Tax Reporting Checklist

Tax Reporting Checklist

Taxpayer Identification

Employer identification number or social security number (enter one): SSN   EIN

Entity Type (select all that apply)

Individual / Sole Proprietor C Corporation S Corporation Partnership Trust / Estate Limited liability company (LLC) Other — specify below

Documentation Received

Indicate which documentation has been provided and retained in the tax file for reporting determination.

Form W-9 (Request for Taxpayer Identification Number) Completed substitute W-9 or equivalent certification Foreign status documentation provided (retained per policy) Other documentation — describe below

Backup Withholding and Reporting Status

Is the payee currently subject to backup withholding?   Yes   No

Is the payee exempt from FATCA reporting?   Yes   No

Reporting Details

Reporting period: Tax year .

Certification

By signing below, the taxpayer certifies under penalties of perjury that the information provided on this checklist and any attached documentation is true, correct and complete to the best of the signer's knowledge. The signer further certifies the following:

1. The taxpayer identification number provided above is the correct taxpayer identification number of the payee.

2. The taxpayer is not subject to backup withholding due to failure to report interest or dividends unless indicated on this form.

3. The taxpayer is a U.S. person for U.S. federal tax purposes unless foreign status documentation has been provided and retained.

4. The documentation retained with this checklist is sufficient to determine withholding and reporting obligations and will be retained in accordance with recordkeeping requirements.

5. The signer agrees to notify the requester within 30 days of any change in circumstances that would cause any certification provided herein to become incorrect.

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