CONTINGENCY AWARDS PROGRAM OFFICAL REQUEST FORM This form must be filled out completely. One event per form, please. W-9 Tax Form – A W-9 Tax Form must be on file for contingency awards to be paid. A new W-9 form must be submitted only if you Official Race Results - A copy of the official race results must be change your address. The Social Security or Tax ID entered on this included. Must show drivers name, make/model of vehicle, club, request form must match the number on the W-9 we have on file. class, and date of event. (MyLaps results are not acceptable). Please allow 6-8 weeks for payment processing. Color photo Required - Your first contingency request each year must be accompanied by current color photos of your race car clearly showing proper placement of Mazda and Mazdaspeed decal place- ment. Mazda/Mazdaspeed Logo Decal Requirement – To be eligible for Open Wheel & Sports Racers (No kit part number) Rules Mazda Contingency Award Program the following decals must be placed on Mazda race vehicle: 1. Mazda logo under brand symbol vertical logo (Winged-M) (part #0000-10-VM16-XX*) on front nose. Stock/production bodywork - Order decal set K-DECL-XX-WM1* for all required items. 2. Mazda logo on both sides of engine cover (16” length) (part number 0000-10-0016-XX*) 1. Mazda logo – 22” length decal on both rear fenders above wheel opening (White, black, silver or blue only) 3. Mazda Patch —5” Mazda patch required on front of driver’s suit (pocket area) for all classes that require a driver’s suit. (part number 2. MAZDASPEED logo -26” length decal on front nose or foremost 0000-10-PTCH-05) part of hood (White, black, silver or blue only) Decals may be ordered using the Mazdaspeed website or by calling 3. Mazda Patch —5” Mazda patch required on front of driver’s suit 800-435-2508. (pocket area) for all classes that require a driver’s suit. *For decals and kits above, replace XX in part number with BL for Blue, BK for Black, SL for Silver, and WH for White PLEASE FILL OUT ALL SECTIONS COMPLETELY Driver Information Date Team Support Number Daytime Phone Driver’s Name Evening Phone Social Security Number OR Tax ID Number Mailing Address City State Zip Check here if address has changed. E-mail Address Race Event Event Date Race Information Mail To: Event Location (Track) Class Model Year Finishing Position Award Amount The first request of the year MUST include a completed W-9 form AND a current color photo of your race vehicle showing the proper placement of the required Mazda decals. MAZDASPEED MOTORSPORTS Attn: Contingency Requests Please mail form to: 1421 Reynolds Avenue Irvine, CA 92614 800-435-2508 2008 Contingency Awards Program Payout Schedule Program Rules - - Mazda Contingency Awards are available to competitors racing a Mazda production vehicle, Mazda based silhouette race vehicle or Mazda- powered open-wheel or sports racer purpose-built race vehicle. - All payout amounts listed require a minimum number of competitors in the class. To be eligible for the amounts listed within this schedule competitor must finish ahead of at least two (2) other competitors in their class. If the Mazda competitor finishes ahead of only one (1) other driver in their class the amount listed is reduced by 25%. No award payout will be made if Mazda competitor does not finish ahead of at least one (1) other class competitor. - To be eligible for year-end (championship) points payout the competitor must have raced a Mazda in every event during the season. Claiming Contingency Award Funds - - To be eligible for the Mazda contingency award program Mazda competitiors must be a Mazda Team Support member in good standing. - A separate Mazda Contingency Award Request Form must be completed and submitted for each event. - Each request form submitted must be accompanied by official (final) event results. Official race results must show the event name and date, driver's finishing position within class and the make/model of vehicle raced. (Note: Results from www.MyLaps.com website will not be accepted since they do not show the vehicle make/model information) - A current color photograph(s) showing your race vehicle and the proper placement of Mazda and Mazdaspeed logo decals must accompany with your first contingency request each season. - A W-9 Tax Form must be on file for a contingency request to be processed and paid. If you submitted a W-9 Tax Form in 2007 you do not need to resubmit another form unless your address has changed. A W-9 Tax Form can be downloaded along with the Mazda Contingency Request Form at www.MazdaMotorsports.com