Request for Taxpayer Identification Number and Certification
1 Name
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.
C Corporation
Individual/sole proprietor or single-member LLC
S Corporation
Partnership
Trust/estate
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
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)
Other (see instructions)
5 Address number, street, and apt. or suite no See instructions.
5 City State Zip
Taxpayer Identification Number (TIN)
First 3 Digits of Social Security Number
Middle 2 digits of Social Security Number
Last 4 digits of Social Security Number
First 2 digits of EAN # Business Only
Last 7 digits of EAN # Business Only
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Signature
Date
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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