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Word Format - Form W-9.doc

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									For m                                            W-9                                                    Request for Taxpayer
                                                                                                                                                                             Give form to the
Subs titute F orm                                                                             Identification Number and Certification                                       reque ster. Do not
State of C ol orado 8- 2007
                                                                                                                                                                             send t o the IRS.
                  See Specific Instructions on page 3.

                                                         Business name, if different from above

                                                         Check appropriate box:
  Print or Type

                                                              Individual/ Sole Proprietor        Corporation   Partnership    Other                      Exempt from backup withholding
                                                         Address (number, street, and apt. or suite no.)                                    Requester:

                                                         City, state, and ZIP code.

                                                         List Account number(s) here (optional)                                                 Phone Number:

Part I                                                      Taxpayer Identificati on Number (TIN)
Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN) However,                                                         Social Security number
for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For
other entities, it is your employer identif ication 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 3 for guidelines on whose                                                                  Employer identification number
number to enter.

Part II                                                     Certification
Under penalties of per jury, I c ertify that:

1. The number s how n on this for m is my corr ect taxpayer identif ication number ( or I am w aiting for a number to be iss ued to me), an d

2. I am not subject to backup w ithholding because . (a) I am ex empt from bac kup w ithholding, or (b) I have not been notif ied by the
   Inter nal Rev enue Serv ice ( IRS) that I am subject to bac kup w ithholding as a r esult of a failure to repor t all interes t or div idends , or
   (c) the IRS has notified me that I am no longer subject to bac kup w ithholding, and

3. I am a U.S. pers on ( inc luding a U.S. r esident alien) .

Certification instructions . You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
w ithholding because you have failed to report all inter est and div idends on your tax retur n. For real estate transactions, item 2 does not apply.
For mortgage inter est paid, acquis ition or abandonment of secured property, cancellation of debt, contributions to an indivi dual retirement
arrangement ( IRA), and gener ally, pay ments other than interest and div idends, you ar e not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 3.)
Sign                                                          Signature o f
Here                                                          U.S. person ►                                                                      Date ►

Minority and Women-ow ned Businesses (M/WBEs) Self Certification (Please check all boxes that apply)

In an effort to track levels of participation by w omen and minorities doing bus iness w ith the State of Colorado, the follow in g infor mation is
requested. Please indicate the appropriate category of ow nership for your company. “ Ow ned” in this context means a bus iness that is at least 51
percent ow ned by an individual(s) w ho also control(s) and operate(s) it. “Control” in this context means exercising th e pow er to make policy
decisions. “ Operate” means actively involved in the day -to-day management. If you business is jointly ow ned by both men and w omen or is a
large publicly held corporation, please check the box labeled “ Not Applicable.”

Gender Inform ation:

□ Female-Ow ned                                                                 □ Male- Ow ned                 □ Not Applicable
Ow ner Ethnicity Inform ation

□ African American                                                              □ Asian/Pacific American       □ White (non- Hispanic)    □ Not Applicable
□ Hispanic American                                                             □ Native A mer ican            □ Other:   _____________________________

Sm all Business Inform ation

Small Business (a business that is organized for profit, is independently ow ned and operated, and has 25 or few er full time e quivalent
□ Yes                                                           □ No
                                                                                                                                                               Page 2

