Tax Conditions Statement

Tax Conditions Statement

This Tax Conditions Statement documents the taxpayer representations, conditions with respect to tax identification, withholding and reporting obligations, and certifications provided to the payor or reporting agent. The undersigned taxpayer affirms that the information supplied herein is true, correct, and complete, and acknowledges the legal consequences of materially false statements.

Taxpayer Information

Entity Type (check one or more that apply)

Individual / Sole Proprietor C Corporation S Corporation Partnership Trust / Estate LLC Other (describe below)

Taxpayer Identification Number (TIN)

Furnish the appropriate taxpayer identification number. Provide either Social Security Number (SSN) or Employer Identification Number (EIN). Failure to provide a correct TIN may subject payor to withholding and reporting requirements and may result in penalties under applicable law.

Tax Conditions and Representations

1. The taxpayer affirms that the TIN furnished above is the correct taxpayer identification number issued by the appropriate authority, or the taxpayer is awaiting issuance of such number and will furnish it promptly upon receipt.

2. The taxpayer represents that it is a United States person for U.S. federal tax purposes unless an explicit foreign person declaration is attached. For purposes of this Statement, “United States person” means a citizen or resident of the United States, a domestic partnership, a domestic corporation, a domestic estate, or a domestic trust.

3. The taxpayer certifies that it is not currently subject to backup withholding due to failure to report interest or dividends, unless the taxpayer has indicated otherwise by checking the box below.

Subject to backup withholding: Yes No

4. The taxpayer agrees to notify the payor in writing within 30 days of any change in circumstances that would render any representation or certification on this Statement incorrect or incomplete, including a change of name, TIN, address, or entity classification.

5. The taxpayer acknowledges that the payor may rely upon this Statement for purposes of tax withholding and information reporting. The taxpayer agrees to indemnify and hold the payor harmless from any liability, taxes, penalties or interest assessed against the payor that arise from the taxpayer’s failure to provide correct or timely information or from materially false statements herein.

6. The taxpayer authorizes the payor to disclose this Statement and the TIN to taxing authorities or other authorized persons as required by law or regulation.

Certification and Perjury Statement

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

1. The taxpayer identification number shown on this Statement is correct and belongs to the taxpayer identified above, or the taxpayer is waiting for issuance of a number.

2. The taxpayer is not subject to backup withholding due to failure to report interest and dividends, except as indicated on this form.

3. The taxpayer is a United States person (including a U.S. resident alien).

4. I have the legal authority to sign this Statement on behalf of the taxpayer and acknowledge that signing this Statement knowingly making false statements may subject me to civil and criminal penalties under applicable law.

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