By signing this application, Customer agrees to the following. High Speed Internet service activation includes a single home run wire to a designated point for handoff to a residential gateway and RTC's Technicians will verify internet connectivity. Any additional work done at the customer's request (including, but not limited to, moving existing jacks or installing new jacks) will be billed at Reservation Telephone Cooperative's (“RTC”) prevailing hourly rate plus materials.
RTC offers one residential gateway for lease as part of the package. Residential gateways, power supplies, and cords remain the property of RTC, and in some cases, may need to be returned when service is disconnected. Equipment that is not returned within five (5) days after disconnection will be billed to the Customer at reasonable retail rates.
RTC provides this service for the purpose of direct access to the Internet. This is not a wholesale service therefore it cannot be resold by the customer. Please read RTC's Acceptable Use Policy; it is listed in the Legal Notices section of our website www.RTC.coop. Violation of the policy may jeopardize your service.
I have read and understand the above information and authorize RTC to install high speed internet service. I am at least 18 years of age and the name on the account where the service will be installed matches the name above. Agreement is nontransferable.
Delivery, Use, Care, Replacement Services, Right of Entry
By signing this application, you agree that any equipment delivered and installed at your address as reflected in our business records, is for personal use at said address. You agree not to remove it from the address except to return it to us. You agree to take reasonable care of the equipment and agree not to open the equipment (except change batteries in the remote control), take apart, or to alter it in any way. You are responsible for all damage to the equipment, beyond reasonable wear from normal use, which occurs before you return or surrender it to us. The equipment must be returned in fully usable condition. Except for damage caused by misuse or abuse, if you notify us of equipment failure, we will repair it or exchange it for properly functioning equipment. You agree to allow us to enter your installation address, at any reasonable time, to inspect, repair, replace, or remove the equipment.
Payment for use of service and failure to comply with agreement
Your use of the equipment and services you receive are subject to the various policies of RTC. Such policies and practices are subject to change. Monthly fees for use of the equipment are billed in advance. If you fail to comply with your commitments contained herein, or with any term of the agreement under which you are receiving services from us, you understand and agree we may do any combination of one or more of the following: 1.) terminate your right to use of the equipment; 2.) terminate your right to receive services from us; 3.) recover the equipment; 4.) bring legal or other action for return of the equipment and any amounts due to us hereunder, together with liquidated damages for failure to return the equipment as required herein.
If you choose to stop using the equipment
You may terminate your use of the equipment by contacting customer service. When you do so, or if we terminate your right to use the equipment as described above, we will ask you to return the equipment. All rental payments and additional charges will be due to us at this time. You agree to cooperate and make yourself available to return the equipment to us. EQUIPMENT NOT RETURNED UPON DISCONNECT IS BILLABLE.
Liquidated damages for failure to return equipment
If you fail to timely return the equipment to us in accordance with your commitment herein, you understand and agree that the costs and damages we will incur are not readily ascertainable and are difficult to predict or calculate at the time. You agree that a reasonable estimate of our damages is the replacement cost for the equipment and power cord(s), plus the costs associated with our attempts to recover the equipment from you. Again, when you are required to return the equipment to us, we appreciate in advance your cooperation in making sure the equipment is promptly returned.
*ALL MATERIALS AND LABOR INSIDE PREMISE WILL BE BILLABLE ABOVE AND BEYOND THE ACTIVATION CHARGE. NOTE: An incomplete application may delay installation of services.
I (We) hereby apply for phone/internet/tv service from RTC, with the understanding that I (We) am (are) fully responsible for payment of the account. I (We) further agree that RTC can apply any accumulated capital credits to the account if the account becomes delinquent. Furthermore, by signing this service agreement, I(We) hereby agree to abide by the rules, regulations and by-laws of the cooperative, which can be found at www.RTC.coop, or by calling the RTC office, and, if applicable, the equipment and internet agreements outlined above.
By entering your initials on the line below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.
Payment Options Brochure
Power Backup Disclosure
As a cooperative member-owner, W-9 is required to pay out Capital Credits. If a joint account, both members must complete a W-9.
