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Fiscal Year 2020-2021

APPLICATION

COMMONWEALTH OF PENNSYLVANIA

OFFICE OF ATTORNEY GENERAL

A message from Attorney General Josh Shapiro

Drug use and addiction is the most serious public health and public safety threat facing our

Commonwealth today. Over 5,500 Pennsylvanians per year die from accidental drug overdose.

That's nearly 15 each day, by far worst it has ever been. As Pennsylvania’s chief law

enforcement officer, this crisis is my top priority. That’s why my office is arresting drug dealers

at record rates. But we can’t arrest our way out of the addiction crisis, because drug addiction

isn’t a crime—it’s a disease. The best way to fight it is to prevent people from becoming

addicted in the first place. That’s why I need your help.

While the vast majority of young adults make the right choices, the fact is drug addiction can

strike any person in any community. Our hardest-hit communities include cities, rural areas, and

everything in between. One out of every four families is affected by drug addiction and sees the

harm firsthand. As heroin and opioid addiction spread and more dangerous drugs like fentanyl

become commonplace, this crisis takes on a new level of urgency.

It’s vital to increase the amount of education and information in every community to help

people defend themselves and their loved ones against the dangers of drug addiction. Because

addiction can affect anyone at any age, we need to ensure that Pennsylvania’s youngest citizens

are receiving this information. That’s why my office offers grants, funded by drug and DUI

offenses, to encourage effective ways for parents, educators, and law enforcement to

communicate with students about the dangers of drugs and alcohol, as well as ways to be safe

and prevent addiction.

We want to work with you to help create a program that’s tailored to the needs of your

community. That’s why, since 1987, our Community Drug Abuse Prevention Grant Program

has given out more than $1.9 million in grants to community groups across the Commonwealth

to strengthen their educational programming. We look forward to working with you to help

make your programs successful.

On behalf of everyone at the Office of Attorney General, thank you for the work you do in your

community.

OFFICE OF ATTORNEY GENERAL:

COMMUNITY DRUG ABUSE PREVENTION GRANT PROGRAM

GRANT GUIDELINES

PURPOSE

The Community Drug Abuse Prevention Grant Program supports the commitment of the Office of

Attorney General to assist parent and community non-profit organizations in their efforts to educate

communities on the dangers of drug and alcohol abuse and offer resources that can be helpful in recovery.

The goals of the program are:

• To educate the public – especially children – about the dangers of illegal drugs and alcohol,

along with related law enforcement and recovery activity.

• To prevent substance abuse by encouraging interaction, collaboration and cooperation among

community groups, parents, educators, students, businesses and law enforcement agencies.

• To help develop and expand community groups and grassroots organizations dedicated to

fighting drug and alcohol abuse.

• To facilitate innovative, age appropriate drug and alcohol prevention programs.

DURATION OF GRANT

A grant project period for the Community Drug Abuse Prevention Grant Program cannot exceed a 12

months. A final Form GA-5 must be submitted not more than 60 days from the completion of the grant event.

Interim reimbursements are authorized using Form GA-5 but should be avoided if possible.

Grant applications must be received and approved before a project can commence. Normally, expenses

incurred prior to the grant approval date are not reimbursable.

ELIGIBILITY

The activity, to be eligible for funding, MUST be drug abuse prevention or demand reduction program

that is community based and include an educational and law enforcement message.

In order to qualify as a “Demand Reduction Program,” the applicant must demonstrate through the

application process, the purpose of the expense must be primarily dedicated to reduce the demand for drugs and

alcohol. Such program needs include, but are not limited to, educational material, comprehensive drug-free

programs, material needed to increase awareness of drug use, technical resources needed to administer the

program or a combination of materials and equipment which demonstrate the program’s purpose to reduce the

demand for drugs or alcohol.

All applicants must be a private, non-profit organization pursuant to 26 U.S.C. § 501 (c) (3) or (4), or a

state, county or local governmental department or agency. No applicant may act as a pass-through entity in

order to provide assistance to another recipient. The applicant must complete the W-9 using the non-profit or

governmental organization’s information.

Parent groups committed to changing the attitudes and perceptions of the public toward the misuse of

drugs and alcohol are eligible for grants.

The Office of Attorney General (OAG) Community Drug Abuse Prevention Grant Program will not

award a grant to any project promoting or supporting “responsible use” of alcohol by minors. All programs

funded by the OAG Community Drug Abuse Prevention Grant Program must adhere to the objectives of the

OAG which emphasis education through proven and fact based means. Projects should be age appropriate and

offer information on legal consequences, emotional consequences, and physical impact on users, families and

the community. Programs are encouraged to offer information on support services when possible along with

reporting information such as OAG’s text tip line.

MATCHING FUNDS

Each applicant should show matching funds from non-grant resources, unless the applicant can show

extenuating circumstances. The OAG Community Drug Abuse Prevention Grant Program strongly suggests a

minimum of 10 percent in matching funds. Special action by the Office of Attorney General’s Grant Review

Committee will be required for any grant award over $1,000.

FORMAT

Applications for a grant must adhere to the following format:

♦ Use forms provided by the Office of Attorney General and complete in full.

• Basic information (Form GA-1)

• Completed IRS Form W-9. The Tax Identification Number, name and address must

match the applicant information used on Form GA-1. The entity listed on the W-9 must

be registered under 26 U.S.C. § 501 (c) (3) or (4) or be a governmental department or

agency. Reimbursement checks will be payable to the entity listed on the W-9.

• Description of the activity, purposes, results expected, evaluation plan and utilization of

resources (Form GA-2)

• Complete budget breakdown showing matching non-grant resources (Form GA-3)

• Assurances (Form GA-4)

• Details of community support for the project (including letters of reference)

SPECIAL REQUIREMENTS

1. School Curriculum – The OAG drafted and then supported the mandatory drug and alcohol

curriculum for grades K-12 in all 500 Pennsylvania school districts. Mandatory K-12 drug

education is the law in Pennsylvania; therefore schools will not be eligible for grant monies to

purchase drug curriculum. All schools should be aware that OAG offers programs free of charge.

Our primary objective is to support and enhance the operation of volunteer community prevention

groups and programs.

2. Coordinated Projects – To encourage the coordinated efforts of organizations that promote drug and

alcohol awareness through networking, coordinated projects from two or more organizations will

receive priority over single-organization projects.

3. Police Departments – Grants will be awarded for material and equipment that fits the Purpose and

Eligibility Sections of these guidelines. We encourage formal programs to accompany the use of

such equipment.

4. Quantity and Amount of Grants – No group shall receive more than one grant per fiscal year; grant

amounts shall be at the discretion of the OAG grant committee. (Unless special action is taken by

the Office of Attorney General’s Grant Review Committee).

REPORTS AND REIMBURSEMENT

In order to receive reimbursement, the applicant must submit original itemized receipts that show proof

of payment. Proof of payment can be in the form of a cancelled check (copy of both sides), bank statement or a

paid vendor receipt showing payment. Do not send receipts with this application. Upon the OAG’s approval of

your application, a Request for Reimbursement form (GA-5) and a photocopy of your completed Budget

Breakdown for Project (GA-3) will be forwarded to the applicant.

The applicant is required to submit a one page Accomplishment Report at the time reimbursement is

requested. Included in this report should be information relating to the number of individuals who benefited

from the project, copies of newspaper articles and any other information relative to the success of the project.

You will then be required to complete the Request for Reimbursement form(GA-5), attach your receipts

and Accomplishment Report and return the entire package to the OAG. Upon receipt, the OAG will review the

package and process for payment. More detailed information regarding the reimbursement process will be

forwarded to the applicant along with their approval letter.