Purpose of Form                                                                                                   requester your correct TIN, make the proper
                                                           Foreign person. If you are a foreign person, do        certifications, and report all your taxable interest
A person w ho is required to file an infor mation          not use For m W-9. Instead, use the appropriate        and dividends on your tax return.
return w ith the IRS, must obtain your correct             For m W-8 (see Publication 515, Withholding of
                                                                                                                  Paym ents you receive w ill be subject to
taxpayer identification number ( TIN) to report, for       Tax on Nonresident Aliens and For eign Entities).
                                                                                                                  backup w ithholding if:
example, income paid to you, real estate                   Nonresident alien w ho becomes a resident                  1. You do not furnish your TIN to the
transactions, mortgage interest you paid,                  alien.                                                 requester,
acquisition or abandonment of secured property,            Generally, only a nonresident alien indiv idual            2. You do not certify your TIN w hen required
cancellation of debt, or contributions you made            may use the ter ms of a tax treaty to reduce or        (see the Part II instructions on page 4 for
to an IRA.                                                 eliminate U.S. tax on certain types of income.         details),
                                                           How ever, most tax treaties contain a provision            3. The IRS tells the requester that you
U.S. person. Use For m W-9 only if you are a
                                                           know n as a “saving clause.” Exceptions specified      furnished an incorrect TIN,
U.S. person (including a resident alien), to
                                                           in the saving clause may per mit an exemption              4. The IRS tells you that you are subject to
provide your correct TIN to the person
                                                           from tax to continue for certain types of income       backup w ithholding because you did not report
requesting it (the requester) and, w hen
                                                           even after the r ecipient has otherw ise become a      all your interest and dividends on your tax return
applicable, to:
   1. Certify that the TIN you are giving is correct       U.S. resident alien for tax purposes.                  (for reportable interest and dividends only), or
(or you are w aiting for a number to be issued),                                                                      5. You do not certify to the requester that you
   2. Certify that you are not subject to backup              If you are a U.S. resident alien w ho is relying    are not subject to backup w ithholding under 4
w ithholding, or                                           on an exception contained in the sav ing c lause       above (for reportable interest and dividend
   3. Claim exemption from backup w ithholding if          of a tax treaty to c laim an exemption from U.S.       accounts opened after 1983 only).
you are a U.S. exempt payee.                               tax on certain types of income, you must attach a          Certain payees and pay ments are exempt
   In 3 above, if applicable, you are also                 statement to For m W-9 that spec ifies the             from bac kup w ithholding. See the instructions
certifying that as a U.S. person, your allocable           follow ing five items:                                 below and the separate Instructions for the
share of any partnership income from a U.S.                   1. The tr eaty country. Generally, this must be     Requester of For m W-9.
trade or business is not subject to the                    the same treaty under w hich you claimed                   Also see Special rules regarding partnerships
w ithholding tax on foreign partners’ share of             exemption from tax as a nonresident alien.             on page 1.
effectively connected income.                                 2. The tr eaty article addressing the income.
                                                              3. The article number (or location) in the tax      Penalties
Note. If a requester gives you a for m other than          treaty that contains the saving clause and its
For m W-9 to request your TIN, you must use the            exceptions.                                            Failure to furnish TIN. If you fail to furnish your
requester’s for m if it is substantially similar to this      4. The type and amount of income that               correct TIN to a requester, you are subject to a
For m W-9.                                                 qualifies for the exemption from tax.                  penalty of $50 for each such failure unless your
   For federal tax purposes, you are cons idered              5. Sufficient facts to justify the exemption from   failure is due to reasonable cause and not to
a person if you are:                                       tax under the ter ms of the treaty article.            w illful neglect.
 An individual w ho is a citizen or resident of the          Example. Article 20 of the U.S.- China income       Civil penalty for false inform ation w ith
   United States,                                          tax treaty allow s an exemption from tax for           respect to w ithholding. If you make a false
 A partnership, corporation, company, or                  scholarship income received by a Chinese               statement w ith no reasonable basis that results
