Orange County NC Website
Farm W-9 Request for Taxpayer Give Form to the <br /> (Rev.December 2014) requester.Do not <br /> Department of the Treasury Identification Number and Certification send to the IRS. <br /> Internal Revenue Service <br /> 1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank. <br /> Orange County <br /> N 2 Business name/disregarded entity name,if different from above <br /> N <br /> a 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to <br /> certain entitles,not Individuals;see <br /> 0 ❑IndivlduaVsole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑Trust/estate instructions on page 3): <br /> o. c single-member LLC Exempt payee code(if any) C <br /> 16 ❑Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)0* <br /> `p 3 Note.For a single-member LLC that is disregarded,do not check LLC;check the appropriate box In the line above for Exemption from FATCA reporting <br /> y the tax classification of the single-member owner. code(If any) <br /> Other(see instructions) Local Government (APpllas toacc.-f &t.1nd..Wde the U.S.)a v <br /> R 5 Address(number,street,and apt,or suite no.) Requester's name and address(optional) <br /> U <br /> c. P.O. Box 8181 <br /> 6 City,state,and ZIP code <br /> N Hillsborough,North Carolina 27278 <br /> 7 List account numbers)here(optional) <br /> •. Taxpayer Identification Number(TIN) <br /> Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid social security number m� <br /> backup withholding.For individuals,this is generally your social security number(SSN).However,fora <br /> resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other <br /> entities,it is your employer identification number(EIN).If you do not have a number,see How to get a <br /> TIN on page 3. or <br /> Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identification number <br /> guidelines on whose number to enter. <br /> <br /> Certification <br /> Under penalties of perjury, I certify that: <br /> 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 <br /> 2. 1 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 <br /> 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 <br /> no longer subject to backup withholding;and <br /> 3. 1 am a U.S.citizen or other U.S,person(defined below);and <br /> 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct. <br /> 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 <br /> 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 <br /> interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and <br /> generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the <br /> instructions on page 3. <br /> Sign Signature of ( <br /> Here U.S.person► ! � ,,(,' Date 01 6 <br /> General Instructions •Form 1098(home mortgage interest),1098-E(student loan interest),1098-T <br /> (tuition) <br /> Section references are to the Internal Revenue Code unless otherwise noted. •Form 1099-C(canceled debt) <br /> Future developments.Information about developments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property) <br /> as legislation enacted after we release It)is at www.irs.gov/fw9. <br /> Use Form W-9 only If you are a U.S.person(including a resident alien),to <br /> Purpose of Form provide your correct TIN. <br /> An individual or entity(Form W-9 requester)who is required to file an information If you do not return Form W-9 to the requester with a TIN,you might be subject <br /> return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What is backup withholding?on page 2. <br /> which may be your social security number(SSN),individual taxpayer identification By signing the filled-out form,you: <br /> number(ITIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number <br /> identification number(EIN),to report on an information return the amount paid to to be issued), <br /> you,or other amount reportable on an information return.Examples of information 2.Certify that you are not subject to backup withholding,or <br /> returns include,but are not limited to,the following: <br /> •Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding If you area U.S.exempt payee,If <br /> •Form 1099-DIV(dividends,including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your allocable share of <br /> any partnership income from a U.S.trade or business is not subject to the <br /> •Form 1099-MISC(various types of Income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected Income,and <br /> •Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are <br /> brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on <br /> •Form 1099-S(proceeds from real estate transactions) page 2 for further information. <br /> •Form 1099-K(merchant card and third party network transactions) <br /> Cat.No.10231X Form W-9(Rev.12-2014) <br />