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rnm W-9 Request for Taxpayer
<br />(Per Decem!rer 1996i Identification Number and Certification
<br />nrym r vnrnr or ;ne Le,snr,
<br />,i Peverv~e 5=,vcr
<br />f Name (II aLomt account or yon changed yen, came. see specific Instructions on page 2 )
<br />r Ca LL ) I 1~ o Lee
<br />Business name. f Off from above_ (See Specific Instructions on page 2 7
<br />o ~
<br />c Chart, appropnate box. u )ndividual/Sole propnec, Corperal:on ~J Partnership
<br />N Address (number. street and air _ or suite no I
<br />o (~~II(✓~~J"~.tJrIVE'
<br />a
<br />City. stare, and ZIP code
<br />? o
<br />Set rJ . rJG 7
<br />FUTM Taxpaver Identification Number (TIN)
<br />Enter your TIN in the appropriate box. For
<br />individuals, this is your social security number
<br />(SSN)_ However. If you are a resident alien OR a
<br />sole proprietor, see the inswctions on page 2.
<br />For other entities. if IS your employer -
<br />identification number (EIN). If you do not have a
<br />number, see How To Get a TIN on page 2.
<br />Note' If the account is in more than one name,
<br />see the chart on page 2 for guidelines on whose
<br />number to enter
<br />Certification
<br />rI :1 rl
<br />Give form to the
<br />requester. Do NOT
<br />send to the IRS.
<br />Other 1
<br />Requesier's name and address (optional
<br />List account numberis) here (optional
<br />ISochi security number
<br />OR
<br />Employer Identification number
<br />SI616Do o I
<br />For Payees Exempt From Backup
<br />Withholding (See the instructions
<br />on page 2_)
<br />Loder ll~
<br />penalties of perjury, I certify that.
<br />1- the number shown on this form is my correct taxpayer identification number (or I am wailing for a number to be issued to me), and
<br />2. 1 am not subject to backup withholding because- (a) I am exempt from backup withholding, or (b) 1 have not been notified by the Internal
<br />Revenue Service (IRS) that 1 am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
<br />notified me that I am no longer subject to backup withholding.
<br />Certification Instructions -You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
<br />withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
<br />For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt. contributions to an individual retirement
<br />arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
<br />provide your correct TIN_ (See the instructions on page 2-1
<br />Sign
<br />Here I Signature 0, _ID zDate ►
<br />Purpose of Form -A person who is
<br />required to file an information return with
<br />the IRS must get your correct taxpayer
<br />identification number (TIN) to report, for
<br />example. income paid to you, real estate
<br />transactions, mortgage interest you paid,
<br />acquisition or abandonment of secured
<br />property, cancellation of debt, or
<br />contributions you made to an IRA.
<br />Use Form W-9 to give your correct TIN
<br />to the person requesting it (the requester)
<br />and, when applicable to.-
<br />1. Certify the TIN you are giving is
<br />correct (or you are waiting for a number to
<br />be issued).
<br />2. Certify you are not subject to backup
<br />withholding, or
<br />3. Claim exemption from backup
<br />withholding if you are an exempt payee.
<br />Note: If a requester gives you a form other
<br />than a W-9 to request your TIN, you must
<br />use the requester's form if it is substantially
<br />similar to this Form W-9.
<br />What Is Backup Withholding?-Persons
<br />making certain payments to you must
<br />withhold and pay to the IRS 31% of such
<br />payments under certain conditions. This is
<br />called "backup withholding.' Payments
<br />that may be subject to backup withholding
<br />include interest, dividends, broker and
<br />barter exchange transactions, rents,
<br />royalties, nonemployee pay, and certain
<br />payments from fishing boat operators. Real
<br />estate transactions are not subject to
<br />backup withholding.
<br />If you give the requester your correct
<br />TIN, make the proper certifications, and
<br />report all your taxable interest and
<br />dividends on your tax return, payments
<br />you receive will not be subject to backup
<br />withholtling. Payments you receive will be
<br />subject to backup withholding if:
<br />1. You do riot furnish your TIN to the
<br />-
<br />requester, or
<br />2. The IRS tells the requester that you
<br />furnished an incorrect TIN, or
<br />3. The IRS tells you that you are subject
<br />to backup withholding because you did not
<br />report all your interest and dividends on
<br />your tax return (for reportable interest and
<br />dividends only), or
<br />4. You do not certify to the requester
<br />that you are not subject to backup
<br />withholding under 3 above (for reportable
<br />interest and dividend accounts opened
<br />after 1983 only), or
<br />S. You do not certify your TIN when
<br />required. See the Part III instructions on
<br />page 2 for details.
<br />Certain payees and payments are
<br />exempt from backup withholding. See the
<br />Part II instructions and the separate
<br />Instructions for the Requester of Form
<br />W-9-
<br />Penalties
<br />Failure To Furnish TIN.-If you fail to
<br />furnish your correct TIN to a requester, you
<br />are subject to a penalty of $50 for each
<br />such failure unless your failure is due to
<br />reasonable cause and not to willful neglect.
<br />Civil Penalty for False Information With
<br />Respect to Withholding.-If you make a
<br />false statement with no reasonable basis
<br />that results in no backup withholding, you
<br />are subject to a $500 penalty.
<br />Criminal Penalty for Falsifying
<br />Information.- Willfully falsifying
<br />certifications or affirmations may subject
<br />you to criminal penalties including fines
<br />and/or imprisonment.
<br />Misuse of TINS. If the requester
<br />discloses or uses TINS in violation of
<br />Federal law, the requester may be subject
<br />to civil and criminal penalties.
<br />Cat. No. 10231% Form W-9 (Rev-12.96)
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