   association created or organized in the United          student temporarily present in the United States.      in no bac kup w ithholding, you are subject to a
   States or under the law s of the United States,         Under U.S. law , this student w ill become a           $500 penalty.
   or                                                      resident alien for tax purposes if his or her stay
 Any estate (other than a foreign estate) or              in the United States exceeds 5 calendar years.         Crim inal penalty for falsifying inform ation.
   trust. See Regulations sections 301.7701-6(a)           How ever, paragraph 2 of the first Protocol to the     Willfully falsifying certifications or affirmations
   and 7(a) for additional infor mation.                   U.S.- China treaty (dated Apr il 30,                   may subject you to criminal penalties including
                                                           1984) allow s the provisions of Article 20 to          fines and/or imprisonment.
Special rules for partnerships. Partnerships               continue to apply even after the Chinese student
that conduct a trade or business in the United                                                                    Misuse of TINs. If the requester discloses or
                                                           becomes a resident alien of the United States. A       uses TINs in violation of federal law , the
States are generally required to pay a
                                                           Chinese student w ho qualifies for this exception      requester may be subject to civil and criminal
w ithholding tax on any foreign partners’ share of
                                                           (under paragraph 2 of the first protocol) and is       penalties.
income from such business. Further, in certain
                                                           relying on this exception to c laim an exemption
cases w here a For m W-9 has not been received,
                                                           from tax on his or her scholarship or fellow ship
a partnership is required to presume that a
                                                           income w ould attach to For m W- 9 a statement         Specific Instructions
partner is a foreign person, and pay the
                                                           that includes the information described above to
w ithholding tax. Therefore, if you are a U.S.
                                                           support that exemption.                                Name
person that is a partner in a partnership
                                                              If you are a nonresident alien or a foreign         If you are an individual, you must generally enter
conducting a trade or business in the United
                                                           entity not subject to bac kup w ithholding, give the   the name show n on your income tax return.
States, provide For m W-9 to the partnership to
                                                           requester the appropr iate completed For m W-8.        How ever, if you have changed your last name,
establish your U.S. status and avoid w ithholding
on your share of partnership income.                       What is backup w ithholding? Persons making            for instance, due to marriage w ithout infor ming
                                                           certain pay ments to you must under certain            the Social Security Administration of the name
   The person w ho gives For m W-9 to the                  conditions w ithhold and pay to the IRS 28% of         change, enter your first name, the last name
partnership for purposes of establishing its U.S.          such pay ments (after December 31, 2002). This         show n on your social security card, and your
status and avoiding w ithholding on its allocable          is called “backup w ithholding.” Pay ments that        new last name.
share of net income from the partnership                                                                              If the account is in joint names, list first, and
                                                           may be subject to backup w ithholding inc lude
conducting a trade or business in the United                                                                      then circle, the name of the person or entity
                                                           interest, dividends, broker and barter exchange
States is in the follow ing cases:                                                                                whose number you entered in Part I of the for m.
                                                           transactions, r ents, royalties, nonemployee pay,
 The U.S. ow ner of a disregarded entity and
                                                           and certain pay ments from fishing boat                Sole proprietor. Enter your individual name as
   not the entity,                                         operators. Real estate transactions are not
 The U.S. grantor or other ow ner of a grantor                                                                   show n on your income tax return on the “ Name”
                                                           subject to bac kup w ithholding.                       line. You may enter your business, trade, or
   trust and not the trust, and                               You w ill not be subject to bac kup w ithholding
 The U.S. trust (other than a grantor trust) and                                                                 “doing business as ( DBA)” name on the
                                                           on pay ments you receive if you give the               “Business name” line.
   not the beneficiar ies of the trust.
                                                                                                                                                                Page 3