under the Contingency Info tab on the front page. - Contingency Request Forms, race results and photos must be mailed to the address on the request form. Faxed copies will not be accepted. Mazda reserves the right to change, modify or cancel any contingency award payouts listed. Club Racing SCCA NATIONAL CLUB RACING GT GT1, GT2, GT3 & GTL SPORTS RACER CSR & DSR FORMULA MAZDA 1st Place $500 1st Place $500 No contingency payout is available per event; 2nd Place $300 2nd Place $300 payout is available for SCCA Runoffs and 3rd Place $150 3rd Place $150 June Sprints. No tow fund is available for Divisional Divisional Runoffs. Championship $1,000 Championship $1,000 Divisional Championship $500 PRODUCTION & PREPARED SPEC MIATA FORMULA E EP, FP & BP & DP Contingency also available for SCCA Runoffs No contingency payout is available per event; 1st Place $500 and June Sprints. No tow fund is available for payout is available for SCCA Runoffs and 2nd Place $300 Runoffs. June Sprints. No tow fund is available for 3rd Place $150 1st Place $250 Runoffs. Divisional 2nd Place $125 Divisional Championship $1,000 Divisional Championship $500 Championship $500 SHOWROOM STOCK & TOURING FORMULA ATLANTIC JUNE SPRINTS Road America Mazda offers the following contingency payout for all SSB, SSC & T2, T3 1st Place $500 classes including Spec Miata, Formula Mazda and 1st Place $500 2nd Place $300 Formula E at Road America's June Sprints event: 2nd Place $300 3rd Place $150 3rd Place $150 Divisional 1st Place $1,000 Divisional Championship $1,000 2nd Place $700 Championship $1,000 3rd Place $400 SCCA NATIONAL RUNOFFS SCCA RUNOFFS TOW FUND Runoffs Tow Fund Payout: 1-200 miles - $0 201-400 miles - $50 All Classes All Classes, except SM, FE AND FM 1st Place $5,000 A Runoffs Tow Fund is available to competitors that finish 401-600 miles - $100 601-800 miles - $200 in the top 3 positions in their division's final points 2nd Place $2,500 801-1000 miles - $300 1001-1200 miles - $400 standings. Payout is based solely on data from SCCA 3rd Place $1,250 showing mileage from residence (on record with SCCA) 1201-1400 miles - $500 1401 + miles - $600 zip code to Heartland Park Topeka. Requesting Runoffs Tow Fund or Divisional Championship Contingency Awards Complete a contingency request form with "Runoffs Tow Fund" or "Divisional Championship" entered as the event description. A copy of the final championship points standings for your division must accompany your request. NASA (National Auto Sport Association) Regional Championship (Year-end Points) All Classes (except TT) 1st Place $1,000 +$200 (*NASA Championship bonus) 2nd Place $750 + $200 (*NASA Championship bonus) 3rd Place $500 + $200 (*NASA Championship bonus) 4th Place $250 5th Place $150 * Mazda drivers who finish 1st, 2nd or 3rd in Regional Championship points are eligible to earn an additional $200 if they participate in the NASA Championship event at Mid-Ohio. To be eligible, driver must have earned all season points in a Mazda and they must be compete in the same class they earned their points. NASA Championships (Mid-Ohio) All Classes except TT) 1st Place $4,500 2nd Place $2,000 3rd Place $1,000 4th Place $750 5th Place $500 All TT Classes 1st Place $500 ARRC (American Road Race of Champions) Road Atlanta All Classes / All Events 1st Place $500 2nd Place $300 3rd Place $150 SOLO SCCA PRO SOLO / SOLO NATIONAL TOUR PRO SOLO PRO SOLO Class Championship SOLO NATIONAL TOUR 1st Place $200 1st Place $1,000 1st Place $200 2nd Place $100 2nd Place $500 2nd Place $100 3rd Place $50 3rd Place $250 3rd Place $50 PRO SOLO CHALLENGE (Open & Ladies) PRO SOLO Championship/Challenge SOLO National Championship 1st Place $500 1st Place $1,500 1st Place $800 2nd Place $250 2nd Place $750 2nd Place $400 3rd Place $125 3rd Place $325 3rd Place $200 Pro Racing American Le Mans Series P2 CLASS P2 CLASS (Sebring & Petit Le Mans) P2 - Manufacturer's Championship 1st Place $8,000 1st Place $10,000 $25,000 2nd Place $5,000 2nd Place $6,000 Payout to be determined based on 3rd Place $3,000 3rd Place $4,000 number of Mazda drivers finishing in top 5 4th - 6th (if no Mazda finishers 1st - 3rd) $1,500 4th - 6th (if no Mazda finishers 1st - 3rd) $2,000 positions within Driver's Points Championship Grand-Am Road Racing Series Rolex Sports Car Series GT Class GT - 24 Hours of Daytona GT - Manufacturer’s Championship 1st Place $8,000 1st Place $10,000 $25,000 2nd Place $5,000 2nd Place $5,000 Payout to be determined based on 3rd Place $3,000 3rd Place $2,500 number of Mazda drivers finishing in top 5 4th - 6th (if no Mazda