Fillable W-9 Form W-9 (Rev. December 2011)

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W-9 Form W-9 (Rev. December 2011)

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Form W-9

(Rev. December 2011)

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 (as shown on your income tax return)

Business name/disregarded entity name, if different from above

Check appropriate box for federal tax classification:

Individual/sole proprietor

C Corporation S Corporation Partnership

Trust/estate

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

▶

Other (see instructions)

▶

Exempt payee

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

City, state, and ZIP code

Requester’s name and address (optional)

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line

to avoid backup withholding. For individuals, this is your social security number (SSN). 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 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).

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

Section references are to the Internal Revenue Code unless otherwise

noted.

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.

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.

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.

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 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.

Cat. No. 10231X

Form W-9 (Rev. 12-2011)

CITY OF BLUE RIDGE

✔

MUNICIPALITY

✔

480 WEST FIRST STREET

BLUE RIDGE, GA 30513

5 8

6 0 1 1 3 8 0

Form W-9 (Rev. 12-2011)

Page 2

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,

• 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.

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).

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 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 a percentage

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.

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 the instructions below and the separate Instructions for the

Requester of Form W-9.

Also see Special rules for partnerships on page 1.

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

Name

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 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 income

tax return on the “Name” line. You may enter your business, trade, or

“doing business as (DBA)” name on the “Business name/disregarded

entity name” line.

Partnership, C Corporation, or S Corporation. Enter the entity's name

on the “Name” line and any business, trade, or “doing business as

(DBA) name” on the “Business name/disregarded entity name” line.

Disregarded entity. Enter the owner's name on the “Name” line. The

name of the entity entered on the “Name” line should never be a

disregarded entity. The name on the “Name” line must be the name

shown on the income tax return on which the income will be reported.

For example, if a foreign LLC that is treated as a disregarded entity for

U.S. federal tax purposes has a domestic owner, the domestic owner's

name is required to be provided on the “Name” line. 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 the “Business name/disregarded entity name” line. If the owner

of the disregarded entity is a foreign person, you must complete an

appropriate Form W-8.

Note. Check the appropriate box for the federal tax classification of the

person whose name is entered on the “Name” line (Individual/sole

proprietor, Partnership, C Corporation, S Corporation, Trust/estate).

Limited Liability Company (LLC). If the person identified on the

“Name” line is an LLC, check the “Limited liability company” box only

and enter the appropriate code for the tax classification in the space

provided. If you are an LLC that is treated as a partnership for federal

tax purposes, enter “P” for partnership. If you are an LLC that has filed a

Form 8832 or a Form 2553 to be taxed as a corporation, enter “C” for

C corporation or “S” for S corporation. If you are an LLC that is

disregarded as an entity separate from its owner under Regulation

section 301.7701-3 (except for employment and excise tax), do not

check the LLC box unless the owner of the LLC (required to be

identified on the “Name” line) is another LLC that is not disregarded for

federal tax purposes. If the LLC is disregarded as an entity separate

from its owner, enter the appropriate tax classification of the owner

identified on the “Name” line.

Form W-9 (Rev. 12-2011)

Page 3

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/

disregarded entity name” line.

Exempt Payee

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/

disregarded entity 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.

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,

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,

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.

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 15.

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

for . . .

Interest and dividend payments All exempt payees except

for 9

Broker transactions Exempt payees 1 through 5 and 7

through 13. Also, C corporations.

Barter exchange transactions and

patronage dividends

Exempt payees 1 through 5

Payments over $600 required to be

reported and direct sales over

$5,000

Generally, exempt payees

1 through 7

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, 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-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.

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

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.

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.

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 item 1, below, and items 4 and 5 on page 4

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 the “Name” line must sign. Exempt payees, see

Exempt Payee on page 3.

Signature requirements. Complete the certification as indicated in

items 1 through 3, below, and items 4 and 5 on page 4.

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.

Form W-9 (Rev. 12-2011)

Page 4

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).

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

Regulation 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

Regulation 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 1.

*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, 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.

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 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. 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.

Fillable W-9 Form W-9 (Rev. December 2011)

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