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. Name 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 employees.) □ 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 www.socialsecurity.gov. 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 www.irs.gov/businesses 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 www.irs.gov 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 line. 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 W-8. 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 instrumentalities, 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. 1940, 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: 3 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 4 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 tax-exempt 4. Other paym ents. You must give your organization 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.