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.
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); and2. 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; and3. I am a U.S. citizen or other U.S. person (defined below); and4. 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.
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 FormAn 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.
By signing the filled-out form, you:1. Certify that the TIN you are giving is correct (or you are waiting for anumber to be issued),2. Certify that you are not subject to backup withholding, or3. Claim exemption from backup withholding if you are a U.S. exemptpayee. If applicable, you are also certifying that as a U.S. person, yourallocable share of any partnership income from a U.S. trade or businessis not subject to the withholding tax on foreign partners' share ofeffectively connected income, and4. Certify that FATCA code(s) entered on this form (if any) indicatingthat you are exempt from the FATCA reporting, is correct. See What isFATCA reporting, later, for further information.Note: If you are a U.S. person and a requester gives you a form otherthan Form W-9 to request your TIN, you must use the requester’s form ifit is substantially similar to this Form W-9.Definition of a U.S. person. For federal tax purposes, you areconsidered 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 ororganized 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 orbusiness in the United States are generally required to pay a withholdingtax under section 1446 on any foreign partners’ share of effectivelyconnected taxable income from such business. Further, in certain caseswhere a Form W-9 has not been received, the rules under section 1446require a partnership to presume that a partner is a foreign person, andpay the section 1446 withholding tax. Therefore, if you are a U.S. personthat is a partner in a partnership conducting a trade or business in theUnited States, provide Form W-9 to the partnership to establish yourU.S. status and avoid section 1446 withholding on your share ofpartnership income.In the cases below, the following person must give Form W-9 to thepartnership for purposes of establishing its U.S. status and avoidingwithholding on its allocable share of net income from the partnershipconducting a trade or business in the United States.• In the case of a disregarded entity with a U.S. owner, the U.S. ownerof the disregarded entity and not the entity;• In the case of a grantor trust with a U.S. grantor or other U.S. owner,generally, the U.S. grantor or other U.S. owner of the grantor trust andnot the trust; and• In the case of a U.S. trust (other than a grantor trust), the U.S. trust(other than a grantor trust) and not the beneficiaries of the trust.Foreign person. If you are a foreign person or the U.S. branch of aforeign bank that has elected to be treated as a U.S. person, do not useForm W-9. Instead, use the appropriate Form W-8 or Form 8233 (seePub. 515, Withholding of Tax on Nonresident Aliens and ForeignEntities).Nonresident alien who becomes a resident alien. Generally, only anonresident alien individual may use the terms of a tax treaty to reduceor eliminate U.S. tax on certain types of income. However, most taxtreaties contain a provision known as a “saving clause.” Exceptionsspecified in the saving clause may permit an exemption from tax tocontinue for certain types of income even after the payee has otherwisebecome a U.S. resident alien for tax purposes.If you are a U.S. resident alien who is relying on an exceptioncontained in the saving clause of a tax treaty to claim an exemptionfrom U.S. tax on certain types of income, you must attach a statementto Form W-9 that specifies the following five items.1. The treaty country. Generally, this must be the same treaty underwhich you claimed exemption from tax as a nonresident alien.2. The treaty article addressing the income.3. The article number (or location) in the tax treaty that contains thesaving clause and its exceptions.4. The type and amount of income that qualifies for the exemptionfrom tax.5. Sufficient facts to justify the exemption from tax under the terms ofthe treaty article.Example. Article 20 of the U.S.-China income tax treaty allows anexemption from tax for scholarship income received by a Chinesestudent temporarily present in the United States. Under U.S. law, thisstudent will become a resident alien for tax purposes if his or her stay inthe United States exceeds 5 calendar years. However, paragraph 2 ofthe first Protocol to the U.S.