First Name

Last Name

Social Security Number or Taxpayer Indentification Number (TIN)

Company Name

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 your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. 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 3.

Address

Check the appropriate box:

Suite / Apt / PO Box No.

City

State

Zip Code

Has your Mailing Address change in the last 12 months?

SPECIAL NOTES or INSTRUCTIONS: