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DocuSign Envelope ID:9F4A8CF5-2029-449B-A53F-956739F1CFD7
<br /> Form Request for Taxpayer Give Form to the
<br /> (Rev,October2015) Identification Number and Certification requester.Do not
<br /> Department of the Treasury send to the IRS.
<br /> internal Revenue Service iw Go to www.lrs.gov/FDrMW9 for Instructions and the latest information.
<br /> 1-Name(as shown an your income tax return},Name Is required On this Hne;do not leave this line blank.
<br /> Matrix Health&Safer Consultants, LLC
<br /> 2 Business nameidisregarded entity name,it drIMOM from above
<br /> m 3 Check appropriate box for(ederal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions(codes apply only to
<br /> m
<br /> � fallowing Seven boxes. certain entities,not Individuals:see
<br /> ca
<br /> a Instructions an page 3
<br /> o ElIndividual/sole proprietor or El Corporation El Corporation ❑ Partnership ElTrust/estate
<br /> single-member LLC Exempt payee code(if Any)
<br /> d)
<br /> + ✓❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)s P
<br /> a Note.Check the appropriate box In the line above for the tax elassificatIon of the single-member owner, Do not check Exemption from FATCA reporting
<br /> C LLC it the LLC is classified as a single-member LLC that is disregarded from the owner unless the Owner Of the LLC Is code(if any)
<br /> anolher LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single•momber LLC that
<br /> Is disregarded from the owner should check the appropriate box for the tax classification of its owner.
<br /> Other(see Instructions)■ fMufMe ro q«ounfs,,,or�i.�r�d n„�ere-rrre u.5.1
<br /> 5 Address(number,street,and apt.or suite no.)See instructions, Requester's name and address(optional)
<br /> 2900 Yonkers Road
<br /> 6 City,state,and ZIP code
<br /> Raleigh, NC 27604
<br /> T List account number(s)here(optional)
<br /> 11 Taxpayer identification Number IN
<br /> Enter your TIN In the appropriate box.The TIN provided must match the name giver)on line 1 to avoid social security number
<br /> backup withholding.For Individuals,this is dgenerallyentity, your social security number ,late.However,for a m —
<br /> resident Allen,sole proprietor,or disregarded entity,see the Instructions for Part i,later.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,later- or
<br /> Note:If the account Is in more then one name,see the instructions for line 1-Also see What Name and Employer identltlasllon number
<br /> Number To Give the Requester for guidelines on whose number to enter,
<br /> M75 3 1 0 1 3 9 1 478 0
<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 because
<br /> you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage Interest paid,
<br /> acquisition or abandonment of secured property,cancellation of debt,contributions to an Individual retirement arrangement(IRA),and generally,payments
<br /> other than Interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions for Part II,later.
<br /> sign Signature or
<br /> Here U.S.parson■ Date r 12/17/2018
<br /> General Instructions •Form 1099-DIV(dividends,including those from stocks or mutual
<br /> funds)
<br /> Section references are to the Internal Revenue Code unless otherwise -Form I099-MISC(various types of income,prizes,awards,or gross
<br /> noted. proceeds)
<br /> Future developments.For the latest Information about developments -Form 1099-8(stock or mutual fund sales and certain other
<br /> related to Form W-9 and its instructions,such as legislation enacted transactions by brokers)
<br /> after they were published,go to www.frs.gov/FormW9. -Form 1099-S
<br /> (proceeds From real estate transactions)
<br /> Purpose of Form ■Form 1099-K(merchant card and third party network transactions)
<br /> An Individual or entity(Form W-9 requester)who Is required to file an -Form 1098(home mortgage Interest),109E-E(student loan Interest),
<br /> Information return with the IRS must obtain your correct taxpayer 1098-T(tultion)
<br /> Identification number(TIN)which may be your social security number -Form 1099-C(canceled debt)
<br /> (SSN),individual taxpayer Identification number(ITIN),adoption -Form 1099-A(acquisition or abandonment of secured property)
<br /> taxpayer identification number(ATIN),or employer identification number
<br /> (EIN),to report on an Information return the amount paid to you,or other Use Form W-9 only if you are a U.S.person(including a resident
<br /> amount reportable on an information return.Examples of Information alien),to provide your correct TIN.
<br /> returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might
<br /> •Form 1099-INT(Interest earned or paid) be subject to backup withholding.Sea What is backup withholding,
<br /> later.
<br /> Cat.No.10231X Form W-9(Rev.1U-2018)
<br />
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