Tax Compliance Form

Tax Compliance Form

Taxpayer Information

Entity Type

Check the box that best describes the taxpayer's federal tax classification for the period covered by this form. If more than one box applies, check all that apply and provide an explanatory statement in the Remarks section.

Tax Period

Tax year or period covered:    Period start:    Period end:

Taxpayer Identification Number (TIN)

Provide the taxpayer identification number to be used for compliance and reporting. Enter either a Social Security Number (SSN) or an Employer Identification Number (EIN), but not both. If an EIN is provided for an individual, provide an explanation in Remarks.

If the TIN has changed since the last filing or previously submitted information, provide prior TIN:

Declarations

Please indicate the taxpayer's current status with respect to withholding and reporting obligations by checking the applicable boxes below.

Certification (Under Penalties of Perjury)

By signing this document, the taxpayer certifies the statements below. Each numbered statement must be true and accurate to the best of the signer's knowledge.

1. The taxpayer identification number provided on this form is correct and will be used for federal tax reporting and compliance purposes.
2. The taxpayer is the person or entity entitled to the income, and the information furnished herein is provided in good faith and is complete and accurate.
3. The taxpayer is not subject to backup withholding due to failure to report interest and dividend income, unless indicated by checking the backup withholding box above.
4. The taxpayer is a U.S. person (including a U.S. resident alien) for U.S. federal tax purposes, unless otherwise indicated in the Remarks section with supporting explanation.
5. The taxpayer acknowledges that willful falsification of any information on this form may be punishable by fines and/or imprisonment under applicable law.

The undersigned further authorizes the release of the information provided on this form to appropriate tax authorities and payors for the purposes of tax reporting, withholding, and verification of compliance, to the extent permitted by law.

Supporting Documentation

List documents attached to substantiate identification, authority, or TIN changes (for example: certified identification, power of attorney, IRS or equivalent correspondence).

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