finishers 1thru 3) $1,500 4th - 6th (if no Mazda finishers 1 thru 3) $2,000 positions within Driver's Points Championship Koni Challenge Series ST ST - Manufacturer’s Championship 1st Place $4,000 $14,000 2nd Place $2,000 Payout to be determined based on 3rd Place $1,000 number of Mazda drivers finishing in top 5 4th - 6th (if no Mazda finishers 1thru 3) $750 positions within Driver's Points Championship IMSA Lites L3 Class Year-End Points Champion 1st Place $5,000 All contingency award payments processed by IMSA Mazda MX-5 Cup Event Payout Year-End Points Championship 1st Place $4,500 11th Place $ 450 1st Place $7,500 2nd Place $3,000 12th Place $ 425 2nd Place $6,000 3rd Place $2,000 13th Place $ 400 3rd Place $5,000 4th Place $1,000 14th Place $ 375 4th Place $4,500 5th Place $900 15th Place $ 350 5th Place $4,000 6th Place $800 16th Place $ 325 6th Place $3,500 7th Place $700 17th Place $ 300 7th Place $3,000 8th Place $600 18th Place $ 275 8th Place $2,500 9th Place $500 19th Place $ 250 9th Place $2,000 10th Place $475 20th Place $ 225 10th Place $1,500 All contingency award payments processed by SCCA Pro Racing NASA Pro Racing U.S. Touring Car 1st Place $2,000 2nd Place $1,000 3rd Place $500 SCCA SPEED World Challenge Touring Car Manufacturer’s Championship 1st Place $10,000 9th Place $1,750 $25,000 2nd Place $6,000 10th Place $1,500 Payout to be determined based on 3rd Place $4,000 11th Place $1,000 number of Mazda drivers finishing in top 5 4th Place $3,500 12th Place $1,000 positions within Driver's Points Championship 5th Place $3,000 13th Place $1,000 6th Place $2,500 14th Place $1,000 7th Place $2,250 15th Place $1,000 8th Place $2,000 Eligible Model: Mazda6 (Touring) Import Drag Racing NOPI BOTI (Battle of the Imports) All Pro Classes All Pro Classes 1st Place $500 1st Place $500 2nd Place $300 2nd Place $300 Class Championship $2,000 Class Championship $2,000 Drifting Formula Drift 1st Place $400 2nd Place $200 Rally MAX Attack, NASA US Rally Championships and Rally America Events 2WD - Overall* 2WD - Overall (Year-end points)* 1st Place $1,500 1st Place $3,000 2nd Place $750 2nd Place $1,500 3rd Place $500 3rd Place $1,000 * CURRENT MODELS ONLY (MAZDA3, MAZDA6, RX-8) - AWARD FOR OTHER MAZDA MODELS IS 25% OF AMOUNTS NOTED ABOVE Track Events Redline Time Attack Team Championship (Per Division) 1st Mazda Finisher $500 2nd Mazda Finisher $300 3rd Mazda Finisher $150 Mazda reserves the right to change, modify or cancel any contingency award payouts listed. Form (Rev. October 2007) W-9 Request for Taxpayer Give form to the requester. Do not Department of the Treasury Identification Number and Certification send to the IRS. Internal Revenue Service Name (as shown on your income tax return) See Specific Instructions on page 2. Business name, if different from above Print or type Check appropriate box: Individual/Sole proprietor Corporation Partnership Exempt Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) payee Other (see instructions) Address (number, street, and apt. or suite no.) Requester’s name and address (optional) MAZDASPEED MOTORSPORTS City, state, and ZIP code CONTINGENCY REQUESTS 1421 REYNOLDS AVE, IRVINE CA 92614 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid Social security number backup withholding. For individuals, this is your social security number (SSN). However, for a 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. or 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. Part II 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. 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 3. I am a U.S. citizen or other U.S. person (defined below). 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 4. Sign Signature of Here U.S. person Date General Instructions Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: Section references are to the Internal Revenue Code unless otherwise noted. ● An individual who is a U.S. citizen or U.S. resident alien, ● A partnership, corporation, company, or association created or Purpose of Form organized in the United States or under the laws of the United A person who is required to file an information return with the States, IRS must obtain your correct taxpayer identification number (TIN) ● An estate (other than a foreign estate), or to report, for example, income paid to you, real estate ● A domestic trust (as defined in Regulations section transactions, mortgage interest you paid, acquisition or 301.7701-7). abandonment of secured property, cancellation of debt, or Special rules for partnerships. Partnerships that conduct a contributions