Envirosight LLC - 593-19 (2) Final contractJuly 18, 2019
Sent Via Email: aclark@envirosight.com
Alice Clark
Envirosight, LLC
111 Canfield Ave, Unit B3
Randolph, NJ 07869
Welcome to BuyBoard!
Re: Notice of The Local Government Purchasing Cooperative Award
Proposal Name and Number: Sewer Inspection and Cleaning Products, Proposal No. 593-19
Congratulations, The Local Government Purchasing Cooperative (Cooperative) has awarded your company a BuyBoard®
contract based on the above-referenced Proposal. The contract is effective 10/1/2019 through 9/30/2020, with two
possible one-year renewals. The contract documents are those identified in Section 3 of the General Terms and Conditions
of the specifications.
To view the items your company has been awarded, please review the proposal tabulation No. 593-19 on the following
web-site: www.buyboard.com/vendor. Only items marked as awarded to your company can be sold through the BuyBoard
contract. In addition, on this website you will find the membership list which will provide you with the names of all entities
with membership in our purchasing cooperative.
Enclosed with this letter you will find the following documents:
1. Vendor Quick Reference Guide 2. BuyBoard License and Identity Standards
You are advised that receipt of a purchase order directly from a Cooperative member is not within the
guidelines of the Cooperative. Accepting purchase orders directly from Cooperative members may result in a violation
of the State of Texas competitive bid statute and termination of this Cooperative BuyBoard contract. Therefore, all
purchase orders must be processed through the BuyBoard in order to comply. Please forward by email to
info@buyboard.com any order received directly from a Cooperative member. If you inadvertently process a purchase
order sent directly to you by a Cooperative member, please email the order info@buyboard.com and note it as RECORD
ONLY to prevent duplication.
As an awarded vendor a BuyBoard user id and password will be sent via e-mail 2 to 3 business days prior to
the start of your contract.
On behalf of the Texas Association of School Boards, we appreciate your interest in the Cooperative and we are looking
forward to your participation in the program. If you have any questions, please contact Cooperative Procurement Staff
at 800-695-2919.
Sincerely,
Arturo Salinas
Department Director, Cooperative Procurement
v.6.5
September 4, 2019
Sent Via Email: aclark@envirosight.com
Alice Clark
Envirosight, LLC
111 Canfield Ave, Unit B3
Randolph, NJ 07869
Welcome to BuyBoard!
Re: Notice of National Purchasing Cooperative Piggy-Back Award
Proposal Name and Number: Sewer Inspection and Cleaning Products, Proposal No. 593-19
Congratulations, The National Purchasing Cooperative (National Cooperative) has awarded your company a BuyBoard®
contract based on the above-referenced Proposal. As provided for in the Proposal and your National Purchasing
Cooperative Vendor Award Agreement, you are authorized to sell the goods and services awarded under the Proposal to National Cooperative members in states other than Texas through the BuyBoard. The contract is effective 10/1/2019
through 9/30/2020, with two possible one-year renewals.
The National Cooperative membership list is available at our website www.buyboard.com/vendor. The list identifies the
current members that may purchase awarded goods and services under your National Cooperative BuyBoard contract.
You are advised that receipt of a purchase order directly from a National Cooperative member is not within BuyBoard guidelines. Accepting purchase orders directly from Cooperative members may result in a violation of
applicable competitive procurement law and termination of this National Cooperative BuyBoard contract. Therefore, all
purchase orders from National Cooperative members must be processed through the BuyBoard. Please
forward by e-mail to info@buyboard.com any order received directly from a National Cooperative member. If you
inadvertently process a purchase order sent directly to you by a National Cooperative member, please fax the order to the
above number and note it as RECORD ONLY to prevent duplication.
As an awarded vendor a BuyBoard user id and password will be sent via e-mail 2 to 3 business
days prior to the start of your contract.
On behalf of the National Cooperative, we are looking forward to your participation in the program. If you have any
questions, please contact Cooperative Procurement Staff at 800-695-2919.
