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Form <br />w_9 <br />Request for Taxpayer <br />Give Form to the <br />(Rev.December 2 <br />Identification Number and Certification <br />on <br />requester. Do not <br />Department of the Treasury <br />Internal Revenue Service <br />Bond to the IRS. <br />1 Name (as shown on your Income tax return). Name is required on this line; do not leave this tine blank. <br />City of Beaumont, TX <br />N <br />2 Business name/disregarded entity name, if different from above <br />d <br />m <br />' <br />cY <br />3 Check appropriate box for federal tax classification; check only one of the following seven boxes: <br />g <br />4 Exemptions codes <br />p ( apply only to <br />o <br />IndlvlduaUsole proprietor or ❑ C Corporation ❑ S Corporation p ❑ TrusVestate <br />p ❑ Partnership <br />certain entitles, not individuals; sea <br />instructions on page 3): <br />o c <br />single -member LLC <br />Limited liability company. Enter the tax classification (C -C corporation, S=S corporation, P=partnership) ► <br />Exempt payee code (if any) <br />o` 2 <br />Note. For a single -member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for <br />"Exemption from FATCA reporting <br />the tax classification of the single -member owner. <br />code (if any) <br />c <br />tL <br />✓ Other see Instructions ► <br />❑ ( ) Municipality <br />WpAas tos= nfs maWalned oAsld. the USJ <br />.E <br />5 Address (number, street, and apt. or suite no.) <br />Requester's name and address (optional) <br />a <br />801 Main Street PO Box 3827 <br />B City, state, and ZIP code <br />m <br />w <br />Beaumont, TX 77704-3827 <br />7 List account number(s) here (optional) <br />1 axpayer 1Qenuncauon NUmDer (i IN) <br />Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number �n <br />backup withholding. For individuals, this is generally your social security number ( page However, for a — M <br />resident alien, sole proprietor, or disregarded entity, see the Part 1 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 I Employer Identification number <br />guidelines on whose number to enter. <br />M74 — 6 0 0J 0 12T778 <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 ► �� 1-14/ � Date ► <br />General Instructions <br />Section references are to the Internal Revenue Code unless otherwise noted. <br />Future developments. Information about developments affecting Form W-9 (such <br />as legislation enacted after we release It) Is at wwwJrs.gov/Av9. <br />Purpose of Form <br />An Individual or entity (Form W-9 requester) who is required to file an Information <br />return with the IRS must obtain your correct taxpayer Identification number (TIN) <br />which may be your social security number (SSN), individual taxpayer Identification <br />number (MM, adoption taxpayer identification number (ATIN), or employer <br />Identification number (EIN), to report on an information return the amount paid to <br />you, or other amount reportable on an Information return. Examples of information <br />returns Include, but are not limited to, the following: <br />• Form 1099 -INT (Interest earned or paid) <br />• Form 1099 -DN (dividends, Including those from stocks or mutual funds) <br />• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) <br />• Form 1099-B (stock or mutual fund sales and certain other transactions by <br />brokers) <br />• Form 1099-S (proceeds from real estate transactions) <br />• Form 1099-K (merchant card and third party network transactions) <br />• Form 1098 (home mortgage Interest), 1098-E (student loan interest), 1098-T <br />(tultlon) <br />• Form 1099-C (canceled debt) <br />• Form 1099-A (acquisition or abandonment of secured property) <br />Use Form W-9 only if you are a U.S. person (including a resident alien), to <br />provide your correct TIN. <br />If you do not return Form W-9 to the requester with a TIN, you might be subject <br />to backup withholding. See What Is backup withholding? on page 2. <br />By signing the filled -out form, you: <br />1. Certify that the TIN you are giving Is correct (or you are waiting for a number <br />to be Issued), <br />2. Certify that you are not subject to backup withholding, or <br />3. Claim exemption from backup withholding If you are a U.S. exempt payee. If <br />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 />withholding tax on foreign partners' share of effectively connected Income, and <br />4. Certify that FATCA code(s) entered on this form (If any) Indicating that you are <br />exempt from the FATCA reporting, is correct. See What Is FATCA reporting? on <br />page 2 for further Information. <br />Cat. No. 10231X <br />Form W-9 (Rev. 12-2014) <br />