Fill & Sign — Form W-9

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Payee Info (Lines 1–2)

Name (as shown on your income tax return)Business name / disregarded entity (if different)Email

ClassificationExempt payee code (if any)FATCA reporting code (if any)

Street addressCity, state, and ZIPAccount number(s) — optional

TIN type

Social Security Number (SSN)Employer ID Number (EIN)

SSN (XXX-XX-XXXX)

Under penalties of perjury, I certify that:

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
I am not subject to backup withholding because: (a) I am exempt, (b) I have not been notified by the IRS that I am subject to backup withholding, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
I am a U.S. citizen or other U.S. person; and
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

I certify the statements above and consent to sign this Form W-9 electronically.

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