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<br />e Request for Taxpayer e
<br />Identification Number and Certification
<br />
<br />Form W-g
<br />
<br />(RlI'I. December 1988)
<br />Department of the Treasury
<br />Internal Revenue Service
<br />Nilme (If jOint IIiImes, list first ilnd circle the name of the person or entity whose number you enter in Palt I below. See IlIItnIctJOIlI under "Nlm."If YOU' 1lIIlI. his chlnpd.)
<br />J
<br />Ii
<br />
<br />HAR
<br />ii Address (number and street)
<br />i 619 BROWNELL
<br />:
<br />: City, state, and ZIP code
<br />~ LA PORTE, TX 77571
<br />
<br />Tax a er Identification Number
<br />
<br />Enter your taxpayer identification number in
<br />the appropriate box. For individuals and sole
<br />proprietors, this is your social security number.
<br />For other entities, it is your employer
<br />identification number. If you do not have a
<br />number, see How To Obtain a nN, below..
<br />
<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 />
<br />
<br />
<br />(, "
<br />OR
<br />
<br />
<br />Give this form
<br />to the requester. Do
<br />NOT send to IRS.
<br />
<br />Ust account number(s)
<br />here (optional).
<br />
<br />
<br />
<br />For Payees Exempt From
<br />Backup Withholding (See
<br />Instructions)
<br />
<br />Requester's name and address (optional)
<br />
<br />Certlflcatlon.-Under penalties of pe~ury, I certify that:
<br />(I) 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) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by ~e
<br />Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c)
<br />the IRS has notified me that I am no longer subject to backup withholding (does not apply to real estate transactions, mortgage interest
<br />paid, the acquisition or abandonment of secured property, contributions to an individual retirement'arrangement (IRA), and payments
<br />other than interest and dividends).
<br />Certlflcatlon Instructlons.- You must cross out item (2) above if you have been notified by IRS that you are currently subject to backup
<br />withholding because of underreporting interest or dividends on your tax return. (Also see Signing the Certification under Specific
<br />Instructions, on page 2.)
<br />
<br />Please
<br />Sip
<br />Here
<br />
<br />Sllnature.
<br />
<br />
<br />Instructions
<br />
<br />(Section references are to the Internal Revenue
<br />Code.)
<br />
<br />Purpose of Form.-A person who is required to
<br />file an information return with IRS must obtain
<br />your correct taxpayer identification number (TIN)
<br />to report income paid to you. real estate
<br />transactions, mortgage interest you paid, the
<br />acquisition or abandonment of secured property,
<br />or contributions you made to an individual
<br />retirement arrangement (IRA). Use Form W-9 to
<br />furnish your correct TIN to the requester (the
<br />person asking you to furnish your TIN). and. when
<br />applicable. (1) to certify that the TIN you are
<br />furnishing is correct (or that you are waiting for a
<br />number to be issued), (2) to certify that you are
<br />not subject to backup withholding, and (3) to
<br />claim exemption from backup withholding if you
<br />are an exempt payee. Furnishing your correct TIN
<br />and making the appropriate certifications will
<br />prevent certain payments from being subject to
<br />the 2096 baCkup withholding.
<br />
<br />Note: " a requester gives you a form other than
<br />a W.9 to request your nN, you must use the
<br />requester's form.
<br />How To Obtain a TIN.-If you do not have a TIN,
<br />apply for one immediately. To apply, get Form
<br />S5-S. Application for a Social Security Number
<br />Card (for individuals) from your local office of the
<br />Social Security Administration, or Form ~,
<br />Application for Employer Identification Number
<br />(for businesses and all other entities), from your
<br />local Internal Revenue Service office.