Sincerely,
Arturo Salinas
Department Director, Cooperative Procurement
v.6.5
Envirosight US Dealer Sales Channel
A&H Equipment – Pennsylvania & West Virginia
1124 McLaughlin Run Road
Bridgeville, PA 15017
Phone: 412-257-1160
Fax: 412-257-4471
EJ Weber ejweber@ahequipment.com
Bell Equipment - Michigan
74 Northpoint Drive
Lake Orion, MI 48359
Phone: 866-597-0716
Clark Bushman cbushman@bellequip.com
Best Equipment Company – Indiana, Ohio, and Kentucky
5550 Poindexter Drive 12359 Abbey Road
Indianapolis, IN 46235 North Royalton, OH 44133
Phone: 317-823-3050 Phone: 440-237-3515
Fax: 317-823-3060 Fax: 440-237-3565
Bill Stoddard billstoddard@bestequipmentco.com
Bruce Municipal Equipment - Wisconsin
N60 W 15835 Kohler Lane
Menomonee Falls, WI 53051
Phone: 262-252-4744
Fax: 262-252-3955
Jim Weedman jbweeds@aol.com
Environmental Products of Florida - Florida
2525 Clarcona Rd 450 NW 27 Avenue
Apopka, FL 32703 Ft. Lauderdale, FL 33311
Phone: 407-798-0004 Phone: 954-518-9923
Fax: 407-798-0014 Fax: 954-518-9926
Nick Causey ncausey@epofc.com
Environmental Products of Georgia – Georgia
4410 Wendell Dr SW
Atlanta, GA 30336
Phone: 404-693-9700
Fax: 404-693-9690
Casey Meehan cmeehan@epofc.com
Green Equipment Company - Texas
2563 Gravel Drive
Fort Worth, TX 76118
Phone: 817-589-2704
Fax: 817-284-1107
Brandon Baker brandonbaker@greenequipco.com
J.F. McDermott – Connecticut, Massachusetts, Rhode Island, Vermont, New
Hampshire, Maine
1235 Auburn Street
Whitman, MA 02382
Phone: 508-580-7740
Fax: 508-580-7747
Brian Kennedy jfmcdermottco@aol.com
Haaker Equipment – Southern California, Southern Nevada and Arizona
2070 North White Avenue
LaVerne, CA 91750
Phone: 909-598-2706
Bryan Fox bryanf@haaker.com
Joe Johnson USA – New York State including New York City
62 LaGrange Avenue 1373 Indian Fields Road
Rochester, NY 14613 Feura Bush, NY 12067
Phone: 585-254-7700
Fax: 585-254-9122
Aaron Gieseke agieseke@jjeusa.com
Key Equipment – Kansas, Missouri, Southern Illinois, Oklahoma
13507 Northwest Industrial Drive 6716 Berger Ave
Bridgeton, MO 63044-1245 Kansas City, KS 66111
Phone: 314-298-8330 Phone: 913-371-8260
Fax: 314-298-8376 Fax: 877-262-0149
Josh Kingsley jkingsley@keyequipment.com
MacQueen Equipment – Minnesota, Eastern North Dakota, South Dakota
595 Aldine Street
St. Paul, MN 55104
Phone: 651-645-5726
Fax: 651-645-6668
Bill McCarthy bmccarthy@macqueeneq.com
Metroquip - Idaho
1953 E. Commercial Street
Meridian, ID 83680
Phone: 208-344-3318
Fax: 208-345-8366
Ray Smith rsmith@metroquip.com
Neverest Equipment Company – Colorado, Utah and Wyoming
3541 Ward Road
Wheat Ridge, CO 80033
Phone: 303-898-9475
Fax: 303-898-9475
Brian Balchumas brian@neverestequipment.com
Nebraska Environmental Products - Nebraska
2621 West M Court
Lincoln, NE 68522
Phone: 402-435-0061
Fax: 402-435-0644
Greg Oliverius greg@transiowaeg.com
Normont Equipment – Montana and Western North Dakota
1157 Wire Mill Rd
Black Eagle, MT 59414
Phone: 406-453-4344
Luke Stewart lstewart@nmeqco.com
Pete’s Equipment – New Mexico
1412 Broadway NE
Albuquerque, NM 87102
Phone: 505-252-6969
Fax: 505-242-4156
Bill Pedigo bpedigo@petesequip.com
Public Works Equipment – North Carolina, South Carolina, Eastern
Tennessee
3405 Westwood Industrial Drive
Monroe, NC 28110
Phone: 704-289-6488
Fax: 704-283-2266
Reed Davis reed@pweasi.com
Sansom Equipment – Mississippi, Alabama, Western Tennessee
1225 Vanderbilt Road
Birmingham, AL 35234
Phone: 205-324-3104
Fax: 205-324-2679
Jeff Bodiford jeffb@secequip.com
Standard Equipment – Northern Illinois (Chicagoland Area) and Hawaii
2033 W Walnut Street
Chicago, IL 60612
Phone: 312-829-1919
Fax: 312-829-6142