REVIEW

Completed grant applications will be reviewed and approved or disapproved by the Office of Attorney

General Grant Review Committee. The decision of the Grant Review Committee shall be final.

Applications will be judged based upon a variety of factors including, but not limited to the following:

♦ The project or program supports innovative, proven, effective messages regarding the

dangers of drugs and underage drinking.

♦ The goals and/or objectives are realistic, achievable, specific and comprehensive.

♦ The evidence of community support and involvement with the applicant’s organization

and/or proposed project or program.

♦ The budget offers proof of accountability, is reasonable and specific. Grant funds cannot be

used for staff salaries, computers or computer-related equipment, or equipment used

primarily for enforcement.

For further information or guidance, contact:

Anita McGovern, Executive Director

Community Drug Abuse Prevention Grant Program

Office of Attorney General

Floor, Strawberry Square

Harrisburg, PA 17120

(717) 787-3391

amcgovern@attorneygeneral.gov

*All Participants must have clearances or certificates required by law for activities.

We will not promote any programs that are not consistent with OAG’s goals and methods.

8. Official Title of Contact

OFFICE OF ATTORNEY GENERAL

COMMUNITY DRUG ABUSE PREVENTION GRANT PROGRAM

GRANT APPLICATION

Form GA-1

1. Project Title

Federal ID from W-9

3. Name of Organization from W-9

4. Organization Contact

5. Address of Organization

7. County:

6. Email Address of Contact (No. 4)

9. a. Phone # of Organization

9. b. Phone # of Contact

11. a. Amount Requested $_________________

b. Date by which

reimbursement ______________________

is requested

12.

Duration of Project

Starting Date ________________________

Completion Date _____________________

13. Check appropriate boxes below when completed and enclosed:

Proposal Narrative (Form GA-2) Budget Breakdown (Form GA-3)

Grant Assurances (Form GA-4)

Two Letters of Support

IRS Form W-9

OAG Use Only

Approved: ___________________________ __________________________ __________

Signature of Authorized Official Title Date

Award to: ______________________________________________________________

Maximum Grant Award Payment: $ ___________________ SAP Vendor Nbr: _______________

Account Code: 6029800000-0000-1411501110-6600900

( ) _______ – ___________ Ext. ______

Grant application must be received and approved before a project can commence.

( ) _______ – ___________ Ext. ______

10. Does this organization/vendor receive a 1099

for incoming funds? Yes No

Please initial for verification of above _________________

GRANT APPLICATION

Form GA-2

PLEASE TYPE OR PRINT CLEARLY

1. Organization’s or applicant’s history and description:

2. Targeted audience:

3. Specifically, how will this grant be utilized:

USE REVERSE SIDE FOR ADDITIONAL INFORMATION

_____________________________________________________

____________________________________________________

_____________________________________________________

4. Identify all agencies, organizations, civic clubs, etc., who will assist in this project. Note primary

party who will carry out grant project:

5. Explain the expected outcome/effect:

6. List the names of board members, or other members of your organization who are participating in

this project, along with a brief description of their involvement:

Name ___________________ Title _______________ Phone _____________

Address ______________________________________________________

Involvement ____________________________________________________

___________________________________________________________

Name ___________________ Title _______________ Phone _____________

Address ______________________________________________________

Involvement ____________________________________________________

___________________________________________________________

*All participants must have clearances or certificates required by law for activities

USE REVERSE SIDE FOR ADDITIONAL INFORMATION

_____________________________________________________

GRANT APPLICATION

Form GA-3

BUDGET BREAKDOWN FOR PROJECT

NAME OF

ORGANIZATION:

