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Substilute Form
<br />\iv_ 9
<br />PRINT OR TYPE
<br />e jail Name (CA'NFR rr rite EN CIR %St; AS NAME Al•t'l.ARS ON IRS GE ROC Al Nu:1Rn V INISTh ATION RFC._
<br />DO Net EhltFR THE dt.SINERs MAW t .1 A SN'' L NC /KA Oh 11-hi 1.INt See Rc I. i 101i.l. idrr luformal:ou
<br />,
<br />Trade Na
<br />Remit Address
<br />7L/f /714,2b94,et Za.,,,sudh
<br />Purchase Order Address - Optional
<br />Check legal entity tyr ii2 and 4.nt 9 digit Toxpilyei- Identification Nun Fir , FIN) hd,,,,,.
<br />(SSN = Social Securii Namber FIN = Efophiyof IficlitOicaboo Numbo)
<br />ri Individual
<br />(Individual's SSN)
<br />_
<br />MOTE 0 11 00:1,r i 06 li 1 0.. . ht A.' /../, - - Itl'm 'L i , ,. 1011 011 .I .t finer 0 , ihr ,1,1,Til . 1 . 11 i r 11,1061.J 10 tt II .I 01 i it TIF 6 sir e smd
<br />[ j Sole Proprietorship (Owner SSN or Business FEIN)
<br />—:: NurE E...er eeth the ,h; , el.', SsN ...,1 he biome; ED, il 11 you ate m4.,r,1 1,, se;
<br />r Partnership r; General ri Limited PartnerOirp's EIN)
<br />_
<br />LJ Estate / Trust
<br />(Legit) Entity EIN)
<br />No] E D f . . 1 , 1 1 / / : I 6e Or . 1 6 , 3 i,rtt I*•'.L, A 1r0 l • l• 6, r ,Ii• • it 1/11
<br />-6.3 6 6 01 ilk 1.1 - .1, i0e rime lha elLie 161 emalon
<br />r---] Other to, (Entity's EIN)
<br />L.relled Liabom Company. 1 Vemuse, CE,. e!:
<br />11 CurpOraDoll Lh■ . ., - u pprorit legal or 'Milk al S1. TV i!,.• ' n Iv r 1 No (COrp'S EIN) -
<br />e0
<br />,1 ; pti,15015i IT1 , Eli 31 ril 1 1 6 , i: ,. r .
<br />X Government (or Government Operated) Enity
<br />l
<br />Organization Exempt from Tax under Section 501(ar (Ois'S EIN) -
<br />t 6 V0,1 pi vide i 1,., 6 a, WI, , t El YeS N
<br />ri
<br />REQUEST FOR TAXPAYER IDENTIFICATION
<br />NUMBER (TIN) VERIFICATION
<br />e CLOSIClt.CE ! (CI
<br />Chca !lc% if you d nor Pave a cSN or PIN. taut have appikd far 1olt Sio 1-:. .01 infauff Imo 01 Jov L. obtain A 1 iN
<br />Loceme: la ea' 1. .,te Urok,u 5: L No
<br />Under Penalties of perjury, I certify that:
<br />(1) Thu number listed un this form is my correct Taxpa}er Identification Number (Di I am waiting for a number to he issued tu 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 suhjcet to backup withholding as a result of a failure to report all interest or dividends or (c) the IRS has notified me that I
<br />am no luager subject to backup withholding (dies not apply to real estate transactions, miing,,it,c interest paid, the acquisition of abandoemem ktf
<br />secured propely, contribution to an individual retirement arrangement (IPA), and payments other than interest and dividend.),),
<br />CERTIFICATION INSTRUCTIONS – must cross out item (2) above if you have been notified by the IRS that you are currently subject to backup
<br />withholding becau 01 under reporting interest or dividends on your taA return. (See Signing the Certification on the reverse ot this form.)
<br />THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS
<br />DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING
<br />AUTHORIZED SIGNATU
<br />Do NOT WRITE BELOW THIS LINE
<br />gene; _ -
<br />(U49 N _
<br />VEND Aodition Ch.mgr
<br />1
<br />NAME (Print or Type) ?Adi
<br />tYL
<br />^ .4 AILL'eVArer
<br />AGENCY SE ONLY
<br />Appro,ed By _ _
<br />&atm. Completed By
<br />57
<br />Do Not enter i n SSN or FIN trim was not
<br />zissignerl to the legal mime mei cAabove.
<br />SSN
<br />EIN
<br />State 1.f Color
<br />Do NOT send to IRS
<br />RETURN Tr) ADDRESS BEI OW
<br />PART II Sue P11011 Inqtructi,ni ou Rook of Form
<br />(Entity's EIN) 5/4 _
<br />TITLE (Pr(t or Type)
<br />-Yr
<br />DATE 1 J PHONE ( C4L__3 ) W„51_
<br />RETURN BOTH COPIES TO ADDRESS ABOVE
<br />Drile
<br />Dalt
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