-China treaty (dated April 30, 1984) allowsthe provisions of Article 20 to continue to apply even after the Chinesestudent becomes a resident alien of the United States. A Chinesestudent who qualifies for this exception (under paragraph 2 of the firstprotocol) and is relying on this exception to claim an exemption from taxon his or her scholarship or fellowship income would attach to FormW-9 a statement that includes the information described above tosupport that exemption.If you are a nonresident alien or a foreign entity, give the requester theappropriate completed Form W-8 or Form 8233.Backup WithholdingWhat is backup withholding? Persons making certain payments to youmust under certain conditions withhold and pay to the IRS 24% of suchpayments. This is called “backup withholding.” Payments that may besubject to backup withholding include interest, tax-exempt interest,dividends, broker and barter exchange transactions, rents, royalties,nonemployee pay, payments made in settlement of payment card andthird party network transactions, and certain payments from fishing boatoperators. Real estate transactions are not subject to backupwithholding.You will not be subject to backup withholding on payments youreceive if you give the requester your correct TIN, make the propercertifications, and report all your taxable interest and dividends on yourtax return.Payments you receive will be subject to backup withholding if:1. You do not furnish your TIN to the requester,2. You do not certify your TIN when required (see the instructions forPart II for details),3. The IRS tells the requester that you furnished an incorrect TIN,4. The IRS tells you that you are subject to backup withholdingbecause you did not report all your interest and dividends on your taxreturn (for reportable interest and dividends only), or5. You do not certify to the requester that you are not subject tobackup withholding under 4 above (for reportable interest and dividendaccounts opened after 1983 only).Certain payees and payments are exempt from backup withholding.See Exempt payee code, later, and the separate Instructions for theRequester of Form W-9 for more information.Also see Special rules for partnerships, earlier.What is FATCA Reporting?The Foreign Account Tax Compliance Act (FATCA) requires aparticipating foreign financial institution to report all United Statesaccount holders that are specified United States persons. Certainpayees are exempt from FATCA reporting. See Exemption from FATCAreporting code, later, and the Instructions for the Requester of FormW-9 for more information.Updating Your InformationYou must provide updated information to any person to whom youclaimed to be an exempt payee if you are no longer an exempt payeeand anticipate receiving reportable payments in the future from thisperson. For example, you may need to provide updated information ifyou are a C corporation that elects to be an S corporation, or if you nolonger are tax exempt. In addition, you must furnish a new Form W-9 ifthe name or TIN changes for the account; for example, if the grantor of agrantor trust dies.PenaltiesFailure to furnish TIN. If you fail to furnish your correct TIN to arequester, you are subject to a penalty of $50 for each such failureunless your failure is due to reasonable cause and not to willful neglect.Civil penalty for false information with respect to withholding. If youmake a false statement with no reasonable basis that results in nobackup withholding, you are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully falsifyingcertifications or affirmations may subject you to criminal penaltiesincluding fines and/or imprisonment.Misuse of TINs. If the requester discloses or uses TINs in violation offederal law, the requester may be subject to civil and criminal penalties.Specific InstructionsLine 1You must enter one of the following on this line; do not leave this lineblank. The name should match the name on your tax return.If this Form W-9 is for a joint account (other than an accountmaintained by a foreign financial institution (FFI)), list first, and thencircle, the name of the person or entity whose number you entered inPart I of Form W-9. If you are providing Form W-9 to an FFI to documenta joint account, each holder of the account that is a U.S. person mustprovide a Form W-9.a. Individual. Generally, enter the name shown on your tax return. Ifyou have changed your last name without informing the Social SecurityAdministration (SSA) of the name change, enter your first name, the lastname as shown on your social security card, and your new last name.Note: ITIN applicant: Enter your individual name as it was entered onyour Form W-7 application, line 1a. This should also be the same as thename you entered on the Form 1040/1040A/1040EZ you filed with yourapplication.b. Sole proprietor or single-member LLC. Enter your individualname as shown on your 1040/1040A/1040EZ on line 1. You may enteryour business, trade, or “doing business as” (DBA) name on line 2.c. Partnership, LLC that is not a single-member LLC, Ccorporation, or S corporation. Enter the entity's name as shown on theentity's tax return on line 1 and any business, trade, or DBA name online 2.d. Other entities. Enter your name as shown on required U.S. federaltax documents on line 1. This name should match the name shown on thecharter or other legal document creating the entity. You may enter anybusiness, trade, or DBA name on line 2.e. Disregarded entity. For U.S. federal tax purposes, an entity that isdisregarded as an entity separate from its owner is treated as a“disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enterthe owner's name on line 1. The name of the entity entered