FEDERAL ID : __________________

A. Purchases (List)

-G

RANT

RESOURCES

GRANT REQUEST TOTAL COST

PPROVED

AMOUNT*

1. ________________________

2. ________________________

3. ________________________

4. ________________________

Subtotals

B. Rentals (List)

-G

RANT

RESOURCES

GRANT REQUEST TOTAL COST

PPROVED

AMOUNT*

1. ________________________

2. ________________________

3. ________________________

4. ________________________

Subtotals

C. Contractual Services (List)

-G

RANT

RESOURCES

GRANT REQUEST TOTAL COST

PPROVED

AMOUNT*

1. ________________________

2. ________________________

3. ________________________

4. ________________________

Subtotals

D. Other Expenses (List)

-G

RANT

RESOURCES

GRANT REQUEST TOTAL COST

PPROVED

AMOUNT*

1. ________________________

2. ________________________

3. ________________________

________________________

Subtotals

Totals

*To be filled out

by OAG only

$0.00

GRANT APPLICATION

Form GA-4

GRANT ASSURANCES

The applicant assures and certifies with respect to the grant that:

1. Applicant has read and understands all of the Grant Guidelines included in this

application.

2. Applicant possesses legal authority to apply for the grant. Authority should be

granted by a motion, resolution or similar action being duly taken as an official act of

the applicant’s governing body.

3. Applicant will comply with all federal and Commonwealth laws pertaining to

discrimination under the program for which the applicant is requesting a grant from

the Office of Attorney General (OAG).

4. Applicant acknowledges that no officer, director, trustee or fiduciary of the applying

organization has been convicted of a felony offense under state or federal law

including any drug offense.

5. Applicant will give to the Commonwealth of Pennsylvania the access to and the right

to examine all records, books and documents related to the grant.

6. If the grant funds are used in a manner other than as set forth in this application or the

assurances certified to in this document are determined to be false, the applicant and

the members of its governing body agree to repay the full amount of the grant to the

Office of Attorney General upon demand.

As a condition of the awarding of this grant, the Applicant, its officers, directors, and/or key

employees, agree to cooperate in the conduct of a criminal background check as may be requested

by OAG and the successful completion of same.

Signature _______________________________________________ Date _______________

Title _______________________________________________________________________

Form W-9

(Rev. December 2014)

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.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

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)

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for

the tax classification of the single-member owner.

Other (see instructions)

4 Exemptions (codes apply only to

certain entities, not individuals; see

instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)

(Applies to accounts maintained outside the U.S.)

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

6 City, state, and ZIP code

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 line 1 to avoid

backup withholding. For individuals, this is generally 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.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for

guidelines on whose number to enter.

Social security number

––

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. See the

instructions on page 3.

Sign

Here

Signature of

U.S. person

Date

General Instructions

Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such

as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an information

return with the IRS must obtain your correct taxpayer identification number (TIN)

which may be your social security number (SSN), individual taxpayer identification

number (ITIN), adoption taxpayer identification number (ATIN), or employer

identification number (EIN), to report on an information return the amount paid to

you, or other amount reportable on an information return. Examples of information

returns include, but are not limited to, the following:

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by

brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T

(tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to

provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject

to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

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, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are

exempt from the FATCA reporting, is correct. See What is FATCA reporting? on

page 2 for further information.

Cat. No. 10231X

Form W-9 (Rev. 12-2014)

Page 2

Note. If you are a U.S. person and 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.

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

person if you are:

• 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

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in

the United States are generally required to pay a withholding tax under section

1446 on any foreign partners’ share of effectively connected taxable income from

such business. Further, in certain cases where a Form W-9 has not been received,

the rules under section 1446 require a partnership to presume that a partner is a

foreign person, and pay the section 1446 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 section 1446 withholding on your share of partnership income.

In the cases below, the following person must give 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:

• In the case of a disregarded entity with a U.S. owner, the U.S. owner of the

disregarded entity and not the entity;

• In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally,

the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and

• In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a

grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank

that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use

the appropriate Form W-8 or Form 8233 (see Publication 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 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.

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.

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, give the requester the

appropriate completed Form W-8 or Form 8233.

