Request Service

(CPNI Password is required when calling RTC.)

Business Broadband Facts Labels

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 Networks' 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 RTC Networks prevailing hourly rate plus materials.

RTC Networks offers one residential gateway for lease as part of the package. Residential gateways, power supplies, and cords remain the property of RTC Networks, 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 Networks 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 Networks' Acceptable Use Policy; it is listed in the Legal Notices section of our website www.myRTCNetworks.com. Violation of the policy may jeopardize your service.

I have read and understand the above information and authorize RTC Networks 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.

All RTC Networks customers are automatically enrolled in our Operation Round Up program, a community-service fundraising initiative. Under this program, your bill will be rounded up to the nearest dollar, and 100% of the additional funds will be awarded to qualifying local community projects based on applications from our members. If you prefer not to participate, please contact us and we will remove you from the program.

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.

This institution is an equal opportunity provider and employer.

Payment Options Brochure

Power Backup Disclosure

W-9 Form

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); and
2. 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; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. 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 Form
An 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.

PAGE 2:

By signing the filled-out form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt
payee. If applicable, you are also certifying that as a U.S. person, your
allocable share of any partnership income from a U.S. trade or business
is not subject to the withholding tax on foreign partners' share of
effectively connected income, and
4. Certify that FATCA code(s) entered on this form (if any) indicating
that you are exempt from the FATCA reporting, is correct. See What is
FATCA reporting, later, for further information.
Note: If you are a U.S. person and a requester gives you a form other
than Form W-9 to request your TIN, you must use the requester’s form if
it is substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered 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 or
organized 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 or
business in the United States are generally required to pay a withholding
tax under section 1446 on any foreign partners’ share of effectively
connected taxable income from such business. Further, in certain cases
where a Form W-9 has not been received, the rules under section 1446
require a partnership to presume that a partner is a foreign person, and
pay the section 1446 withholding tax. Therefore, if you are a U.S. person
that is a partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to establish your
U.S. status and avoid section 1446 withholding on your share of
partnership income.
In the cases below, the following person must give Form W-9 to the
partnership for purposes of establishing its U.S. status and avoiding
withholding on its allocable share of net income from the partnership
conducting a trade or business in the United States.
• In the case of a disregarded entity with a U.S. owner, the U.S. owner
of 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 and
not 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 a
foreign bank that has elected to be treated as a U.S. person, do not use
Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see
Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
Nonresident alien who becomes a resident alien. Generally, only a
nonresident alien individual may use the terms of a tax treaty to reduce
or eliminate U.S. tax on certain types of income. However, most tax
treaties contain a provision known as a “saving clause.” Exceptions
specified in the saving clause may permit an exemption from tax to
continue for certain types of income even after the payee has otherwise
become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an exemption
from U.S. tax on certain types of income, you must attach a statement
to Form W-9 that specifies the following five items.
1. The treaty country. Generally, this must be the same treaty under
which 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 the
saving clause and its exceptions.
4. The type and amount of income that qualifies for the exemption
from tax.
5. Sufficient facts to justify the exemption from tax under the terms of
the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an
exemption from tax for scholarship income received by a Chinese
student temporarily present in the United States. Under U.S. law, this
student will become a resident alien for tax purposes if his or her stay in
the United States exceeds 5 calendar years. However, paragraph 2 of
the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows
the provisions of Article 20 to continue to apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of the first
protocol) and is relying on this exception to claim an exemption from tax
on his or her scholarship or fellowship income would attach to Form
W-9 a statement that includes the information described above to
support that exemption.
If you are a nonresident alien or a foreign entity, give the requester the
appropriate completed Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons making certain payments to you
must under certain conditions withhold and pay to the IRS 24% of such
payments. This is called “backup withholding.” Payments that may be
subject 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 and
third party network transactions, and certain payments from fishing boat
operators. Real estate transactions are not subject to backup
withholding.
You will not be subject to backup withholding on payments you
receive if you give the requester your correct TIN, make the proper
certifications, and report all your taxable interest and dividends on your
tax 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 for
Part 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 withholding
because you did not report all your interest and dividends on your tax
return (for reportable interest and dividends only), or
5. You do not certify to the requester that you are not subject to
backup withholding under 4 above (for reportable interest and dividend
accounts opened after 1983 only).
Certain payees and payments are exempt from backup withholding.
See Exempt payee code, later, and the separate Instructions for the
Requester 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 a
participating foreign financial institution to report all United States
account holders that are specified United States persons. Certain
payees are exempt from FATCA reporting. See Exemption from FATCA
reporting code, later, and the Instructions for the Requester of Form
W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you
claimed to be an exempt payee if you are no longer an exempt payee
and anticipate receiving reportable payments in the future from this
person. For example, you may need to provide updated information if
you are a C corporation that elects to be an S corporation, or if you no
longer are tax exempt. In addition, you must furnish a new Form W-9 if
the name or TIN changes for the account; for example, if the grantor of a
grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such failure
unless your failure is due to reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you
make a false statement with no reasonable basis that results in no
backup withholding, you are subject to a $500 penalty.