you made to an IRA. trade or business in the United States are generally required to Use Form W-9 only if you are a U.S. person (including a pay a withholding tax on any foreign partners’ share of income resident alien), to provide your correct TIN to the person from such business. Further, in certain cases where a Form W-9 requesting it (the requester) and, when applicable, to: has not been received, a partnership is required to presume that 1. Certify that the TIN you are giving is correct (or you are a partner is a foreign person, and pay the withholding tax. waiting for a number to be issued), Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, 2. Certify that you are not subject to backup withholding, or provide Form W-9 to the partnership to establish your U.S. 3. Claim exemption from backup withholding if you are a U.S. status and avoid withholding on your share of partnership exempt payee. If applicable, you are also certifying that as a income. U.S. person, your allocable share of any partnership income from The person who gives Form W-9 to the partnership for a U.S. trade or business is not subject to the withholding tax on purposes of establishing its U.S. status and avoiding withholding foreign partners’ share of effectively connected income. on its allocable share of net income from the partnership Note. If a requester gives you a form other than Form W-9 to conducting a trade or business in the United States is in the request your TIN, you must use the requester’s form if it is following cases: substantially similar to this Form W-9. ● The U.S. owner of a disregarded entity and not the entity, Cat. No. 10231X Form W-9 (Rev. 10-2007) Form W-9 (Rev. 10-2007) Page 2 ● The U.S. grantor or other owner of a grantor trust and not the 4. The IRS tells you that you are subject to backup trust, and withholding because you did not report all your interest and ● The U.S. trust (other than a grantor trust) and not the dividends on your tax return (for reportable interest and beneficiaries of the trust. dividends only), or Foreign person. If you are a foreign person, do not use Form 5. You do not certify to the requester that you are not subject W-9. Instead, use the appropriate Form W-8 (see Publication to backup withholding under 4 above (for reportable interest and 515, Withholding of Tax on Nonresident Aliens and Foreign dividend accounts opened after 1983 only). Entities). Certain payees and payments are exempt from backup withholding. See the instructions below and the separate Nonresident alien who becomes a resident alien. Generally, Instructions for the Requester of Form W-9. 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. Also see Special rules for partnerships on page 1. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may Penalties permit an exemption from tax to continue for certain types of Failure to furnish TIN. If you fail to furnish your correct TIN to a income even after the payee has otherwise become a U.S. requester, you are subject to a penalty of $50 for each such resident alien for tax purposes. failure unless your failure is due to reasonable cause and not to If you are a U.S. resident alien who is relying on an exception willful neglect. contained in the saving clause of a tax treaty to claim an Civil penalty for false information with respect to exemption from U.S. tax on certain types of income, you must withholding. If you make a false statement with no reasonable attach a statement to Form W-9 that specifies the following five basis that results in no backup withholding, you are subject to a items: $500 penalty. 1. The treaty country. Generally, this must be the same treaty Criminal penalty for falsifying information. Willfully falsifying under which you claimed exemption from tax as a nonresident certifications or affirmations may subject you to criminal alien. penalties including fines and/or imprisonment. 2. The treaty article addressing the income. Misuse of TINs. If the requester discloses or uses TINs in 3. The article number (or location) in the tax treaty that violation of federal law, the requester may be subject to civil and contains the saving clause and its exceptions. criminal penalties. 4. The type and amount of income that qualifies for the exemption from tax. Specific Instructions 5. Sufficient facts to justify the exemption from tax under the Name terms of the treaty article. If you are an individual, you must generally enter the name Example. Article 20 of the U.S.