Lim ited liability com pany (LLC). If you are a           12. A common trust fund operated by a bank                 get For m SS-5, Application for a Soc ial Secur ity
single- member LLC (including a foreign LLC w ith      under section 584(a),                                         Car d, from your local Social Secur ity
a domestic ow ner) that is disregarded as an              13. A financial institution,                               Administration office or get this for m online at
entity separate from its ow ner under Treasury            14. A middleman know n in the investment          You may also get this
regulations section 301.7701-3, enter the              community as a nominee or custodian, or                       form by calling 1-800-772-1213. Use For m W-7,
ow ner’s name on the “ Name” line. Enter the              15. A trust exempt from tax under section 664              Application for IRS Indiv idual Taxpayer
LLC’s name on the “ Business name” line. Chec k        or described in section 4947.                                 Identification Number, to apply for an ITIN, or
the appropr iate box for your filing status (sole         The chart below show s types of payments that              For m SS-4, Application for Employer
proprietor, corporation, etc.), then check the box     may be exempt from backup w ithholding. The                   Identification Number, to apply for an EIN. You
for “Other” and enter “LLC” in the space               chart applies to the exempt rec ipients listed                can apply for an EIN online by accessing the IRS
provided.                                              above, 1 through 15.                                          website at and c licking
                                                                                                                     on Employer ID Numbers under Related Topics.
Other entities. Enter your bus iness name as
                                                       IF the payment is for THEN the payment is                     You can get For ms W-7 and SS-4 from the IRS
show n on required federal tax documents on the
                                                                                                                     by visiting or by calling 1-800- TAX-
“Name” line. This name should match the name           ...                   exempt
                                                                             for . . .                               FORM (1-800-829-3676).
show n on the charter or other leg al document
                                                                                                                        If you are asked to complete For m W-9 but do
creating the entity. You may enter any business,       Interest and dividend All exempt recipients
                                                                                                                     not have a TIN, w rite “Applied For” in the space
trade, or DBA name on the “Business name”              payments              except for 9
                                                                                                                     for the TIN, sign and date the for m, and give it to
                                                                                                                     the requester. For interest and dividend
Note. You are requested to check the                   Broker transactions        Exempt recipients 1                pay ments, and certain pay ments made w ith
appropr iate box for your status (indiv idual/sole                                through 13. Also, a
                                                                                                                     respect to readily tradable instruments, generally
proprietor, corporation, etc.).                                                   person registered under
                                                                                                                     you w ill have 60 days to get a TIN and give it to
                                                                                  the Investment Advisers
                                                                                  Act of 1940 who regularly          the requester before you are subject to backup
Exempt From Backup Withholding                                                                                       w ithholding on pay ments. The 60-day rule does
                                                                                  acts as a broker
If you are exempt, enter your name as described                                                                      not apply to other types of pay ments. You w ill be
above and chec k the appropriate box for your                                                                        subject to bac kup w ithholding on all such
                                                       Barter exchange            Exempt recipients 1
status, then check the “ Ex empt from bac kup          transactions and           through 5
                                                                                                                     pay ments until you provide your TIN to the
w ithholding” box in the line follow ing the           patronage dividends                                           requester.
business name, sign and date the form.                                                                               Note. Writing “Applied For” means that you have
    Generally, indiv iduals (including sole                                                                          already applied for a TIN or that you intend to
proprietors) are not exempt from bac kup                                                                             apply for one soon.
w ithholding. Corporations are exempt from             Payments over $600         Generally, exempt
                                                       required to be             recipients 1 through 72            Caution: A disregarded domestic entity that has
backup w ithholding for certain pay ments, such
                                                       reported and direct
as interest and div idends.                                                                                          a foreign owner must use the appropriate Form
                                                       sales over $5,0001
Note. If you are exempt from backup
w ithholding, you should still complete this form to
                                                       1. See Form 1099-MISC, Miscellaneous Income, and its
avoid possible erroneous backup w ithholding.          instructions.
Exem pt payees. Backup w ithholding is not             2. Howev er, the f ollowing pay ments made to a corporation
required on any pay ments made to the follow ing       (including gross proceeds paid to an attorney under section
payees:                                                6045(f ), ev en if the attorney is a corporation) and
   1. An organization exempt from tax under            reportable on Form 1099- MISC are not exempt from
                                                       backup withholding: medical and health care pay ments,
section 501(a), any IRA, or a custodial account        attorneys’ f ees; and pay ments f or serv ices paid by a
under section 403(b)(7) if the account satisfies       f ederal executiv e agency .
the requirements of section 401(f)(2),
   2. The United States or any of its agencies or
                                                       Part I. Taxpayer Identification
   3. A state, the District of Columbia, a             Number (TIN)
possession of the United States, or any of their
political subdivisions or instrumentalities,           Enter your TIN in the appropriate box. If you
   4. A foreign government or any of its political     are a resident alien and you do not have and are
subdivisions, agencies, or instrumentalities, or       not eligible to get an SSN, your TIN is your IRS
   5. An international organization or any of its      individual taxpayer identification number ( ITIN).
agencies or instrumentalities.                         Enter it in the social security number box. If you
      Other payees that may be exempt from             do not have an ITIN, see How to get a TIN
   backup w ithholding inc lude:                       below .
   6. A corporation,                                      If you are a sole proprietor and you have an
   7. A foreign central bank of issue,                 EIN, you may enter either your SSN or EIN.
   8. A dealer in securities or commodities            How ever, the IRS prefers that you use your
required to register in the United States, the         SSN.
District of Columbia, or a possession of the              If you are a single-ow ner LLC that is
United States,                                         disregarded as an entity separate from its ow ner
   9. A futures commission merchant registered         (see Limited liability company (LLC) on page 2),
w ith the Commodity Futures Trading                    enter your SSN (or EIN, if you have one). If the
Commission,                                            LLC is a corporation, partnership, etc., enter the
   10. A real estate investment trust,                 entity ’s EIN.
   11. An entity registered at all times during the    Note. See the chart on page 4 for further
tax year under the Investment Company Act of           clarification of name and TIN combinations.
                                                       How to get a TIN. If you do not have a TIN,
                                                       apply for one immediately. To apply for an SSN,
                                                                                                                         Page 4