PAGE 3:

Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal penalties
including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of
federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Line 1
You must enter one of the following on this line; do not leave this line
blank. The name should match the name on your tax return.
If this Form W-9 is for a joint account (other than an account
maintained by a foreign financial institution (FFI)), list first, and then
circle, the name of the person or entity whose number you entered in
Part I of Form W-9. If you are providing Form W-9 to an FFI to document
a joint account, each holder of the account that is a U.S. person must
provide a Form W-9.
a. Individual. Generally, enter the name shown on your tax return. If
you have changed your last name without informing the Social Security
Administration (SSA) of the name change, enter your first name, the last
name as shown on your social security card, and your new last name.
Note: ITIN applicant: Enter your individual name as it was entered on
your Form W-7 application, line 1a. This should also be the same as the
name you entered on the Form 1040/1040A/1040EZ you filed with your
application.
b. Sole proprietor or single-member LLC. Enter your individual
name as shown on your 1040/1040A/1040EZ on line 1. You may enter
your business, trade, or “doing business as” (DBA) name on line 2.
c. Partnership, LLC that is not a single-member LLC, C
corporation, or S corporation. Enter the entity's name as shown on the
entity's tax return on line 1 and any business, trade, or DBA name on
line 2.
d. Other entities. Enter your name as shown on required U.S. federal
tax documents on line 1. This name should match the name shown on the
charter or other legal document creating the entity. You may enter any
business, trade, or DBA name on line 2.
e. Disregarded entity. For U.S. federal tax purposes, an entity that is
disregarded as an entity separate from its owner is treated as a
“disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter
the owner's name on line 1. The name of the entity entered on line 1
should never be a disregarded entity. The name on line 1 should be the
name shown on the income tax return on which the income should be
reported. For example, if a foreign LLC that is treated as a disregarded
entity 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. If
the direct owner of the entity is also a disregarded entity, enter the first
owner that is not disregarded for federal tax purposes. Enter the
disregarded entity's name on line 2, “Business name/disregarded entity
name.” If the owner of the disregarded entity is a foreign person, the
owner 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 2
If you have a business name, trade name, DBA name, or disregarded
entity name, you may enter it on line 2.
Line 3
Check the appropriate box on line 3 for the U.S. federal tax
classification of the person whose name is entered on line 1. Check only
one box on line 3.
IF the entity/person on line 1 is
a(n) . . .
THEN check the box for . . .
• Corporation Corporation
• Individual
• Sole proprietorship, or
• Single-member limited liability
company (LLC) owned by an
individual and disregarded for U.S.
federal tax purposes.
Individual/sole proprietor or singlemember
LLC
• LLC treated as a partnership for
U.S. federal tax purposes,
• LLC that has filed Form 8832 or
2553 to be taxed as a corporation,
or
• LLC that is disregarded as an
entity separate from its owner but
the owner is another LLC that is
not disregarded for U.S. federal tax
purposes.
Limited liability company and enter
the appropriate tax classification.
(P= Partnership; C= C corporation;
or S= S corporation)
• Partnership Partnership
• Trust/estate Trust/estate
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting,
enter in the appropriate space on line 4 any code(s) that may apply to
you.
Exempt payee code.
• Generally, individuals (including sole proprietors) are not exempt from
backup withholding.
• Except as provided below, corporations are exempt from backup
withholding for certain payments, including interest and dividends.
• Corporations are not exempt from backup withholding for payments
made in settlement of payment card or third party network transactions.
• Corporations are not exempt from backup withholding with respect to
attorneys’ fees or gross proceeds paid to attorneys, and corporations
that provide medical or health care services are not exempt with respect
to payments reportable on Form 1099-MISC.
The following codes identify payees that are exempt from backup
withholding. Enter the appropriate code in the space in line 4.
1—An organization exempt from tax under section 501(a), any IRA, or
a custodial account under section 403(b)(7) if the account satisfies the
requirements of section 401(f)(2)
2—The United States or any of its agencies or instrumentalities
3—A state, the District of Columbia, a U.S. commonwealth or
possession, or any of their political subdivisions or instrumentalities
4—A foreign government or any of its political subdivisions, agencies,
or instrumentalities
5—A corporation
6—A dealer in securities or commodities required to register in the
United States, the District of Columbia, or a U.S. commonwealth or
possession
7—A futures commission merchant registered with the Commodity
Futures Trading Commission
8—A real estate investment trust
9—An entity registered at all times during the tax year under the
Investment Company Act of 1940
10—A common trust fund operated by a bank under section 584(a)
11—A financial institution
12—A middleman known in the investment community as a nominee or
custodian
13—A trust exempt from tax under section 664 or described in section
4947

