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Form w_9
<br />(Rev. December 2014)
<br />Department of the Treasury
<br />Internal Revenue Service
<br />Request for Taxpayer
<br />Identification Number and Certification
<br />T Name (as shown on your Income tax return). Name is required on this
<br />ELJ INCORPORATED
<br />a uumnaoa 1a111arumeymuuu enury name, a olrterem Trom
<br />ao not leave this line
<br />3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
<br />❑ Indlvlduaysole proprietor or ❑ C Corporation ✓❑ S Corporation ❑ Partnership ❑ Trustlestate
<br />single -member LLC
<br />❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ►
<br />Note. For a single -member LLC that Is disregarded, do not check LLC; check the appropriate box in the line above for
<br />the tax classification of the single -member owner.
<br />❑ Other (see instructions) ►
<br />5 Address (number, street, and apt. or suite no.)
<br />133 BATTING CAGE TRAIL
<br />8 City, state, and ZIP code
<br />JACKSONVILLE, NC 28540
<br />7 List account number(s) here (oolional)
<br />on Numger
<br />054
<br />Give Form to the
<br />requester. Do not
<br />send to the IRS.
<br />4 Exemptions (codes apply only to
<br />certain entities, not individuals; see
<br />Instructions on page 3):
<br />Fxempt payee code (if any)
<br />Exemption from FATCA reporting
<br />code (if any)
<br />(gopfi s to accounts nwnlamd outside the U.S.)
<br />Requesters name and address (optional)
<br />Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
<br />backup withholding. For individuals, this is generally your social security number (SSN). However, for a
<br />resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
<br />entities, It Is your employer identification number (EIN). If you do not have a number, see How to get a
<br />TIN on page 3.
<br />Note. If the account is In more than one name, see the instructions for line 1 and the chart on page 4 for
<br />guidelines on whose number to enter.
<br />&iEM Certification
<br />Under penalties of perjury, I certify that:
<br />( Social security number
<br />-m -�
<br />or
<br />Employer identification number
<br />5 6— F2 1 F8T71 5 5 5
<br />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
<br />2. 1 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
<br />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 has notified me that I am
<br />no longer subject to backup withholding; and
<br />3. 1 am a U.S. citizen or other U.S. person (defined below); and
<br />4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
<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 withholding
<br />because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
<br />interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
<br />generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
<br />instructions on page 3. n
<br />%�'yl r Signature of
<br />Here I U.S.person►
<br />General Instructions
<br />Section references are to the Internal Revenue Code unless otherwise noted.
<br />Future developments. Information about developments affecting Form W-9 (such
<br />as legislation enacted after we release It) Is at www.irs.gov/iw9.
<br />Purpose of Form
<br />An Individual or entity (Form W-9 requester) who is required to file an Information
<br />return with the IRS must obtain your correct taxpayer identification number (TIN)
<br />which may be your social security number (SSN), individual taxpayer identification
<br />number (]TIN), adoption taxpayer identification number (AT1N), or employer
<br />Identification number (EIN), to report on an information return the amount paid to
<br />you, or other amount reportable on an information retum. Examples of information
<br />returns include, but are not limited to, the following:
<br />• Form 1099 -INT (interest earned or paid)
<br />• Form 1099 -DIV (dividends, Including those from stocks or mutual funds)
<br />• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
<br />• Form 1099-B (stock or mutual fund sales and certain other transactions by
<br />brokers)
<br />• Form 1099-S (proceeds from real estate transactions)
<br />• Form 1099-K (merchant card and third party network transactions)
<br />Date ► M - UL -1— MA
<br />• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T
<br />(tultlon)
<br />• Form 1099-C (canceled debt)
<br />• Form 1099-A (acquisition or abandonment of secured property)
<br />Use Form W-9 only if you are a U.S. person (Including a resident alien), to
<br />provide your correct TIN.
<br />If you do not return Form W-9 to the requester with a TiN, you might be subject
<br />to backup withholding. See What is backup withholding? on page 2.
<br />By signing the filled -out form, you:
<br />1. Certify that the TIN you are giving is correct (or you are waiting for a number
<br />to be issued),
<br />2. Certify that you are not subject to backup withholding, or
<br />3. Claim exemption from backup withholding If you are a U.S. exempt payee. If
<br />applicable, you are also certifying that as a U.S. person, your allocable share of
<br />any partnership Income from a U.S. trade or business is not subject to the
<br />withholding tax on foreign partners' share of effectively connected Income, and
<br />4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
<br />exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
<br />page 2 for further information.
<br />Cat. No. 10231X Form W-9 (Rev. 12-2014)
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