-China income tax treaty allows shown on your income tax return. However, if you have changed an exemption from tax for scholarship income received by a your last name, for instance, due to marriage without informing Chinese student temporarily present in the United States. Under the Social Security Administration of the name change, enter U.S. law, this student will become a resident alien for tax your first name, the last name shown on your social security purposes if his or her stay in the United States exceeds 5 card, and your new last name. calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of If the account is in joint names, list first, and then circle, the Article 20 to continue to apply even after the Chinese student name of the person or entity whose number you entered in Part I becomes a resident alien of the United States. A Chinese of the form. student who qualifies for this exception (under paragraph 2 of Sole proprietor. Enter your individual name as shown on your the first protocol) and is relying on this exception to claim an income tax return on the “Name” line. You may enter your exemption from tax on his or her scholarship or fellowship business, trade, or “doing business as (DBA)” name on the income would attach to Form W-9 a statement that includes the “Business name” line. information described above to support that exemption. Limited liability company (LLC). Check the “Limited liability If you are a nonresident alien or a foreign entity not subject to company” box only and enter the appropriate code for the tax backup withholding, give the requester the appropriate classification (“D” for disregarded entity, “C” for corporation, “P” completed Form W-8. for partnership) in the space provided. What is backup withholding? Persons making certain payments For a single-member LLC (including a foreign LLC with a to you must under certain conditions withhold and pay to the domestic owner) that is disregarded as an entity separate from IRS 28% of such payments. This is called “backup withholding.” its owner under Regulations section 301.7701-3, enter the Payments that may be subject to backup withholding include owner’s name on the “Name” line. Enter the LLC’s name on the interest, tax-exempt interest, dividends, broker and barter “Business name” line. exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate For an LLC classified as a partnership or a corporation, enter transactions are not subject to backup withholding. the LLC’s name on the “Name” line and any business, trade, or DBA name on the “Business name” line. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the Other entities. Enter your business name as shown on required proper certifications, and report all your taxable interest and federal tax documents on the “Name” line. This name should dividends on your tax return. match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA Payments you receive will be subject to backup name on the “Business name” line. withholding if: Note. You are requested to check the appropriate box for your 1. You do not furnish your TIN to the requester, status (individual/sole proprietor, corporation, etc.). 2. You do not certify your TIN when required (see the Part II Exempt Payee instructions on page 3 for details), 3. The IRS tells the requester that you furnished an incorrect If you are exempt from backup withholding, enter your name as TIN, described above and check the appropriate box for your status, then check the “Exempt payee” box in the line following the business name, sign and date the form. Form W-9 (Rev. 10-2007) Page 3 Generally, individuals (including sole proprietors) are not exempt Part I. Taxpayer Identification from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. Number (TIN) Note. If you are exempt from backup withholding, you should Enter your TIN in the appropriate box. If you are a resident still complete this form to avoid possible erroneous backup alien and you do not have and are not eligible to get an SSN, withholding. your TIN is your IRS individual taxpayer identification number The following payees are exempt from backup withholding: (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below. 