on line 1should never be a disregarded entity. The name on line 1 should be thename shown on the income tax return on which the income should bereported. For example, if a foreign LLC that is treated as a disregardedentity for U.S. federal tax purposes has a single owner that is a U.S.person, the U.S. owner's name is required to be provided on line 1. Ifthe direct owner of the entity is also a disregarded entity, enter the firstowner that is not disregarded for federal tax purposes. Enter thedisregarded entity's name on line 2, “Business name/disregarded entityname.” If the owner of the disregarded entity is a foreign person, theowner must complete an appropriate Form W-8 instead of a Form W-9.This is the case even if the foreign person has a U.S. TIN.Line 2If you have a business name, trade name, DBA name, or disregardedentity name, you may enter it on line 2.Line 3Check the appropriate box on line 3 for the U.S. federal taxclassification of the person whose name is entered on line 1. Check onlyone box on line 3.IF the entity/person on line 1 isa(n) . . .THEN check the box for . . .• Corporation Corporation• Individual• Sole proprietorship, or• Single-member limited liabilitycompany (LLC) owned by anindividual and disregarded for U.S.federal tax purposes.Individual/sole proprietor or singlememberLLC• LLC treated as a partnership forU.S. federal tax purposes,• LLC that has filed Form 8832 or2553 to be taxed as a corporation,or• LLC that is disregarded as anentity separate from its owner butthe owner is another LLC that isnot disregarded for U.S. federal taxpurposes.Limited liability company and enterthe appropriate tax classification.(P= Partnership; C= C corporation;or S= S corporation)• Partnership Partnership• Trust/estate Trust/estateLine 4, ExemptionsIf you are exempt from backup withholding and/or FATCA reporting,enter in the appropriate space on line 4 any code(s) that may apply toyou.Exempt payee code.• Generally, individuals (including sole proprietors) are not exempt frombackup withholding.• Except as provided below, corporations are exempt from backupwithholding for certain payments, including interest and dividends.• Corporations are not exempt from backup withholding for paymentsmade in settlement of payment card or third party network transactions.• Corporations are not exempt from backup withholding with respect toattorneys’ fees or gross proceeds paid to attorneys, and corporationsthat provide medical or health care services are not exempt with respectto payments reportable on Form 1099-MISC.The following codes identify payees that are exempt from backupwithholding. Enter the appropriate code in the space in line 4.1—An organization exempt from tax under section 501(a), any IRA, ora custodial account under section 403(b)(7) if the account satisfies therequirements of section 401(f)(2)2—The United States or any of its agencies or instrumentalities3—A state, the District of Columbia, a U.S. commonwealth orpossession, or any of their political subdivisions or instrumentalities4—A foreign government or any of its political subdivisions, agencies,or instrumentalities5—A corporation6—A dealer in securities or commodities required to register in theUnited States, the District of Columbia, or a U.S. commonwealth orpossession7—A futures commission merchant registered with the CommodityFutures Trading Commission8—A real estate investment trust9—An entity registered at all times during the tax year under theInvestment Company Act of 194010—A common trust fund operated by a bank under section 584(a)11—A financial institution12—A middleman known in the investment community as a nominee orcustodian13—A trust exempt from tax under section 664 or described in section4947
The following chart shows types of payments that may be exemptfrom backup withholding. The chart applies to the exempt payees listedabove, 1 through 13.IF the payment is for . . . THEN the payment is exemptfor . . .Interest and dividend payments All exempt payees exceptfor 7Broker transactions Exempt payees 1 through 4 and 6through 11 and all C corporations.S corporations must not enter anexempt payee code because theyare exempt only for sales ofnoncovered securities acquiredprior to 2012.Barter exchange transactions andpatronage dividendsExempt payees 1 through 4Payments over $600 required to bereported and direct sales over$5,0001Generally, exempt payees1 through 52Payments made in settlement ofpayment card or third party networktransactionsExempt payees 1 through 41 See Form 1099-MISC, Miscellaneous Income, and its instructions.2 However, the following payments made to a corporation andreportable on Form 1099-MISC are not exempt from backupwithholding: medical and health care payments, attorneys’ fees, grossproceeds paid to an attorney reportable under section 6045(f), andpayments for services paid by a federal executive agency.Exemption from FATCA reporting code. The following codes identifypayees that are exempt from reporting under FATCA. These codesapply to persons submitting this form for accounts maintained outsideof the United States by certain foreign financial institutions. Therefore, ifyou