Rev January 2003
Request for Taxpayer
Identification Number and Certification
Return Form to Requester
Business Name (If different from above)
Corporation, Partnership, Other
(Street & number, P.O. Box or Route number)
name and address:
1323 Vista Del
San Antonio, TX
City, State, ZIP
Taxpayer Identification Number (TIN)
your TIN in the appropriate box. For individuals, this is your
social security number (SSN).
For other entities, it is your employer identification number (EIN).
Employer identification number Note: If the account is in more
than one name, see the chart on page 4 for guidelines on whose
number to enter.
Social Security #
Employer ID #
number shown on this form is my correct taxpayer identification
number (or I am waiting for a number to be issued to me), and
I 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
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.
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. Under
penalties of perjury, I certify that:
am a U.S. person (including a U.S. resident alien).
Use Form W-9
only if you are a U.S. person (including a resident alien), to provide
your correct TIN to the person requesting it (the requester) and, when
Certify that the
TIN you are giving is correct (or you are waiting for a number to be
Certify that you
are not subject to backup withholding, or
from backup withholding if you are a U.S. exempt payee.
are a foreign person, use the appropriate Form W-8 (see Pub. 515,
Withholding of Tax on Nonresident Aliens and Foreign Entities). A
person who is required to file an information return with the IRS,
must obtain your correct taxpayer identification number (TIN) to
report, for example, income paid to you, real estate transactions,
mortgage interest you paid, acquisition or abandonment of secured
property, cancellation of debt, or contributions you made to an IRA.
Note: If a requester gives you a form other than Form W-9 to
request your TIN, you must use the requester’s form if it is
substantially similar to this Form W-9.
who becomes a resident alien.
Generally, only a
nonresident alien individual may use the terms of a tax treaty to
reduce or eliminate U.S. tax on certain types of income. However, most
tax treaties contain a provision known as a "saving clause."
Exceptions specified in the saving clause may permit an exemption from
tax to continue for certain types of income even after the recipient
has otherwise become a U.S. resident alien for tax purposes. If you
are a U.S. resident alien who is relying on an exception contained in
the saving clause of a tax treaty to claim an exemption from U.S. tax
on certain types of income, you must attach a statement that specifies
the following five items:
The treaty country.
Generally, this must be the same treaty under which you claimed
exemption from tax as a nonresident alien.
The treaty article
addressing the income.
The article number
(or location) in the tax treaty that contains the saving clause and
The type and amount
of income that qualifies for the exemption from tax.
Sufficient facts to
justify the exemption from tax under the terms of the treaty article.
Form W-9 (Rev 1-2003)