REQUEST FOR TAXPAYER IDENTIFICATION NUMBER
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: __________________