are only submitting this form for an account you hold in the UnitedStates, you may leave this field blank. Consult with the personrequesting this form if you are uncertain if the financial institution issubject to these requirements. A requester may indicate that a code isnot required by providing you with a Form W-9 with “Not Applicable” (orany similar indication) written or printed on the line for a FATCAexemption code.A—An organization exempt from tax under section 501(a) or anyindividual retirement plan as defined in section 7701(a)(37)B—The United States or any of its agencies or instrumentalitiesC—A state, the District of Columbia, a U.S. commonwealth orpossession, or any of their political subdivisions or instrumentalitiesD—A corporation the stock of which is regularly traded on one ormore established securities markets, as described in Regulationssection 1.1472-1(c)(1)(i)E—A corporation that is a member of the same expanded affiliatedgroup as a corporation described in Regulations section 1.1472-1(c)(1)(i)F—A dealer in securities, commodities, or derivative financialinstruments (including notional principal contracts, futures, forwards,and options) that is registered as such under the laws of the UnitedStates or any stateG—A real estate investment trustH—A regulated investment company as defined in section 851 or anentity registered at all times during the tax year under the InvestmentCompany Act of 1940I—A common trust fund as defined in section 584(a)J—A bank as defined in section 581K—A brokerL—A trust exempt from tax under section 664 or described in section4947(a)(1)M—A tax exempt trust under a section 403(b) plan or section 457(g)planNote: You may wish to consult with the financial institution requestingthis form to determine whether the FATCA code and/or exempt payeecode should be completed.Line 5Enter your address (number, street, and apartment or suite number).This is where the requester of this Form W-9 will mail your informationreturns. If this address differs from the one the requester already has onfile, write NEW at the top. If a new address is provided, there is still achance the old address will be used until the payor changes youraddress in their records.Line 6Enter your city, state, and ZIP code.Part I. Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. If you are a resident alien andyou do not have and are not eligible to get an SSN, your TIN is your IRSindividual taxpayer identification number (ITIN). Enter it in the socialsecurity number box. If you do not have an ITIN, see How to get a TINbelow.If you are a sole proprietor and you have an EIN, you may enter eitheryour SSN or EIN.If you are a single-member LLC that is disregarded as an entityseparate from its owner, enter the owner’s SSN (or EIN, if the owner hasone). Do not enter the disregarded entity’s EIN. If the LLC is classified asa corporation or partnership, enter the entity’s EIN.Note: See What Name and Number To Give the Requester, later, forfurther clarification of name and TIN combinations.How to get a TIN. If you do not have a TIN, apply for one immediately.To apply for an SSN, get Form SS-5, Application for a Social SecurityCard, from your local SSA office or get this form online atwww.SSA.gov. You may also get this form by calling 1-800-772-1213.Use Form W-7, Application for IRS Individual Taxpayer IdentificationNumber, to apply for an ITIN, or Form SS-4, Application for EmployerIdentification Number, to apply for an EIN. You can apply for an EINonline by accessing the IRS website at www.irs.gov/Businesses andclicking on Employer Identification Number (EIN) under Starting aBusiness. Go to www.irs.gov/Forms to view, download, or print FormW-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms toplace an order and have Form W-7 and/or SS-4 mailed to you within 10business days.If you are asked to complete Form W-9 but do not have a TIN, applyfor a TIN and write “Applied For” in the space for the TIN, sign and datethe form, and give it to the requester. For interest and dividendpayments, and certain payments made with respect to readily tradableinstruments, generally you will have 60 days to get a TIN and give it tothe requester before you are subject to backup withholding onpayments. The 60-day rule does not apply to other types of payments.You will be subject to backup withholding on all such payments untilyou provide your TIN to the requester.Note: Entering “Applied For” means that you have already applied for aTIN or that you intend to apply for one soon.Caution: A disregarded U.S. entity that has a foreign owner must usethe appropriate Form W-8.Part II. CertificationTo establish to the withholding agent that you are a U.S. person, orresident alien, sign Form W-9. You may be requested to sign by thewithholding agent even if item 1, 4, or 5 below indicates otherwise.For a joint account, only the person whose TIN is shown in Part Ishould sign (when required). In the case of a disregarded entity, theperson identified on line 1 must sign. Exempt payees, see Exempt payeecode, earlier.Signature requirements. Complete the certification as indicated initems 1 through 5 below.