<br />
<br />To complete Form W-9 if you do not have a
<br />TIN, write .Applied For" in the space for the TIN
<br />in Part I. sign and date the form, and give it to the
<br />n!lfuester. Generally, you will then have 60 days
<br />to obtain a TIN and furnish it to the requester. If
<br />the requester does not receive your TIN within 60
<br />days. backup withholding, if applicable, will begin
<br />
<br />and continue til you r h your TIN to the
<br />requester. For reporta Ie interest or dividend
<br />payments, the payer must exercise one of the
<br />fallowing options concerning backup withholding
<br />during this 60.day period. Under option (1), a
<br />payer must backup withhold on any withdrawals
<br />you make from your account after 7 business
<br />days after the requester receives this form back
<br />from you. Under option (2), the payer must
<br />backup withhold on any reportable Interest or
<br />dividend payments made to your account,
<br />regardless of whether you make any withdrawals.
<br />The baCkup withholding under option (2) must
<br />begin no later than 7 business days after the
<br />requester receives this form back. Under aptian .
<br />(2) the payer is reqaired to refund the amounts
<br />withheld if your certified TIN is received within
<br />the 6o-day period and you were not subject to
<br />backup withholding during that period.
<br />Note: Writing -Applied For- on the form meanS
<br />that you have already applied for a TIN OR that
<br />you intend to apply for one in the near future.
<br />As soon as you receive your TIN, complete
<br />another Form W.9. include your TIN, sign and
<br />date the form, and give it to the requester.
<br />What Is Backup Wlthholdlngl-Persons making
<br />certain payments to you are required to withhold
<br />and pay to IRS 2096 of such payments under
<br />certain conditions. This is called "backup
<br />withholding." Payments that could be subject to
<br />backup withholding include interest, dividends,
<br />broker and barter exchange transactions. rents.
<br />royalties. nonemployee compensation, and
<br />certain payments from fishing boat operators, but
<br />do not include real estate transactions.
<br />If you give the requester your correct TIN,
<br />make the appropriate certifications, and report all
<br />your taxable interest and dividends on your tax
<br />return, your payments will not be subject to
<br />backup withholding. Payments you receive will be
<br />subject to backup withholding if:
<br />
<br />. Date.
<br />
<br />
<br />(1) You do not furnish your TIN to the
<br />requester. or
<br />(2) IRS notifies the requester that you
<br />furnished an incorrect TIN. or
<br />(3) You are notified by IRS that you are
<br />subject to backup withholding because you failed
<br />to report all your interest and dividends on your
<br />tax return (for interest and dividend accounts
<br />only), or
<br />(4) You fail to certify to the requester that you
<br />are not subject to backup withholding under (3)
<br />above (far interest and dividend accounts opened
<br />after 1983 only). or
<br />(5) You fail to certify your TIN. This applies
<br />only to interest, dividend. broker. or barter
<br />exchange accounts opened after 1983, or broker
<br />accounts considered inactive in 1983.
<br />Far other payments, you are subject to backup
<br />withholding only if (1) or (2) above applies.
<br />Certain payees and payments are exempt from
<br />backup withholding and information reporting.
<br />See Payees and Payments Exempt From Backup
<br />Withholding, below, and Exempt Payees and
<br />Payments under Specific Instructions, on page 2,
<br />if you are an exempt payee.
<br />)Payees and Payments Exempt From Backup
<br />\.. Wlthholdlng.- The following is a list of payees
<br />-exempt from backup withholding and for which
<br />no information reporting is required. For interest
<br />and dividends. all listed payees are exempt
<br />except item (9). Far broker transactions, payees
<br />listed in (1) through (13), and a person registered
<br />under the Investment Advisers Act of 1940 who
<br />regularly acts as a broker are exempt. Payments
<br />subject to reporting under sections 6041 and
<br />6041A are generally exempt from backup
<br />withholding only if made to payees described in
<br />items (1) through (7), except that a corporation
<br />that provides medical and health care services or
<br />bills and collects payments for such services is
<br />not exempt from backup witl!.holding or
<br />
<br />Form W.g (Rev. 12-88)
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