Mike O’Connor moconnor@standardequipment.com
Trans – Iowa - Iowa
4607 SE Rio Ct.
Ankeny, IA 50021
Phone: 515-289-9994
Fax: 515-289-9995
Eric Thorson eric@transiowaeq.com
True North Equipment – Oregon, Washington, and Alaska
3150 SE Century Blvd – Suite 100
Hillsboro, OR 97123
Phone: 503-848-3276
Jim Brown jbrown@truenorthenviro.com
Virginia Public Works – Virginia & Maryland
8383 Old Richfood Road
Mechanicsville, VA 23116
Phone: 804-730-4040
Fax: 804-730-4033
Luke Kahelski luke@vpwe.com
WinCan, LLC – Wincan Orders Only
200 Cedar Ridge Drive Unit 207
Pittsburgh, PA 15205
Phone: 412-489-6229
Melanie Westerfield m.westerfield@wincam.com
Pipeline Renewal Technologies – QuickLock Orders Only
111 Canfield Ave Unit B3
Randolph, NJ 07869
Phone: 973-252-6700
Alice Clark aclark@envirosight.com
Form W-9
(Rev. October 2018)
Department of the Treasury Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
a Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.Print or type. See Specific Instructions on page 3.1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
Individual/sole proprietor or
single-member LLC
C Corporation S Corporation Partnership Trust/estate
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) a
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions) a
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions.
6 City, state, and ZIP code
Requester’s name and address (optional)
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Social security number
– –
or
Employer identification number
–
Part II Certification
Under penalties of perjury, I certify that:
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
2. I 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
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
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
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
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,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
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.
Sign
Here Signature of
U.S. person a Date a
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
tions
HAAKER EQUIPMENT COMPANY
✔
2070 N WHITE AVE
LA VERNE, CA 91750
9 5 2 7 5 6 0 6 4
1-16-19
Signature of
U.S. person).
Sign
Hero
Date ► 9
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest Information about developments
related to Form W-9 and its Instructions, such as legislation enacted
after they were published, go to Invw.Irs.gov/FormW9.
Purpose of Form
M Individual or entity (Form W-9 requester) who Is required to file an
Information return with the IRS must obtain your correct taxpayer
Identification number (TIN) which may be your social security number
(SSN), Individual taxpayer Identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer Identification number
(E(N), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of Information
returns Include, but are not limited to, the following.
• Form 1099•INT (interest earned or paid)
• Form 1099-GIV (dividends, Including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 109941 (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099•K (merchant card and third party network transactions)
• Form 1098 (home mortgage Interest), 1098-E (student loan Interest),
1098-T (tuition)
• Form 1099•C (canceled debt)
• Form 1099•A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
if you do not return Form W-9 to the requester wfth a 77N, you might
be subject to backup withholding. See What is backup withholding, later.
Employer Identification number 1
or
Give Form to the
requester. Do not
send to tho IRS.
