Form W-9 - Request For Taxpayer Identification Number And Certification - 2011 Page 4

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Form W-9 (Rev. 12-2011)

Page

4. Other payments. You must give your correct TIN, but you do not

Note. If no name is circled when more than one name is listed, the

have to sign the certification unless you have been notified that you

number will be considered to be that of the first name listed.

have previously given an incorrect TIN. “Other payments” include

Secure Your Tax Records from Identity Theft

payments made in the course of the requester’s trade or business for

rents, royalties, goods (other than bills for merchandise), medical and

Identity theft occurs when someone uses your personal information

health care services (including payments to corporations), payments to

such as your name, social security number (SSN), or other identifying

a nonemployee for services, payments to certain fishing boat crew

information, without your permission, to commit fraud or other crimes.

members and fishermen, and gross proceeds paid to attorneys

An identity thief may use your SSN to get a job or may file a tax return

(including payments to corporations).

using your SSN to receive a refund.

5. Mortgage interest paid by you, acquisition or abandonment of

To reduce your risk:

secured property, cancellation of debt, qualified tuition program

• Protect your SSN,

payments (under section 529), IRA, Coverdell ESA, Archer MSA or

• Ensure your employer is protecting your SSN, and

HSA contributions or distributions, and pension distributions. You

must give your correct TIN, but you do not have to sign the certification.

• Be careful when choosing a tax preparer.

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

What Name and Number To Give the Requester

notice from the IRS, respond right away to the name and phone number

printed on the IRS notice or letter.

For this type of account:

Give name and SSN of:

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

1. Individual

The individual

think you are at risk due to a lost or stolen purse or wallet, questionable

2. Two or more individuals (joint

The actual owner of the account or,

credit card activity or credit report, contact the IRS Identity Theft Hotline

account)

if combined funds, the first

at 1-800-908-4490 or submit Form 14039.

individual on the account

For more information, see Publication 4535, Identity Theft Prevention

3. Custodian account of a minor

The minor

and Victim Assistance.

(Uniform Gift to Minors Act)

Victims of identity theft who are experiencing economic harm or a

4. a. The usual revocable savings

The grantor-trustee

system problem, or are seeking help in resolving tax problems that have

trust (grantor is also trustee)

not been resolved through normal channels, may be eligible for

b. So-called trust account that is

The actual owner

not a legal or valid trust under

Taxpayer Advocate Service (TAS) assistance. You can reach TAS by

state law

calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD

5. Sole proprietorship or disregarded

The owner

1-800-829-4059.

entity owned by an individual

Protect yourself from suspicious emails or phishing schemes.

The grantor*

6. Grantor trust filing under Optional

Phishing is the creation and use of email and websites designed to

Form 1099 Filing Method 1 (see

mimic legitimate business emails and websites. The most common act

Regulation section 1.671-4(b)(2)(i)(A))

is sending an email to a user falsely claiming to be an established

For this type of account:

Give name and EIN of:

legitimate enterprise in an attempt to scam the user into surrendering

7. Disregarded entity not owned by an

The owner

private information that will be used for identity theft.

individual

The IRS does not initiate contacts with taxpayers via emails. Also, the

8. A valid trust, estate, or pension trust

Legal entity

IRS does not request personal detailed information through email or ask

9. Corporation or LLC electing

The corporation

taxpayers for the PIN numbers, passwords, or similar secret access

corporate status on Form 8832 or

information for their credit card, bank, or other financial accounts.

Form 2553

If you receive an unsolicited email claiming to be from the IRS,

10. Association, club, religious,

The organization

forward this message to phishing@irs.gov. You may also report misuse

charitable, educational, or other

tax-exempt organization

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

The partnership

11. Partnership or multi-member LLC

suspicious emails to the Federal Trade Commission at: spam@uce.gov

12. A broker or registered nominee

The broker or nominee

or contact them at or 1-877-IDTHEFT

13. Account with the Department of

The public entity

(1-877-438-4338).

Agriculture in the name of a public

entity (such as a state or local

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

government, school district, or

your risk.

prison) that receives agricultural

program payments

14. Grantor trust filing under the Form

The trust

1041 Filing Method or the Optional

Form 1099 Filing Method 2 (see

Regulation section 1.671-4(b)(2)(i)(B))

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.

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.