Tax Government Form

TAX GOVERNMENT FORM

Taxpayer Information

Taxpayer Name:

Requester's Name / Payer (if applicable):

Entity Type / Classification

Select entity type (check one): Individual / Sole Proprietor C Corporation S Corporation Partnership Trust / Estate LLC Other

Taxpayer Identification Number (TIN)

Provide the taxpayer identification number used for reporting. Enter either Social Security Number OR Employer Identification Number; do not enter both.

Social Security Number:

Employer Identification Number:

Certification and Declaration

Under penalties of perjury, I certify that the statements made on this form are true, correct, and complete. I understand that intentional false statements or omissions may be punishable by fines or imprisonment under applicable law.

1. The taxpayer identification number provided on this form is correct to the best of my knowledge. If a number has not yet been issued, I have indicated that status herein and will supply the number when available.

2. I certify that I am not subject to backup withholding due to failure to report interest and dividends, unless I have crossed the box below indicating that I am subject to backup withholding because I have been notified that I am subject to backup withholding for failure to report all interest or dividends.

Subject to backup withholding: Yes

3. I certify that I am a U.S. person (including a U.S. resident alien). For entities, I certify that the entity is organized under U.S. law or otherwise treated as a U.S. person for tax purposes.

4. I will notify the payer within 30 days if any information provided on this form becomes incorrect or incomplete, including a change in name, address, or taxpayer identification number.

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