Part II. Certification                               What Name and Number To Give the
To establish to the w ithholding agent that you      Requester
are a U.S. person, or res ident alien, sign For m    For this type of account:         Give name and SSN of:
W-9. You may be requested to sign by the             1. Individual              The individual
w ithholding agent even if items 1, 4, and 5 below   2. Tw o or more            The actual owner of the
indicate otherw ise.                                    individuals (joint      account or, if combined
                                                        account)                funds, the first individual
For a joint account, only the person w hose IN is                               on the account 1
show n in Part I should sign (w hen required).       3. Custodian account of a The minor 2
Ex empt recipients, see Exempt From Backup              minor (Uniform Gift to
Withholding on page 2.                                  Minors Act)
                                                     4. a. The usual revocable The grantor-trustee 1
Signature requirements. Complete the
                                                        savings trust (grantor
certification as indicated in 1 through 5 below .
                                                        is also trustee)
   1. Interest, dividend, and barter exchange        b. So-called trust account The actual owner 1
accounts opened before 1984 and broker                  that is not a legal or
accounts considered active during 1983. You             valid trust under state
must give your correct TIN, but you do not have         law
to sign the certification.                           5. Sole proprietorship or The ow ner 3
                                                        single-owner LLC
   2. Interest, dividend, broker, and barter
exchange accounts opened after 1983 and
broker accounts considered inactive during           For this type of account:         Give name and EIN of:
1983. You must sign the certification or backup      6. Sole proprietorship or         The ow ner
w ithholding w ill apply. If you are subject to          single-owner LLC
backup w ithholding and you are merely providing     7. A valid trust, estate, or      Legal entity
your correct TIN to the requester, you must cross        pension trust
out item 2 in the certification before signing the   8. Corporate or LLC               The corporation
form.                                                    electing corporate
                                                         status on Form 8832
  3. Real estate transactions. You must s ign        9. Association, club,             The organization
the certification. You may cross out item 2 of the       religious, charitable,
certification.                                           educational, or other
   4. Other paym ents. You must give your
correct TIN, but you do not have to sign the         10. Partnership or multi-         The partnership
certification unless you have been notifie d that        member LLC
you have pr evious ly given an incorrect TIN.        11. A broker or registered        The broker or nominee
“Other pay ments” include pay ments made in the          nominee
course of the requester’s trade or business for      12. Account with the              The public entity
rents, royalties, goods (other than bills for            Department of
merchandise), medical and health care services           Agric ulture in the
(including pay ments to corporations), pay ments         name of a public
to a nonemployee for services, pay ments to              entity (such as a
certain fishing boat crew members and                    state or local
fishermen, and gr oss proceeds paid to attorneys         government, school
(including pay ments to corporations).                   district, or pris on) that
                                                         receiv es agricultural
  5. Mortgage interest paid by you,                      program payments
acquisition or abandonme nt of secured
property, cancellation of debt, qualified            1. List f irst and circle the name of the person whose
tuition program payments (under section                 number y ou f urnish. If only one person on a joint
529), IRA, Coverdell ESA, Archer MSA or HSA             account has an SSN, that person’s number must be
                                                        f urnished.
contributions or distributions, and pension          2. Circle the minor’s name and f urnish the minor’s SSN.
distributions. You must give your correct TIN,       3. Y ou must show y our indiv idual name and y ou may also
but you do not have to s ign the certification.         enter y our business or “DBA” name on the second name
                                                        line. Y ou may use either y our SSN or EIN (if y ou hav e
                                                        one). If y ou are a sole proprietor, IRS encourages y ou to
                                                        use y our SSN.
                                                     4. List f irst and circle the name of the legal trust, estate, or
                                                        pension trust. (Do not f urnish the TIN of the personal
                                                        representativ e or trustee unless the legal entity itself is
                                                        not designated in the account title.) Also see Special
                                                        rules regarding partnershi ps 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.

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