Tax Acknowledgement Form

TAX ACKNOWLEDGEMENT FORM

Taxpayer Information

Entity Type

Indicate the entity type for the tax information provided. Check all that apply:

Individual / Sole Proprietor

C Corporation

S Corporation

Partnership

Trust / Estate

Limited Liability Company (LLC)

Other:

Tax Period

Tax year or tax period for which the acknowledgement applies: Year:   Or Period Start:  End:

Taxpayer Identification Number

Provide either your Social Security Number (SSN) or Employer Identification Number (EIN). Complete only one.

Acknowledgement and Representations

By executing this form, the taxpayer affirms the following representations and acknowledges the stated obligations and potential consequences for inaccurate statements.

1. The taxpayer attests that the Taxpayer Identification Number provided on this form is correct to the best of the taxpayer's knowledge and that such number identifies the taxpayer named above.
2. The taxpayer acknowledges responsibility for the accuracy and completeness of the tax information furnished, and agrees to provide supporting documentation upon reasonable request by the requesting party to substantiate the information provided.
3. The taxpayer acknowledges that intentionally providing false or fraudulent information may subject the taxpayer to administrative or civil penalties, including penalties for perjury where applicable under law.
4. The taxpayer acknowledges and consents that the information on this form may be retained in records and disclosed to other parties as required for tax reporting, withholding determinations, or collection of tax obligations.
5. If the taxpayer is subject to backup withholding or a similar withholding requirement under applicable tax regulations, the taxpayer will promptly notify the requester and provide any documentation necessary to demonstrate exempt status.

Certification (Perjury Statement)

Under penalty of perjury, I certify the following statements are true and correct:

1. The information provided on this form is complete and accurate.
2. I am the individual or an authorized representative of the entity identified on this form and am authorized to disclose the Taxpayer Identification Number and other requested information.
3. I understand that this certification is made for the purpose of establishing the taxpayer's identity and correct taxpayer identification number for tax reporting and withholding purposes.
4. I understand that making a false statement on this form may subject me to penalties under applicable law.

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