PAGE 4:

The following chart shows types of payments that may be exempt
from backup withholding. The chart applies to the exempt payees listed
above, 1 through 13.
IF the payment is for . . . THEN the payment is exempt
for . . .
Interest and dividend payments All exempt payees except
for 7
Broker transactions Exempt payees 1 through 4 and 6
through 11 and all C corporations.
S corporations must not enter an
exempt payee code because they
are exempt only for sales of
noncovered securities acquired
prior to 2012.
Barter exchange transactions and
patronage dividends
Exempt payees 1 through 4
Payments over $600 required to be
reported and direct sales over
$5,0001
Generally, exempt payees
1 through 52
Payments made in settlement of
payment card or third party network
transactions
Exempt payees 1 through 4
1 See Form 1099-MISC, Miscellaneous Income, and its instructions.
2 However, the following payments made to a corporation and
reportable on Form 1099-MISC are not exempt from backup
withholding: medical and health care payments, attorneys’ fees, gross
proceeds paid to an attorney reportable under section 6045(f), and
payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify
payees that are exempt from reporting under FATCA. These codes
apply to persons submitting this form for accounts maintained outside
of the United States by certain foreign financial institutions. Therefore, if
you are only submitting this form for an account you hold in the United
States, you may leave this field blank. Consult with the person
requesting this form if you are uncertain if the financial institution is
subject to these requirements. A requester may indicate that a code is
not required by providing you with a Form W-9 with “Not Applicable” (or
any similar indication) written or printed on the line for a FATCA
exemption code.
A—An organization exempt from tax under section 501(a) or any
individual retirement plan as defined in section 7701(a)(37)
B—The United States or any of its agencies or instrumentalities
C—A state, the District of Columbia, a U.S. commonwealth or
possession, or any of their political subdivisions or instrumentalities
D—A corporation the stock of which is regularly traded on one or
more established securities markets, as described in Regulations
section 1.1472-1(c)(1)(i)
E—A corporation that is a member of the same expanded affiliated
group as a corporation described in Regulations section 1.1472-1(c)(1)(i)
F—A dealer in securities, commodities, or derivative financial
instruments (including notional principal contracts, futures, forwards,
and options) that is registered as such under the laws of the United
States or any state
G—A real estate investment trust
H—A regulated investment company as defined in section 851 or an
entity registered at all times during the tax year under the Investment
Company Act of 1940
I—A common trust fund as defined in section 584(a)
J—A bank as defined in section 581
K—A broker
L—A trust exempt from tax under section 664 or described in section
4947(a)(1)
M—A tax exempt trust under a section 403(b) plan or section 457(g)
plan
Note: You may wish to consult with the financial institution requesting
this form to determine whether the FATCA code and/or exempt payee
