Form W-9.doc

Form W-9 (Massachusetts Substitute W-9 Form) Rev. April 2009 Request for Taxpayer Identification Number and Certification Completed form should be given to the requesting department or the department you are currently doing business with. Name ( List legal name, if joint names, list first circle the name of the person whose TIN you enter in Part I-See Specific Instruction on page 2) Business name, if different from above. (See Specific Instruction on page 2) Check the appropriate box: □ Individual/Sole proprietor □ Corporation □ Partnership □ Other ? Legal Address: number, street, and apt. or suite no. Remittance Address: if different from legal address number, street, and apt. or suite no. City, state and ZIP code City, state and ZIP code Phone # ( ) Fax # ( ) Email address: Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instruction on page 2. 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 2. Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter. Vendors: Dunn and Bradstreet Universal Numbering System (DUNS)) Social security number ???-??-???? OR Employer identification number ??-??????? DUNS ????????? f Part II Certification f Under penalties of perjury, I certify that: 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 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 Services (IRS) that I am s