Form W-9 Request for Taxpayer Name - Indiana

1 Give form to therequester. Do notsend to the for TaxpayerIdentification Number and Certification(Rev. January 2003)Department of the TreasuryInternal Revenue ServiceNameList account number(s) here (optional)Address (number, street, and apt. or suite no.)City, state, and ZIP codePrint or typeSee Specific Instructions on page Identification Number (TIN)Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN).However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions onpage 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 security number orRequester s name and address (optional)Employer identification numberNote: If the account is in more than one name, see the chart on page 4 for guidelines on whose numberto enter.

2 Number shown on this form is my correct Taxpayer identification number (or I am waiting for a number to be issued to me), andI am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the InternalRevenue 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 hasnotified me that I am no longer subject to backup withholding, instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backupwithholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirementarrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you mustprovide your correct TIN.

3 (See the instructions on page 4.)SignHereSignature person Date Purpose of FormFormW-9(Rev. 1-2003)Part IPart IIBusiness name, if different from aboveCat. No. 10231 XCheck appropriate box:Under penalties of perjury, I certify person. Use Form W-9 only if you are a person(including a resident alien), to provide your correct TIN to theperson requesting it (the requester) and, when applicable, to:1. Certify that the TIN you are giving is correct (or you arewaiting for a number to be issued),2. Certify that you are not subject to backup withholding,or3. Claim exemption from backup withholding if you are exempt person. If you are a foreign person, use theappropriate Form W-8 (see Pub. 515, Withholding of Tax onNonresident Aliens and foreign entities ). am a person (including a resident alien).A person who is required to file an information return withthe IRS, must obtain your correct Taxpayer identificationnumber (TIN) to report, for example, income paid to you, realestate transactions, mortgage interest you paid, acquisitionor abandonment of secured property, cancellation of debt, orcontributions you made to an proprietorCorporationPartnershipOther Exempt from backupwithholdingNote: If a requester gives you a for m other than For m W-9to Request your TIN, you should use the requester s for , this for m must meet the acceptable specificationsdescr ibed in Pub.

4 1167, General Rules and Specifications forSubstitute Tax For ms and alien who becomes a resident , only a nonresident alien individual may use theterms of a tax treaty to reduce or eliminate tax oncertain types of income. However, most tax treaties contain aprovision known as a saving clause. Exceptions specifiedin the saving clause may permit an exemption from tax tocontinue for certain types of income even after the recipienthas otherwise become a resident alien for tax you are a resident alien who is relying on anexception contained in the saving clause of a tax treaty toclaim an exemption from tax on certain types of income,you must attach a statement that specifies the following fiveitems:1. The treaty country. Generally, this must be the sametreaty under which you claimed exemption from tax as anonresident The treaty article addressing the The article number (or location) in the tax treaty thatcontains the saving clause and its The type and amount of income that qualifies for theexemption from Sufficient facts to justify the exemption from tax underthe terms of the treaty W-9 (Rev.)

5 1-2003)Page2 Sole proprietor. Enter your individual name as shown onyour social security card on the Name line. You may enteryour business, trade, or doing business as (DBA) name onthe Business name entities . Enter your business name as shown onrequired Federal tax documents on the Name line. Thisname should match the name shown on the charter or otherlegal document creating the entity. You may enter anybusiness, trade, or DBA name on the Business name the account is in joint names, list first, and then circle,the name of the person or entity whose number you enteredin Part I of the liability company (LLC). If you are a single-memberLLC (including a foreign LLC with a domestic owner) that isdisregarded as an entity separate from its owner underTreasury regulations section , enter the owner sname on the Name line.

6 Enter the LLC s name on the Business name InstructionsNameExempt From Backup WithholdingGenerally, individuals (including sole proprietors) are notexempt from backup withholding. Corporations are exemptfrom backup withholding for certain payments, such asinterest and You do not certify to the requester that you are notsubject to backup withholding under 4 above (for reportableinterest and dividend accounts opened after 1983 only).Certain payees and payments are exempt from backupwithholding. See the instructions below and the separateInstructions for the Requester of Form penalty for false information with respect towithholding. If you make a false statement with noreasonable basis that results in no backup withholding, youare subject to a $500 penalty for falsifying information. Willfullyfalsifying certifications or affirmations may subject you tocriminal penalties including fines and/or to furnish TIN.

7 If you fail to furnish your correct TINto a requester, you are subject to a penalty of $50 for eachsuch failure unless your failure is due to reasonable causeand not to willful of TINs. If the requester discloses or uses TINs inviolation of Federal law, the requester may be subject to civiland criminal you are an individual, you must generally enter the nameshown on your social security card. However, if you havechanged your last name, for instance, due to marriagewithout informing the Social Security Administration of thename change, enter your first name, the last name shown onyour social security card, and your new last payees. Backup withholding is not required on anypayments made to the following payees:1. An organization exempt from tax under section 501(a),any IRA, or a custodial account under section 403(b)(7) if theaccount satisfies the requirements of section 401(f)(2);2.

8 The United States or any of its agencies orinstrumentalities;3. A state, the District of Columbia, a possession of theUnited States, or any of their political subdivisions orinstrumentalities;4. A foreign government or any of its political subdivisions,agencies, or instrumentalities; or5. An international organization or any of its agencies payees that may be exempt from backupwithholding include:6. A corporation;7. A foreign central bank of issue;8. A dealer in securities or commodities required to registerin the United States, the District of Columbia, or apossession of the United States;If you are exempt, enter your name as described above andcheck the appropriate box for your status, then check the Exempt from backup withholding box in the line followingthe business name, sign and date the The IRS tells you that you are subject to backupwithholding because you did not report all your interest anddividends on your tax return (for reportable interest anddividends only), or3.

9 The IRS tells the requester that you furnished anincorrect TIN, or2. You do not certify your TIN when required (see the PartII instructions on page 4 for details), orYou will not be subject to backup withholding on paymentsyou receive if you give the requester your correct TIN, makethe proper certifications, and report all your taxable interestand dividends on your tax You do not furnish your TIN to the requester, orWhat is backup withholding? Persons making certainpayments to you must under certain conditions withhold andpay to the IRS 30% of such payments (29% after December31, 2003; 28% after December 31, 2005). This is called backup withholding. Payments that may be subject tobackup withholding include interest, dividends, broker andbarter exchange transactions, rents, royalties, nonemployeepay, and certain payments from fishing boat operators.

10 Realestate transactions are not subject to backup you receive will be subject to backupwithholding if:If you are a nonresident alien or a foreign entity notsubject to backup withholding, give the requester theappropriate completed Form Article 20 of the income tax treatyallows an exemption from tax for scholarship incomereceived by a Chinese student temporarily present in theUnited States. Under law, this student will become aresident alien for tax purposes if his or her stay in the UnitedStates exceeds 5 calendar years. However, paragraph 2 ofthe first Protocol to the treaty (dated April 30,1984) allows the provisions of Article 20 to continue to applyeven after the Chinese student becomes a resident alien ofthe United States. A Chinese student who qualifies for thisexception (under paragraph 2 of the first protocol) and isrelying on this exception to claim an exemption from tax onhis or her scholarship or fellowship income would attach toForm W-9 a statement that includes the informationdescribed above to support that : You are requested to check the appropr iate box foryour status (individual/sole propr ietor, corporation, etc.)