1. An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account If you are a sole proprietor and you have an EIN, you may satisfies the requirements of section 401(f)(2), enter either your SSN or EIN. However, the IRS prefers that you use your SSN. 2. The United States or any of its agencies or If you are a single-member LLC that is disregarded as an instrumentalities, entity separate from its owner (see Limited liability company 3. A state, the District of Columbia, a possession of the United (LLC) on page 2), enter the owner’s SSN (or EIN, if the owner States, or any of their political subdivisions or instrumentalities, has one). Do not enter the disregarded entity’s EIN. If the LLC is 4. A foreign government or any of its political subdivisions, classified as a corporation or partnership, enter the entity’s EIN. agencies, or instrumentalities, or Note. See the chart on page 4 for further clarification of name 5. An international organization or any of its agencies or and TIN combinations. instrumentalities. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application Other payees that may be exempt from backup withholding for a Social Security Card, from your local Social Security include: Administration office or get this form online at www.ssa.gov. You 6. A corporation, may also get this form by calling 1-800-772-1213. Use Form 7. A foreign central bank of issue, W-7, Application for IRS Individual Taxpayer Identification 8. A dealer in securities or commodities required to register in Number, to apply for an ITIN, or Form SS-4, Application for the United States, the District of Columbia, or a possession of Employer Identification Number, to apply for an EIN. You can the United States, apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification 9. A futures commission merchant registered with the Number (EIN) under Starting a Business. You can get Forms W-7 Commodity Futures Trading Commission, and SS-4 from the IRS by visiting www.irs.gov or by calling 10. A real estate investment trust, 1-800-TAX-FORM (1-800-829-3676). 11. An entity registered at all times during the tax year under If you are asked to complete Form W-9 but do not have a TIN, the Investment Company Act of 1940, write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend 12. A common trust fund operated by a bank under section payments, and certain payments made with respect to readily 584(a), tradable instruments, generally you will have 60 days to get a 13. A financial institution, TIN and give it to the requester before you are subject to backup 14. A middleman known in the investment community as a withholding on payments. The 60-day rule does not apply to nominee or custodian, or other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to 15. A trust exempt from tax under section 664 or described in the requester. section 4947. Note. Entering “Applied For” means that you have already The chart below shows types of payments that may be applied for a TIN or that you intend to apply for one soon. exempt from backup withholding. The chart applies to the Caution: A disregarded domestic entity that has a foreign owner exempt payees listed above, 1 through 15. must use the appropriate Form W-8. IF the payment is for . . . THEN the payment is exempt Part II. Certification for . . . To establish to the withholding agent that you are a U.S. person, Interest and dividend payments All exempt payees except or resident alien, sign Form W-9. You may be requested to sign for 9 by the withholding agent even if items 1, 4, and 5 below indicate Broker transactions Exempt payees 1 through 13. otherwise. Also, a person registered under For a joint account, only the person whose TIN is shown in the Investment Advisers Act of Part I should sign (when required). Exempt payees, see Exempt 1940 who regularly acts as a Payee on page 2. broker Signature requirements. Complete the certification as indicated Barter exchange transactions Exempt payees 1 through 5 in 1 through 5 below. and patronage dividends 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active Payments over $600 required Generally, exempt payees 2 during 1983. You must give your correct TIN, but you do not to be reported and direct 1 through 7 have to sign the certification. 1 sales over $5,000 2. Interest, dividend, broker, and barter exchange 1 accounts opened after 1983 and broker accounts considered See Form 1099-MISC, Miscellaneous Income, and its instructions. 