code should be completed.
Line 5
Enter your address (number, street, and apartment or suite number).
This is where the requester of this Form W-9 will mail your information
returns. If this address differs from the one the requester already has on
file, write NEW at the top. If a new address is provided, there is still a
chance the old address will be used until the payor changes your
address in their records.
Line 6
Enter 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 and
you do not have and are not eligible to get an SSN, your TIN is your IRS
individual taxpayer identification number (ITIN). Enter it in the social
security number box. If you do not have an ITIN, see How to get a TIN
below.
If you are a sole proprietor and you have an EIN, you may enter either
your SSN or EIN.
If you are a single-member LLC that is disregarded as an entity
separate from its owner, enter the owner’s SSN (or EIN, if the owner has
one). Do not enter the disregarded entity’s EIN. If the LLC is classified as
a corporation or partnership, enter the entity’s EIN.
Note: See What Name and Number To Give the Requester, later, for
further 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 Security
Card, from your local SSA office or get this form online at
www.SSA.gov. You may also get this form by calling 1-800-772-1213.
Use Form W-7, Application for IRS Individual Taxpayer Identification
Number, to apply for an ITIN, or Form SS-4, Application for Employer
Identification Number, to apply for an EIN. You can apply for an EIN
online by accessing the IRS website at www.irs.gov/Businesses and
clicking on Employer Identification Number (EIN) under Starting a
Business. Go to www.irs.gov/Forms to view, download, or print Form
W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to
place an order and have Form W-7 and/or SS-4 mailed to you within 10
business days.
If you are asked to complete Form W-9 but do not have a TIN, apply
for a TIN and write “Applied For” in the space for the TIN, sign and date
the form, and give it to the requester. For interest and dividend
payments, and certain payments made with respect to readily tradable
instruments, generally you will have 60 days to get a TIN and give it to
the requester before you are subject to backup withholding on
payments. The 60-day rule does not apply to other types of payments.
You will be subject to backup withholding on all such payments until
you provide your TIN to the requester.
Note: Entering “Applied For” means that you have already applied for a
TIN or that you intend to apply for one soon.
Caution: A disregarded U.S. entity that has a foreign owner must use
the appropriate Form W-8.
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or
resident alien, sign Form W-9. You may be requested to sign by the
withholding agent even if item 1, 4, or 5 below indicates otherwise.
For a joint account, only the person whose TIN is shown in Part I
should sign (when required). In the case of a disregarded entity, the
person identified on line 1 must sign. Exempt payees, see Exempt payee
code, earlier.
Signature requirements. Complete the certification as indicated in
items 1 through 5 below.

PAGE 5:

