REQUEST FOR TAXPAYER IDENTIFICATION NUMBER

 

Name: _________________________

 

Address: _________________________

City: _________________________

State: ___

Zip Code: __________

 

Taxpayer Identification Number:

Social Security Number: ___________

 

 

Certification: Under penalty 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 that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.

 

 

___________________________________ Date: __________________

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