2 inactive during 1983. You must sign the certification or backup However, the following payments made to a corporation (including gross proceeds paid to an attorney under section 6045(f), even if the attorney is a withholding will apply. If you are subject to backup withholding corporation) and reportable on Form 1099-MISC are not exempt from and you are merely providing your correct TIN to the requester, backup withholding: medical and health care payments, attorneys’ fees, and you must cross out item 2 in the certification before signing the payments for services paid by a federal executive agency. form. Form W-9 (Rev. 10-2007) Page 4 3. Real estate transactions. You must sign the certification. Secure Your Tax Records from Identity Theft You may cross out item 2 of the certification. Identity theft occurs when someone uses your personal 4. Other payments. You must give your correct TIN, but you information such as your name, social security number (SSN), or do not have to sign the certification unless you have been other identifying information, without your permission, to commit notified that you have previously given an incorrect TIN. “Other fraud or other crimes. An identity thief may use your SSN to get payments” include payments made in the course of the a job or may file a tax return using your SSN to receive a refund. requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services To reduce your risk: (including payments to corporations), payments to a ● Protect your SSN, nonemployee for services, payments to certain fishing boat crew ● Ensure your employer is protecting your SSN, and members and fishermen, and gross proceeds paid to attorneys ● Be careful when choosing a tax preparer. (including payments to corporations). Call the IRS at 1-800-829-1040 if you think your identity has 5. Mortgage interest paid by you, acquisition or been used inappropriately for tax purposes. abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Victims of identity theft who are experiencing economic harm Coverdell ESA, Archer MSA or HSA contributions or or a system problem, or are seeking help in resolving tax distributions, and pension distributions. You must give your problems that have not been resolved through normal channels, correct TIN, but you do not have to sign the certification. 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. What Name and Number To Give the Requester Protect yourself from suspicious emails or phishing For this type of account: Give name and SSN of: schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and 1. Individual The individual websites. The most common act is sending an email to a user 2. Two or more individuals (joint The actual owner of the account or, account) if combined funds, the first falsely claiming to be an established legitimate enterprise in an individual on the account 1 attempt to scam the user into surrendering private information 3. Custodian account of a minor The minor 2 that will be used for identity theft. (Uniform Gift to Minors Act) 1 The IRS does not initiate contacts with taxpayers via emails. 4. a. The usual revocable savings The grantor-trustee Also, the IRS does not request personal detailed information trust (grantor is also trustee) through email or ask taxpayers for the PIN numbers, passwords, 1 b. So-called trust account that is The actual owner or similar secret access information for their credit card, bank, or not a legal or valid trust under other financial accounts. state law 5. Sole proprietorship or disregarded The owner 3 If you receive an unsolicited email claiming to be from the IRS, entity owned by an individual forward this message to email@example.com. You may also report Give name and EIN of: misuse of the IRS name, logo, or other IRS personal property to For this type of account: the Treasury Inspector General for Tax Administration at 6. Disregarded entity not owned by an The owner 1-800-366-4484. You can forward suspicious emails to the individual Federal Trade Commission at: firstname.lastname@example.org or contact them at 4 7. A valid trust, estate, or pension trust Legal entity www.consumer.gov/idtheft or 1-877-IDTHEFT(438-4338). 8. Corporate or LLC electing The corporation corporate status on Form 8832 Visit the IRS website at www.irs.gov to learn more about 9. Association, club, religious, The organization identity theft and how to reduce your risk. charitable, educational, or other tax-exempt organization 10. Partnership or multi-member LLC The partnership 11. A broker or registered nominee The broker or nominee 12. Account with the Department of The public entity Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments 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 second 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. 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. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S. possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax 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. Payers must generally withhold 28% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
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