Form W-9
(Rev. October 2018)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
► Go to www.irs.govlFormW9 for instructions and the latest Information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Neverest Equipment Company LLC
2 Business name/disregarded entity name, tf different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on fine 1. Check only one of the
following seven boxes.
q Individual/sole proprietor or q C Corporation q S Corporation q partnership q Tnnt/estate
single-member LLC
o Limited Lability company. Enter the tax classification (C•C corporation, S4 corporation. P•Partnership) ► S
Note: Check the appropriate box In the tine above for the tax classification of the single-member owner. Do not check
tic if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that Is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
Is disregarded from the owner should check the appropriate box for the tax classification of Its owner.
o Other (see Instructkins)1
5 Address (number. street. and apt. or suite no.) See instructions.
6681 Colorado Blvd Unit 5
0 City. state, and ZIP code
Commerce City CO 80022
4 Exemptions (codes apply only to
certain entities, not incrrviduals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
Pa** b waxen mobtahoef beds lb US)
Requester's name and address (optional)
7 List account number(s) here (optional)
UM Taxpayer Identification Number (TIN)
Enter your TIN In the appropriate box. The 71N provided must match the name given on line 1 to avoid
backup withholding. For Individuals, this Is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Instructions for Part I, later. For other
entitles, It Is your employer Identification number (EIN). If you do not have a number, see How to get a
77N, later.
Note: It the account Is In more than one name, see the Instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Part II Certification
Under penalties of perjury, I certify that
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
2.1am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that tam subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that 1 am
no longer subject to backup withholding; and
3.1am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (If an indicating that I am exempt from FATCA reporting is correct.
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
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,
acquisition or abandonment of secured properly, cancellation of debt, contributions to an Individual retirement arrangement (RA), and generally, payments
other than Interest and dividends, you are not required to sign the certification, but you must provide your correctliN. See the Instructions for Part II, later.
Cat No. 10231X Form W-9 (Rev. 10-2018)
Social security number
4WD •••
2 6 2 8 3 2 1 5 7
January 21, 2019
Form W-9 Request for Taxpayer Give Form to the
(Rev. December 2011} Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS. Internal Revenue Service
Name (as shown on your Income tax return}
C\i Business name/disregarded entity name, If different from above
Ql
a. Check appropriate box for federal tax classification: C: 0 D Individual/sole proprietor D C Corporation D S Corporation D Partnership D Trust/estate
Cl)"'
C. §D Exempt payee �+:l D Limited llablllty company. Enter the tax classification (C=C corporation, S=S corporation, P=partnershlp) � ... C.l --------------------------------0 2 ...... Cu,'C .5 D Other (see Instructions} � a.C.l !5 C.l Address (number, street, and apt. or suite no.}
Cl) C. U) City, state, and ZIP code
Requester's name and address (optional}
Ql Ql Cl)
List account number(s} here (optional}
•:.f:1 , .. Taxpayer Identification Number (TIN)
I Social security number I Enter �our TIN in -t�e app�opriate ?o�. !he TIN �r�vided mus� match �he name given on the "Name" line to avoid backup w1thhold1ng. For 1nd1v1duals, this 1s your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. DJ] -[I] -I I I I I
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.
I Employer identification number ITJ-1 I I 11 111 1@11M Certification
Under penalties of perjury, I certify that:
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
2. I 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 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 no longer subject to backup withholding, and
3.I am a U.S. citizen or other U.S. person (defined below).
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 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, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4.
Sign Signature of Here U.S. person � Date �
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Purpose of Form
A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage Interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exemptpayee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income.
Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:
•An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,
•An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S, status and avoid withholding on your share of partnership income.
Cat. No. 10231X Form W-9 (Rev. 12-2011)
Pipeline Renewal Technologies
3/14/16
27 1844228
111 Canfield Ave. Unit B3
Randolph, NJ 07869
x
Form W-9
(Rev. October 2018)
Department of the Treasury Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
a Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.Print or type. See Specific Instructions on page 3.1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
Individual/sole proprietor or
single-member LLC
C Corporation S Corporation Partnership Trust/estate
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) a
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions) a
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions.
6 City, state, and ZIP code
Requester’s name and address (optional)
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Social security number
––
or
Employer identification number
–
Part II Certification
Under penalties of perjury, I certify that:
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
2. I 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
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
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
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
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,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
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.
Sign
Here Signature of
U.S. person a Date a
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
ends, you are not required to sign the
ctions
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