1. Interest, dividend, and barter exchange accounts opened
before 1984 and broker accounts considered active during 1983.
You must give your correct TIN, but you do not have to sign the
certification.
2. Interest, dividend, broker, and barter exchange accounts
opened after 1983 and broker accounts considered inactive during
1983. You must sign the certification or backup withholding will apply. If
you are subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2 in the
certification before signing the form.
3. Real estate transactions. You must sign the certification. You may
cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but you do not
have to sign the certification unless you have been notified that you
have previously given an incorrect TIN. “Other payments” include
payments made in the course of the requester’s trade or business for
rents, royalties, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to
a nonemployee for services, payments made in settlement of payment
card and third party network transactions, payments to certain fishing
boat crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified tuition program
payments (under section 529), ABLE accounts (under section 529A),
IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct
TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account: Give name and SSN of:
1. Individual The individual
2. Two or more individuals (joint
account) other than an account
maintained by an FFI
The actual owner of the account or, if
combined funds, the first individual on
the account1
3. Two or more U.S. persons
(joint account maintained by an FFI)
Each holder of the account
4. Custodial account of a minor
(Uniform Gift to Minors Act)
The minor2
5. a. The usual revocable savings trust
(grantor is also trustee)
b. So-called trust account that is not
a legal or valid trust under state law
The grantor-trustee1
The actual owner1
6. Sole proprietorship or disregarded
entity owned by an individual
The owner3
7. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Regulations 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 an
individual
The owner
9. A valid trust, estate, or pension trust Legal entity4
10. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
The corporation
11. Association, club, religious,
charitable, educational, or other taxexempt
organization
The organization
12. Partnership or multi-member LLC The partnership
13. A broker or registered nominee The broker or nominee
For this type of account: Give name and EIN of:
14. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
The public entity
15. Grantor trust filing under the Form
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulations section 1.671-4(b)(2)(i)(B))
The trust
1 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 number
must 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 your
business or DBA name on the “Business name/disregarded entity”
name line. You may use either your SSN or EIN (if you have one), but the
IRS encourages you to use your SSN.
4 List first and circle the name of the trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the
legal entity itself is not designated in the account title.) Also see Special
rules 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, the
number will be considered to be that of the first name listed.
Secure Your Tax Records From Identity Theft
Identity theft occurs when someone uses your personal information
such as your name, SSN, or other identifying information, without your
permission, to commit fraud or other crimes. An identity thief may use
your SSN to get a job or may file a tax return using your SSN to receive
a 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 a
notice from the IRS, respond right away to the name and phone number
printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you
think you are at risk due to a lost or stolen purse or wallet, questionable
credit card activity or credit report, contact the IRS Identity Theft Hotline
at 1-800-908-4490 or submit Form 14039.
For more information, see Pub. 5027, Identity Theft Information for
Taxpayers.
Victims of identity theft who are experiencing economic harm or a
systemic problem, or are seeking help in resolving tax problems that
have not been resolved through normal channels, may be eligible for
Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD
1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of email and websites designed to
mimic legitimate business emails and websites. The most common act
is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
private information that will be used for identity theft.

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The IRS does not initiate contacts with taxpayers via emails. Also, the
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers, passwords, or similar secret access
information 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 phishing@irs.gov. You may also report misuse
of the IRS name, logo, or other IRS property to the Treasury Inspector
General for Tax Administration (TIGTA) at 1-800-366-4484. You can
forward suspicious emails to the Federal Trade Commission at
spam@uce.gov or report them at www.ftc.gov/complaint. You can
contact 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.gov
and Pub. 5027.
Visit www.irs.gov/IdentityTheft to learn more about identity theft and
how to reduce your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your
correct TIN to persons (including federal agencies) who are required to
file information returns with the IRS to report interest, dividends, or
certain other income paid to you; mortgage interest you paid; the
acquisition or abandonment of secured property; the cancellation of
debt; or contributions you made to an IRA, Archer MSA, or HSA. The
person collecting this form uses the information on the form to file
information returns with the IRS, reporting the above information.
Routine uses of this information include giving it to the Department of
Justice for civil and criminal litigation and to cities, states, the District of
Columbia, and U.S. commonwealths and possessions for use in
administering their laws. The information also may be disclosed to other
countries under a treaty, to federal and state agencies to enforce civil
and criminal laws, or to federal law enforcement and intelligence
agencies to combat terrorism. You must provide your TIN whether or
not you are required to file a tax return. Under section 3406, payers
must generally withhold a percentage of taxable interest, dividend, and
certain other payments to a payee who does not give a TIN to the payer.
Certain penalties may also apply for providing false or fraudulent
information.