Form W-9 (Short) - Request For Taxpayer Identification Number And Certification - 2015

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Job #
Request for Taxpayer
Identification Number and Certification
Give form to the requester. Do
not send to the IRS
Name (as shown on your income tax return)
Business name, if different from above
If exempt from 1099
Check appropriate box:
reporting, check here
Individual/Sole Propri
Limited liability company. Enter the tax classification (D-disregarded entity, C=Corporation, P=Partnership) _____
Other (see instructions for W9)
City, state, and ZIP code
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Social security number
1 to avoid backup withholding. For individuals this is your social security number (SSN).
For entities, it is your employer identification number (EIN).
Employer Identification Number
Part II
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer federal 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).
Person completing this form (please type or print):
Phone: (
Sign Here
Signature of
US Perso
Date ►
W-9 Form Instructions:


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Parent category: Financial