you are asked to complete Form W-9 but do not have a
TIN, write Applied Forin 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.
Note: Writing Applied Formeans 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.
Form W-9 (Rev. 1-2003) Page 4
Part II. Certification
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, 3,
and 5 below indicate otherwise.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt recipients, see
Exempt from backup withholding on page 2.
Signature requirements. Complete the certification as
indicated in 1 through 5 below.
1.
Interest, dividend, and barter exchange accounts
opened befor
e 1984 and broker accounts considered
active during 1983. You must give your correct TIN, but you
do not have to sign the certification.
2.
Inter
est, dividend, broker
, and barter exchange
accounts opened after 1983 and br
oker 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.
3.
Real estate transactions. You must sign the
ce
rtification. You may cross out item 2 of the certification.
4.
Other payments.
You must give your corr
ect TIN, but
you do not have to sign the ce
rtification unless you have
been notified that you have previously given an incorrect TIN.
Other paymentsinclude payments made in the course of
the requesters 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).
5.
Mortgage interest paid by you, acquisition or
abandonment of secur
ed property, cancellation of debt,
qualified tuition program payments (under section 529),
IRA or Archer MSA contributions or distributions, and
pension distributions. You must give your correct TIN, but
you do not have to sign the certification.
What Name and Number To Give the
Requester
For this type of account: Give name and SSN of:
1. Individual
2. Two or more individuals (joint
account)
3. Custodian account of a minor
(Uniform Gift to Minors Act)
4.
a. The usual revocable
savings trust (grantor is
also trustee)
b. So-called trust account
that is not a legal or valid
trust under state law
5. Sole proprietorship or
single-owner LLC
The individual
The actual owner of the account
or, if combined funds, the first
individual on the account
1
The minor
2
The grantor-trustee
1
The actual owner
1
The owner
3
For this type of account: Give name and EIN of:
6. Sole proprietorship or
single-owner LLC
7. A valid trust, estate, or
pension trust
8. Corporate or LLC electing
corporate status on Form
8832
9. Association, club, religious,
charitable, educational, or
other tax-exempt organization
10. Partnership or multi-member
LLC
11. A broker or registered
nominee
12. 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
The owner
3
Legal entity
4
The corporation
The organization
The partnership
The broker or nominee
The public entity
1
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 persons number must be
furnished.
2
Circle the minors name and furnish the minors SSN.
3
You must show your individual name, but you may also enter your
business or DBAname. You may use either your SSN or EIN (if you have
one).
4
List first and circle the name of the legal 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.)
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.
Privacy Act Notice
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. 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, and the District of Columbia to carry out their
tax laws. We may also disclose this information to other countries under a tax treaty, or to Federal and state agencies to enforce
Federal nontax criminal laws and to combat terrorism.
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.