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� <br /> . .__.._ _... . _ _ . _ _ _ . _ _ _ __ <br /> F°^^ W�� Request for Taxpayer Give form to the <br /> (Rev. Oaober 2007) reque9t0r. Do not �� <br /> �, DeparoneMoltheTnnury Identification Number and Certification eendtoMelRS. � <br /> �'. �ma�w� Herenue serwc. - <br /> Neme (as s�own on your i�ome tex refum) . <br /> fV <br /> � m af s,q m ��� iro <br /> � � � � �VV�M v\ .- <br /> ° Che a 10 riete boz: ❑ InEividuaVSOle <br /> .� PP P priator ❑ Corporation ❑ PaMership <br /> �.: �— ❑Limitetl IIa601ry mmpeny. EnterMe tax GassiRCation (D=ElsregartlaC enllry, C=corporation, Pepartnership) D ❑ Exemp�. <br /> :`o y�' �'OUer (see instrucflons) > M�A. Vl� (� Cn i PaYee � . <br /> � p ` • <br /> a c <br /> e A/{Q; (nu ber. SVeat, apl. or suHe no.) Requectels nama and adtlress (optional) <br /> ! m �U � <br /> � tate,anDLP tle� ��� <br /> � <br /> ` Liat aecouni numberys) hare �o nap <br /> Tax a er ldentificetion Number TIN <br /> ' Enter your TIN in NB epproPtlete boz. The TIN ptovWeE must metdi Ihe name given on L1ne 1 lo Bvold 6oeW nacuAry numMr <br /> � beticup wiMholtlinp. For NCFritluals, this IS your sodai sewriry number (SSN). Haxever, tor e realtleM . <br /> �: eiien, ede propriator, or disregar0etl enllty, aee ihe PaK I inatrucllona on pape 3. For other entilies, it Is <br /> � i your empbyer WeMlflcetlon number (EIN)Jf you do not Mve a num6er, see How te get a TIN on pepe 3. o � . <br /> ' Nob. If Me accourit Ia in mo�e Ihan one name, ase the Mart on page 4 for puidelinea on whose ov« ihnti0utio numh.r <br /> ' nunber to emer. �(� � I ' � � . <br /> Certiflcation <br /> ! unCer penaNies a1 perJuy, I cenHy thet: : <br /> �'� t. Tha nwnber shown on this kmi Is my corteet taqieyer WeMlfication number (or 1 am waitinp lor a numDer to De issuetl to me), anA . <br /> ���; 2. I am na wbbct to backup withhoMirp benuse: (e) I am exempt from baakup wiMholdhfp, or (b) I have not Deen notifletl by lhe IMema1 <br /> Ravenue Serviea (IRS) thel I am subjec[ to Gackup wNhhoWinp as e resutt of a telWre to rapo� ell inmreat or tlivitlantls, or (c) !he IRS hes �. <br /> notifleE me Mal 1 am no lorqer subject to bedcup withhddirry, enE ' <br /> ' 3.1 am a U.S, tltlzen or other 11.S, parson (tlefined below). <br /> i CeNfkatlon insiructlons. Vou must crocs out Item 2 ebove it you �ave been notlfied by Uro IRS that you are curtently subjeat to beckup � <br /> �- with�oWinp becauea you I�eve faaetl W repurt all intaresl an0 divitlend¢ on your laz retum. For real estate transactione, item 2 tloes not epply. <br /> ��� For mortpage iMeres[ peiQ ecAWSl�on or ebanAOnmeM oi searetl property, cance0ation of tlebt, conkibu[lons to en InEivitlual retiremeM <br /> '�: ertangement (IRA), antl erplly, paymeMS other then interest and diWdenas, you are na requiratl to sign Ihe Cen�ration, but you must <br /> ': provide your cortect TIN: Se the insW clbnc on pape 4. � <br /> . . Slgn s"ryn.tunm t � 1I :. <br /> -'� Here UB. panon : i Dm > � <br /> FOR COUNTY DEPARTMENT USE ONLY <br /> I approve this eddkion of a naw PEIDlvendor record or requested changes to existing PEID record. <br /> � Date Requestetl: <br /> Requester Name: <br /> Authorized A/P Approver Signature: <br /> s <br /> Rev 01lO6I2017 <br />