Backup Withholding

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, payments made in

settlement of payment card and third party network transactions, 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,

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

3 for details),

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

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. 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 Exempt

payee code on page 3 and the separate Instructions for the Requester of Form

W-9 for more information.

Also see Special rules for partnerships above.

What is FATCA reporting?

The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign

financial institution to report all United States account holders that are specified

United States persons. Certain payees are exempt from FATCA reporting. See

Exemption from FATCA reporting code on page 3 and the Instructions for the

Requester of Form W-9 for more information.

Updating Your Information

You must provide updated information to any person to whom you claimed to be

an exempt payee if you are no longer an exempt payee and anticipate receiving

reportable payments in the future from this person. For example, you may need to

provide updated information if you are a C corporation that elects to be an S

corporation, or if you no longer are tax exempt. In addition, you must furnish a new

Form W-9 if the name or TIN changes for the account; for example, if the grantor

of a grantor trust dies.

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

Line 1

You must enter one of the following on this line; do not leave this line blank. The

name should match the name on your tax return.

If this Form W-9 is for a joint account, list first, and then circle, the name of the

person or entity whose number you entered in Part I of Form W-9.

a. Individual. Generally, enter the name shown on your tax return. If you have

changed your last name without informing the Social Security Administration (SSA)

of the name change, enter your first name, the last name as shown on your social

security card, and your new last name.

Note. ITIN applicant: Enter your individual name as it was entered on your Form

W-7 application, line 1a. This should also be the same as the name you entered on

the Form 1040/1040A/1040EZ you filed with your application.

b. Sole proprietor or single-member LLC. Enter your individual name as

shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade,

or “doing business as” (DBA) name on line 2.

c. Partnership, LLC that is not a single-member LLC, C Corporation, or S

Corporation. Enter the entity's name as shown on the entity's tax return on line 1

and any business, trade, or DBA name on line 2.

d. Other entities. Enter your name as shown on required U.S. federal tax

documents on line 1. 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 line 2.

e. Disregarded entity. For U.S. federal tax purposes, an entity that is

disregarded as an entity separate from its owner is treated as a “disregarded

entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on

line 1. The name of the entity entered on line 1 should never be a disregarded

entity. The name on line 1 should be the name shown on the income tax return on

which the income should be reported. For example, if a foreign LLC that is treated

as a disregarded entity for U.S. federal tax purposes has a single owner that is a

U.S. person, the U.S. owner's name is required to be provided on line 1. If the

direct owner of the entity is also a disregarded entity, enter the first owner that is

not disregarded for federal tax purposes. Enter the disregarded entity's name on

line 2, “Business name/disregarded entity name.” If the owner of the disregarded

entity is a foreign person, the owner must complete an appropriate Form W-8

instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.

Form W-9 (Rev. 12-2014)

Page 3

Line 2

If you have a business name, trade name, DBA name, or disregarded entity name,

you may enter it on line 2.

Line 3

Check the appropriate box in line 3 for the U.S. federal tax classification of the

person whose name is entered on line 1. Check only one box in line 3.

Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a

partnership for U.S. federal tax purposes, check the “Limited Liability Company”

box and enter “P” in the space provided. If the LLC has filed Form 8832 or 2553 to

be taxed as a corporation, check the “Limited Liability Company” box and in the

space provided enter “C” for C corporation or “S” for S corporation. If it is a

single-member LLC that is a disregarded entity, do not check the “Limited Liability

Company” box; instead check the first box in line 3 “Individual/sole proprietor or

single-member LLC.”

Line 4, Exemptions

If you are exempt from backup withholding and/or FATCA reporting, enter in the

appropriate space in line 4 any code(s) that may apply to you.

Exempt payee code.

• Generally, individuals (including sole proprietors) are not exempt from backup

withholding.

• Except as provided below, corporations are exempt from backup withholding

for certain payments, including interest and dividends.

