Page 3 of 4
SECTION 5: Certification and signatures
Under the penalties of perjury I certify:
1. The number shown on this form is my correct taxpayer identification number, 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
(If you have been notified by the IRS that you are currently subject to backup withholding
because of under reporting interest or dividends on your tax return, you must cross out and
initial this item.)
3. I am a U.S. citizen or other U.S. person, and;
4. I am not subject to FATCA reporting because I am a U.S. person and the account is located within the
(If you are not a U.S. Citizen or other U.S. person for tax purposes, please cross out the last
two certifications and complete appropriate IRS documentation, e.g. IRS Form W-8BEN for
individuals, which can be found on the IRS website).
The Internal Revenue Service does not require your consent to any provision of this document other
than the certifications required to avoid backup withholding.
All Owners must sign this form. Any Irrevocable Beneficiary or Collateral Assignee must sign this form.
Please sign as shown below:
A Partnership The full name of the firm should be printed with the signature of all general partners
(not limited partners).
A Sole Proprietorship The full name of the business should be printed with the signature of the owner
followed by the word “owner.”
A Trust Signatures, followed by the word "Trustee," of all required Trustees. Also submit a
Trust Certification, which is available from your representative, sales office, or the
appropriate number listed under How to Submit This Form.
A Corporation The signature and title of one officer (other than the insured).
An Individual acting on The full name of the Owner's fiduciary or agent and the legal documentation of the
behalf of the Owner authority to act (e.g., power of attorney, guardianship papers, etc.).