1. Interest, dividend, and barter exchange accounts openedbefore 1984 and broker accounts considered active during 1983.You must give your correct TIN, but you do not have to sign thecertification.2. Interest, dividend, broker, and barter exchange accountsopened after 1983 and broker accounts considered inactive during1983. You must sign the certification or backup withholding will apply. Ifyou are subject to backup withholding and you are merely providingyour correct TIN to the requester, you must cross out item 2 in thecertification before signing the form.3. Real estate transactions. You must sign the certification. You maycross out item 2 of the certification.4. Other payments. You must give your correct TIN, but you do nothave to sign the certification unless you have been notified that youhave previously given an incorrect TIN. “Other payments” includepayments made in the course of the requester’s trade or business forrents, royalties, goods (other than bills for merchandise), medical andhealth care services (including payments to corporations), payments toa nonemployee for services, payments made in settlement of paymentcard and third party network transactions, payments to certain fishingboat crew members and fishermen, and gross proceeds paid toattorneys (including payments to corporations).5. Mortgage interest paid by you, acquisition or abandonment ofsecured property, cancellation of debt, qualified tuition programpayments (under section 529), ABLE accounts (under section 529A),IRA, Coverdell ESA, Archer MSA or HSA contributions ordistributions, and pension distributions. You must give your correctTIN, but you do not have to sign the certification.What Name and Number To Give the RequesterFor this type of account: Give name and SSN of:1. Individual The individual2. Two or more individuals (jointaccount) other than an accountmaintained by an FFIThe actual owner of the account or, ifcombined funds, the first individual onthe account13. Two or more U.S. persons(joint account maintained by an FFI)Each holder of the account4. Custodial account of a minor(Uniform Gift to Minors Act)The minor25. a. The usual revocable savings trust(grantor is also trustee)b. So-called trust account that is nota legal or valid trust under state lawThe grantor-trustee1The actual owner16. Sole proprietorship or disregardedentity owned by an individualThe owner37. Grantor trust filing under OptionalForm 1099 Filing Method 1 (seeRegulations section 1.671-4(b)(2)(i)(A))The grantor*For this type of account: Give name and EIN of:8. Disregarded entity not owned by anindividualThe owner9. A valid trust, estate, or pension trust Legal entity410. Corporation or LLC electingcorporate status on Form 8832 orForm 2553The corporation11. Association, club, religious,charitable, educational, or other taxexemptorganizationThe organization12. Partnership or multi-member LLC The partnership13. A broker or registered nominee The broker or nomineeFor this type of account: Give name and EIN of:14. Account with the Department ofAgriculture in the name of a publicentity (such as a state or localgovernment, school district, orprison) that receives agriculturalprogram paymentsThe public entity15. Grantor trust filing under the Form1041 Filing Method or the OptionalForm 1099 Filing Method 2 (seeRegulations section 1.671-4(b)(2)(i)(B))The trust1 List first and circle the name of the person whose number you furnish.If only one person on a joint account has an SSN, that person’s numbermust be furnished.2 Circle the minor’s name and furnish the minor’s SSN.3 You must show your individual name and you may also enter yourbusiness or DBA name on the “Business name/disregarded entity”name line. You may use either your SSN or EIN (if you have one), but theIRS encourages you to use your SSN.4 List first and circle the name of the trust, estate, or pension trust. (Donot furnish the TIN of the personal representative or trustee unless thelegal entity itself is not designated in the account title.) Also see Specialrules for partnerships, earlier.