|
00029
<br />054
<br />---
<br />Form
<br />Wast
<br />Request for Taxpayer
<br />(live Forrn to the
<br />Del' ° ..t of r 2014)
<br />Department of the Treasury
<br />Identification Number and Certification
<br />requester. Do not
<br />Internal Revenue Service
<br />send to the IRS.
<br />1 Name (as shown on your Income tax return). Name Is required on this line; do not leave this line blank.
<br />ELJINCORPORATED
<br />N
<br />2 Bushes namefdisragarded entity name, if different from above
<br />m
<br />cr3
<br />Check appropriate box for federal tax classification; clunk only one of the following seven boxes:
<br />❑ Indivlduallsole proprietor or ❑ C Corporation ❑✓ S Corporation ❑Partnership ❑ Trust/estate
<br />4 Exemption codes
<br />oertaln entltks not Individuals;agenate
<br />single -member LLC
<br />kens on papa 3):
<br />`o
<br />❑ Umited liability company. Enter the tax classification (C=C corporation. S=S corporation, P=pannershi)) ►
<br />FxwW payee code Of any)
<br />Nate. For a single -member LLC that Is disregarded, do not check LLC; check the appropriate box in the DrF9 above for
<br />the tax deastflcetlon of the single -member owner.
<br />Exemption from FATCA reporting
<br />❑rrA
<br />Other (see instnroWns) P-
<br />code Ar a
<br />OkF1oMe b,mp„Y• mNN•auQ •IArk7• el• UB.J
<br />5
<br />5 Address (number, Street, and apt. or suite no) Requester's name and address (optionep
<br />133 BATTING CAGE TRAIL
<br />e City, state, and ZIP code
<br />JACKSONVILLE, NC 28540
<br />7 Ust account numberW here (optional)
<br />ramTsvnaysr
<br />IdsnKiw�A.... v....-��
<br />- --- - -- - - • ny
<br />Enter your TIN in the appropriate box. The TIN provided must match the name given on Brie 1 to avoid social security number
<br />backup withholding. For individuals, this is generally your social security number (SSM. However, fora
<br />resident alien, sole proprietor, or disregardedd 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. or
<br />Nota. if the account is In more than one name, see the Instructions for line 1 and the chart on page 4 for +Pbye► kdendflostion number
<br />guidelines on whose number to enter. m
<br />5 6-1211181715151,61
<br />• Certification
<br />Under penalties of perjury, l certify that:
<br />1. The number shown on this form is my correct taxpayer ideritifk:ation 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 wiBntnolding 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 Of any) indicating that I am exempt from FATCA reporting is correct.
<br />Certification instructions. You must cross out kern 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, kern 2 does not apply. For mortgage
<br />Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement ORA), and
<br />generally, payments other then interest and dividends, you are not required to sign the certification, but you must provide your correct 11N. See the
<br />instructlorts on page 3
<br />Sign Signature of
<br />Here UA person 0- oats► 210M
<br />General Instructions
<br />Section references are to the Internal Revenue Code unless otherwise noted.
<br />Rftm devalopmerrb. information about devdopnkenb affeating Forth W-9 {such
<br />as legialation ernnexed after we release IQ Is at www.ks govAW.
<br />Purpose of Form
<br />An Individual or entity (Form W-9 requester) who Is required to nue an Information
<br />rdum 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 QW4, adoption taxpayer identlpcation n (AT V), or employer
<br />llerdkloation number (EIN), to report on an Ir fo matim return the amount paid to
<br />you, or other amount reportable on an Information retcm. Examples of information
<br />returns Include, but are not limited to, the following:
<br />• Form 1099 -INT tirnterast earned or pako
<br />• Form 1099 -DIV (divIderds, including those from stooks or mutual funds)
<br />• Form 1099-MISC (various types of Income, prizes, awards, or gross proceeds)
<br />• Form 1099-B tstock or mutual fund sales and certain other transections by
<br />brokers)
<br />• Form 10995 (proceeds from real estate transactions)
<br />• Form 1099-K (merchant cad and third party network transactions)
<br />• Form 1098 (home mortgage interesQ, 1095-E (student ban kAersaQ, 1098-T
<br />nen)
<br />• Form 1099-C (canceled debQ
<br />• Form 1099-A (acquisition or abandonment of secured properly)
<br />Liao Form W-9 only k you are a U.S. person (Including a resident alien), to
<br />provide your correct TIN.
<br />Nyou do not mtum Form W-9 to the requester wfth a 71N, you might be scA/ect
<br />to backup wlthho/afng: Sae Moth backup whiftA ft? on page 2.
<br />By signing the filled -out form. you:
<br />1. Certify that the TIN you we giving is correct (or you are waking for a number
<br />to be Issued),
<br />2. Certify that you are not subject to backup withholding, or
<br />3. Clalm exemption from backup withholding If you are a U.S. exempt payee. k
<br />apq>ifoable, you are also certifying that as a U.S. person, your allocable Share of
<br />Wry partnership Income from a U.S. trade or business Is not Subject to the
<br />wRhholding tax on foreign patters' share of ~1ct ' ly connoted Income, and
<br />4. CWW that FATCA cod*) entered on this form (if any) indicating that you are
<br />exempt from the FATCA reporting, Is correct. See MW Is FATCA reporfYay9 on
<br />page 2 for further information.
<br />Cat No. 10231X Form W-9 (Rev. 12-2014)
<br />
|