• Corporations are not exempt from backup withholding for payments made in

settlement of payment card or third party network transactions.

• Corporations are not exempt from backup withholding with respect to attorneys'

fees or gross proceeds paid to attorneys, and corporations that provide medical or

health care services are not exempt with respect to payments reportable on Form

1099-MISC.

The following codes identify payees that are exempt from backup withholding.

Enter the appropriate code in the space in line 4.

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 U.S. commonwealth or possession, or

any of their political subdivisions or instrumentalities

4—A foreign government or any of its political subdivisions, agencies, or

instrumentalities

5—A corporation

6—A dealer in securities or commodities required to register in the United

States, the District of Columbia, or a U.S. commonwealth or possession

7—A futures commission merchant registered with the Commodity Futures

Trading Commission

8—A real estate investment trust

9—An entity registered at all times during the tax year under the Investment

Company Act of 1940

10—A common trust fund operated by a bank under section 584(a)

11—A financial institution

12—A middleman known in the investment community as a nominee or

custodian

13—A trust exempt from tax under section 664 or described in section 4947

The following chart shows types of payments that may be exempt from backup

withholding. The chart applies to the exempt payees listed above, 1 through 13.

IF the payment is for . . . THEN the payment is exempt for . . .

Interest and dividend payments All exempt payees except

for 7

Broker transactions Exempt payees 1 through 4 and 6

through 11 and all C corporations. S

corporations must not enter an exempt

payee code because they are exempt

only for sales of noncovered securities

acquired prior to 2012.

Barter exchange transactions and

patronage dividends

Exempt payees 1 through 4

Payments over $600 required to be

reported and direct sales over $5,000

Generally, exempt payees

1 through 5

Payments made in settlement of

payment card or third party network

transactions

Exempt payees 1 through 4

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

However, the following payments made to a corporation and reportable on Form

1099-MISC are not exempt from backup withholding: medical and health care

payments, attorneys' fees, gross proceeds paid to an attorney reportable under

section 6045(f), and payments for services paid by a federal executive agency.

Exemption from FATCA reporting code. The following codes identify payees

that are exempt from reporting under FATCA. These codes apply to persons

submitting this form for accounts maintained outside of the United States by

certain foreign financial institutions. Therefore, if you are only submitting this form

for an account you hold in the United States, you may leave this field blank.

Consult with the person requesting this form if you are uncertain if the financial

institution is subject to these requirements. A requester may indicate that a code is

not required by providing you with a Form W-9 with “Not Applicable” (or any

similar indication) written or printed on the line for a FATCA exemption code.

A—An organization exempt from tax under section 501(a) or any individual

retirement plan as defined in section 7701(a)(37)

B—The United States or any of its agencies or instrumentalities

C—A state, the District of Columbia, a U.S. commonwealth or possession, or

any of their political subdivisions or instrumentalities

D—A corporation the stock of which is regularly traded on one or more

established securities markets, as described in Regulations section

1.1472-1(c)(1)(i)

E—A corporation that is a member of the same expanded affiliated group as a

corporation described in Regulations section 1.1472-1(c)(1)(i)

F—A dealer in securities, commodities, or derivative financial instruments

(including notional principal contracts, futures, forwards, and options) that is

registered as such under the laws of the United States or any state

G—A real estate investment trust

H—A regulated investment company as defined in section 851 or an entity

registered at all times during the tax year under the Investment Company Act of

1940

I—A common trust fund as defined in section 584(a)

J—A bank as defined in section 581

K—A broker

L—A trust exempt from tax under section 664 or described in section 4947(a)(1)

M—A tax exempt trust under a section 403(b) plan or section 457(g) plan

Note. You may wish to consult with the financial institution requesting this form to

determine whether the FATCA code and/or exempt payee code should be

completed.

Line 5

Enter your address (number, street, and apartment or suite number). This is where

the requester of this Form W-9 will mail your information returns.