*Note: The grantor also must provide a Form W-9 to trustee of trust.Note: If no name is circled when more than one name is listed, thenumber will be considered to be that of the first name listed.Secure Your Tax Records From Identity TheftIdentity theft occurs when someone uses your personal informationsuch as your name, SSN, or other identifying information, without yourpermission, to commit fraud or other crimes. An identity thief may useyour SSN to get a job or may file a tax return using your SSN to receivea refund.To reduce your risk:• Protect your SSN,• Ensure your employer is protecting your SSN, and• Be careful when choosing a tax preparer.If your tax records are affected by identity theft and you receive anotice from the IRS, respond right away to the name and phone numberprinted on the IRS notice or letter.If your tax records are not currently affected by identity theft but youthink you are at risk due to a lost or stolen purse or wallet, questionablecredit card activity or credit report, contact the IRS Identity Theft Hotlineat 1-800-908-4490 or submit Form 14039.For more information, see Pub. 5027, Identity Theft Information forTaxpayers.Victims of identity theft who are experiencing economic harm or asystemic problem, or are seeking help in resolving tax problems thathave not been resolved through normal channels, may be eligible forTaxpayer Advocate Service (TAS) assistance. You can reach TAS bycalling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD1-800-829-4059.Protect yourself from suspicious emails or phishing schemes.Phishing is the creation and use of email and websites designed tomimic legitimate business emails and websites. The most common actis sending an email to a user falsely claiming to be an establishedlegitimate enterprise in an attempt to scam the user into surrenderingprivate information that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails. Also, theIRS does not request personal detailed information through email or asktaxpayers for the PIN numbers, passwords, or similar secret accessinformation for their credit card, bank, or other financial accounts.If you receive an unsolicited email claiming to be from the IRS,forward this message to firstname.lastname@example.org. You may also report misuseof the IRS name, logo, or other IRS property to the Treasury InspectorGeneral for Tax Administration (TIGTA) at 1-800-366-4484. You canforward suspicious emails to the Federal Trade Commission email@example.com or report them at www.ftc.gov/complaint. You cancontact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338).If you have been the victim of identity theft, see www.IdentityTheft.govand Pub. 5027.Visit www.irs.gov/IdentityTheft to learn more about identity theft andhow to reduce your risk.Privacy Act NoticeSection 6109 of the Internal Revenue Code requires you to provide yourcorrect TIN to persons (including federal agencies) who are required tofile information returns with the IRS to report interest, dividends, orcertain other income paid to you; mortgage interest you paid; theacquisition or abandonment of secured property; the cancellation ofdebt; or contributions you made to an IRA, Archer MSA, or HSA. Theperson collecting this form uses the information on the form to fileinformation returns with the IRS, reporting the above information.Routine uses of this information include giving it to the Department ofJustice for civil and criminal litigation and to cities, states, the District ofColumbia, and U.S. commonwealths and possessions for use inadministering their laws. The information also may be disclosed to othercountries under a treaty, to federal and state agencies to enforce civiland criminal laws, or to federal law enforcement and intelligenceagencies to combat terrorism. You must provide your TIN whether ornot you are required to file a tax return. Under section 3406, payersmust generally withhold a percentage of taxable interest, dividend, andcertain other payments to a payee who does not give a TIN to the payer.Certain penalties may also apply for providing false or fraudulentinformation.
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