page4
Form W-9 (Rev. 12-2011)
Page
4
4. Other payments.
You must give your correct TIN, but you
do not
have to sign the certification unless you have been
notified that you
have previously given an incorrect TIN. “Other
payments” include
payments made in the course of the
requester’s trade or business for
rents, royalties, goods (other
than bills for merchandise), medical and
health care services
(including payments to corporations), payments to
a
nonemployee for services, payments to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified tuition program
payments (under section 529), IRA, Coverdell ESA, Archer MSA or
HSA contributions or distributions, and pension distributions.
You
must give your
correct TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account:
Give name and SSN of:
1. Individual
The individual
2. Two or more individuals (joint
account)
The actual owner of the account or,
if combined funds, the first
individual on the account
1
3. Custodian account of a minor
(Uniform Gift to Minors Act)
The minor
2
4. a. The usual revocable savings
trust (grantor is also trustee)
b. So-called trust account that is
not a legal or valid trust under
state law
The grantor-trustee
1
The actual owner
1
5. Sole proprietorship or disregarded
entity owned by an individual
The owner
3
6. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Regulation section 1.671-4(b)(2)(i)(A))
The grantor*
For this type of account:
Give name and EIN of:
7. Disregarded entity not owned by an
individual
The owner
8. A valid trust, estate, or pension trust
Legal entity
4
9. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
The corporation
10. Association, club, religious,
charitable, educational, or other
tax-exempt organization
The organization
11. Partnership or multi-member LLC
The partnership
12. A broker or registered nominee
The broker or nominee
13. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
The public entity
14. Grantor trust filing under the Form
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulation section 1.671-4(b)(2)(i)(B))
The trust
1
List first and circle the name of the person whose number you furnish. If only one person
on a
joint account has an SSN, that person’s number must be furnished.
2
Circle the minor’s name and furnish the minor’s SSN.
3
You must show your individual name and you may also enter your business or “DBA”
name on
the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you
have one),
but the IRS encourages you to use your SSN.
4
List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN
of the
personal representative or trustee unless the legal entity itself is not designated in
the account
title.) Also see
Special rules for partnerships
on page 1.
*Note.
Grantor also must provide a Form W-9 to trustee of trust.
Note.
If no name is circled when more than one name is listed,
the
number will be considered to be that of the first name listed.
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal information
such as your name, social security number (SSN), or other identifying
information, without your permission, to commit fraud or other crimes.
An identity thief may use your SSN to get a job or may file a tax return
using your SSN to receive a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a
notice from the IRS, respond right away to the name and phone number
printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you
think you are at risk due to a lost or stolen purse or wallet, questionable
credit card activity or credit report, contact the IRS Identity Theft Hotline
at 1-800-908-4490 or submit Form 14039.
For more information, see Publication 4535, Identity Theft Prevention
and Victim Assistance.
Victims of identity theft who are experiencing economic harm or a
system problem, or are seeking help in resolving tax problems that have
not been resolved through normal channels, may be eligible for
Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD
1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of email and
websites designed to
mimic legitimate business emails and
websites. The most common act
is sending an email to a user
falsely claiming to be an established
legitimate enterprise in an
attempt to scam the user into surrendering
private information
that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails. Also, the
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers, passwords, or similar secret access
information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to
phishing@irs.gov.
You may also report misuse
of the IRS name, logo, or other IRS property to the Treasury Inspector
General for Tax Administration at 1-800-366-4484. You can forward
suspicious emails to the Federal Trade Commission at:
spam@uce.gov
or contact them at
www.ftc.gov/idtheft
or 1-877-IDTHEFT
(1-877-438-4338).
Visit IRS.gov
to learn more about identity theft and how to reduce
your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with
the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation
of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS,
reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District
of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies
to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to
file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a
TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.