Line 6

Enter your city, state, and ZIP code.

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-member LLC that is disregarded as an entity separate from its

owner (see Limited Liability Company (LLC) on this page), 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.

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

SSA 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 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, apply for a TIN

and 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.

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 U.S. entity that has a foreign owner must use the

appropriate Form W-8.

Form W-9 (Rev. 12-2014)

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, 4, or 5 below indicate otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign

(when required). In the case of a disregarded entity, the person identified on line 1

must sign. Exempt payees, see

Exempt payee code

earlier.

Signature requirements. Complete the certification as indicated in items 1

through 5 below.

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.

3. Real estate transactions. You must sign the certification. You may cross out

item 2 of the certification.

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 made in

settlement of payment card and third party network transactions, 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 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.

What Name and Number To Give the Requester

For this type of account:

Give name and SSN of:

1. Individual

The individual

2. Two or more individuals (joint

account)

The actual owner of the account or,

if combined funds, the first

individual on the account

3. Custodian account of a minor

(Uniform Gift to Minors Act)

The minor

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

The grantor-trustee

The actual owner

5. Sole proprietorship or disregarded

entity owned by an individual

The owner

6. Grantor trust filing under Optional

Form 1099 Filing Method 1 (see

Regulations section 1.671-4(b)(2)(i)

(A))

The grantor*

For this type of account:

Give name and EIN of:

7. Disregarded entity not owned by an

individual

The owner

8. A valid trust, estate, or pension trust

Legal entity

9. Corporation or LLC electing

corporate status on Form 8832 or

Form 2553

The corporation

10. Association, club, religious,

charitable, educational, or other tax-

exempt organization

The organization

11. Partnership or multi-member LLC

The partnership

12. A broker or registered nominee

The broker or nominee

13. 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 public entity

14. Grantor trust filing under the Form

1041 Filing Method or the Optional

Form 1099 Filing Method 2 (see

Regulations section 1.671-4(b)(2)(i)

(B))

The trust

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 “Business name/disregarded entity” 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 2.

*Note. Grantor also must provide a Form W-9 to trustee of trust.

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.

Secure Your Tax Records from Identity Theft

Identity theft occurs when someone uses your personal information such as your

name, 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.

To reduce your risk:

• Protect your SSN,

• Ensure your employer is protecting your SSN, and

• Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a notice from

the IRS, respond right away to the name and phone number printed on the IRS

notice or letter.

If your tax records are not currently affected by identity theft but you think you

are at risk due to a lost or stolen purse or wallet, questionable credit card activity

or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit

Form 14039.

For more information, see Publication 4535, Identity Theft Prevention and Victim

Assistance.

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 property to the Treasury Inspector General for Tax Administration

(TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal

Trade Commission at: spam@uce.gov or contact them at www.ftc.gov/idtheft or

1-877-IDTHEFT (1-877-438-4338).

Visit IRS.gov to learn more about identity theft and how to reduce your risk.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct

TIN to persons (including federal agencies) who are required to file information

returns with the IRS to report interest, dividends, or certain other income paid to

you; mortgage interest you paid; the acquisition or abandonment of secured

property; the cancellation of debt; or contributions you made to an IRA, Archer

MSA, or HSA. The person collecting this form uses the information on the form to

file information returns with the IRS, reporting the above information. Routine uses

of this information include giving it to the Department of Justice for civil and

criminal litigation and to cities, states, the District of Columbia, and U.S.

commonwealths and possessions for use in administering their laws. The

information also may be disclosed to other countries under a treaty, to federal and

state agencies to enforce civil and criminal laws, or to federal law enforcement and

intelligence agencies to combat terrorism. You must provide your TIN whether or

not you are required to file a tax return. Under section 3406, payers must generally

withhold a percentage of taxable interest, dividend, and certain other payments to

a payee who does not give a TIN to the payer. Certain penalties may also apply for

providing false or fraudulent information.

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