HomeMy WebLinkAboutA003 - Request for Taxpayer Identification Number and Certification - Clinic Building Company Form 'M ' Request for 'taxpayer Give Form to the
(Rev.August o T20 Identification Number and Certification requester.Do not
Department of the Treasury Send to the IRS.
Internal Revenue Service
Name(as shown on your' come tax return)
C%i Business name/disregarded entity name,if fferent from above
a)
M
m
a Check appropriate box for federal tax classification: Exemptions(see instructions):
L
❑Individual/sole proprietor C Corporation
p p � p ❑ S Corporation ❑ Partnership ❑TrusVestate
d c
0 0 Exempt payee code(if any)
u ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)► Exemption from FATCA reporting
02
c H code(if any)
.0 ❑ Other(see instructions)►
u
Address(number,street,and apt.or suite o.) Requester's name and address(optional)
G
City,sta ,and ZIP code
List account number(s)bere(optional)
Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line Social security number
to avoid backup withholding.For individuals,this is your social security number pas However,fora _m _
resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN on page 3.
Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose Employer identification number
number to enter.
Certification
Under penalties of perjury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and
2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding,and
3. 1 am a U.S.citizen or other U.S.person(defined below),and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
instructions on page 3.
Sign Signature of
Here U.S.person No- Date► - f' /
General Instructl�na withholding tax on foreign partners'share of effectively connected income,and
4.Certify that FATCA code(s)entered on this form(if any)indicating that you are
Section references are to the Internal Revenue Code unless otherwise noted, exempt from the FATCA reporting,is correct.
Future developments.The IRS has created a page on IRS.gov for information Note.If you are a U.S.person and a requester gives you a form other than Form
about Form W-9,at wwwJrs.gov/w9.Information about any future developments W-9 to request your TIN,you must use the requester's form if it is substantially
affecting Form W-9(such as legislation enacted after we release it)will be posted similar to this Form W-9.
on that page.
Definition of a U.S.person.For federal tax purposes,you are considered a U.S.
Purpose of Form person if you are:
A person who is required to file an information return with the IRS must obtain your -An Individual who is a U.S.citizen or U.S.resident alien,
correct taxpayer identification number(TIN)to report,for example,income paid to •A partnership,corporation,company,or association created or organized in the
you,payments made to you in settlement of payment card and third party network United States or under the laws of the United States,
transactions,real estate transactions,mortgage interest you paid,acquisition or .An estate(other than a foreign estate),or
abandonment of secured property,cancellation of debt,or contributions you made
to an IRA. •A domestic trust(as defined in Regulations section 301.7701-7).
Use Form W-9 only if you are a U.S.person(including a resident alien),to Special rules for partnerships.Partnerships that conduct a trade or business in
provide your correct TIN to the person requesting it(the requester)and,when the United States are generally required to pay a withholding tax under section
applicable,to: 1446 on any foreign partners'share of effectively connected taxable income from
1.Certify that the TIN you are giving is correct(or you are walling for a number such business.Further,in certain cases where a Form W-9 has not been received,
the rules under.sectioh 1446 require a partnership to presume that a partner is a
to be issued), foreign person,and pay the section 1446 withholding tax.Therefore,if you are a
2.Certify that you are not subject to backup withholding,or U.S.person that is a partner in a partnership conducting a trade or business in the
3.Claim exemption from backup withholding if you are a U.S.exempt payee.If United States,provide Form W-9 to the partnership to establish your U.S.status
applicable,you are also certifying that as a U.S.person,your allocable share of and avoid section 1446 withholding on your share of partnership income.
any partnership income from a U.S.trade or business is not subject to the
Cat.No.10231X Form W-9(Rev.8-2013)