Tax Legislation Document

TAX LEGISLATION DOCUMENT

Taxpayer Identification

Entity Type

Select the entity type that accurately describes the taxpayer. Check one or more as applicable.

Individual / Sole Proprietor

C Corporation

S Corporation

Partnership

Trust / Estate

Limited Liability Company (LLC)

Other (specify below)

Taxpayer Identification Number (TIN)

Provide the taxpayer identification number used for federal tax reporting. Enter either Social Security Number (SSN) or Employer Identification Number (EIN). Do not enter both.

Notice / Election Under Applicable Tax Legislation

Use this section to notify a payer or the appropriate authority of an election, claim, or other action under applicable tax legislation. Select the type of notice or election being submitted and provide required particulars. Attach supporting documentation as indicated.

Claim of exemption or exclusion under applicable tax legislation

Election of alternative tax treatment or method of accounting

Request for retroactive or prospective relief under enacted legislation

Notification of legislative change affecting reporting or withholding

Other (explain below)

Supporting Documentation

Indicate whether supporting documentation is attached. Supporting documentation may include legislative citations, schedules, statements, or other evidence relied upon to make this notice or election. Keep copies for your records.

Yes — documentation attached

No — documentation will be furnished upon request

Attestation and Certification

Under penalties of perjury, the undersigned certifies that the following statements are true, correct, and complete to the best of the undersigned's knowledge and belief:

1. The taxpayer identification information provided on this form is complete and accurate.

2. The notice, election, or claim set forth herein is made knowingly and intentionally, and the undersigned has authority to submit this notice or election on behalf of the taxpayer.

3. Any election made by this document is intended to be effective as of the effective date stated above and shall be interpreted in accordance with the applicable provisions of enacted tax legislation and governing administrative rules.

4. The undersigned will retain and, upon request, furnish supporting documentation substantiating the factual and legal bases for this notice, election, or claim.

5. The undersigned understands that making a false statement or submitting false documentation may subject the taxpayer and the signatory to civil and criminal penalties as provided by law.

By signing below, the signatory certifies that they are authorized to sign on behalf of the taxpayer and acknowledges the foregoing attestation.

Authorized Agent (if applicable)

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