85222 C2b484b614667f4ffff8004ffffe906

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LORENZO'S
TRUCKING SERVICES

INFORMATION

LORENJOS TRUCKING SERVICES STARTED: JUNE/2008
MCS 663226

FED )O* 26-0452579

USOOT a J24W21

BOND POLICY #22512

BOND LIMIT: $10,000.00

BOND INFORMATION:
PACIFIC FINANCIAL ASSOCIATION
SAN DIEGO. CALIFORNIA
PHN; 800.595.2616
EFFECTIVE' NOVEMBER I 2008

WAIN OFFICE;
1517 E. ALBA DRIVE

OWNER / DISPATCH: JOSE GARCIA
ACCOUNTS PAYABLE: BERENICE GARCIA
ACCOUNTS RECIEVEABLE: DEMISE GARCIA

CASA GRANDE. AZ 85222
PHN S20.836.8083 FAX: S20.838 2115

OTHER LOCATIONS.
LOS ANGELES, CA
ROSALlO TAPIA

PHOENIX. AZ

fREDDY GONZALEZ
PHN 623 385 6084 FAX: 623.386 2696
-LOS ANGELES
JOSEPH LOPEZ
PHN: 951.243 2566

FAX; 9S1.413.B3O5

PHN: SKT05.S373

FAX 626 918.5122

LOS ANGELES, CA
ABLE V1DALES
PHN: 951.462.3077

FAX 861.242.0147

BILLING INFORMATK3N:
MAIN OFFICE
-1517 E ALBA DRIVE
CASA GRANDE. AZ 85222
PHN 520.836 8083 FAX 520 836.2115

OWNER ' DISPATCH: JOSE GARCIA
ACCOUNTS PAYABLE: BERENICE GARCIA
ACCOUNTS RECtEVEABLE: DEMISE GARCIA

i LOAD PAPERWORK MUST BE SENT TO THE MAIN OFFICE FOR PAYMENT, LORENZO WILL REMIT PAYMENT WITHIN 3Q
i DAYS FROM RECEIVING PAPERWORK AS LONG AS ORIGINAL SIGNED BILLS, CLEAR DELIVERY RECEIPTS, CURRENT
! INSURANCE. SIGNED CONFIRMATION SHEET IS ON FILE FOR BILLED SHIPMENT, AND LOAD HAS BEEN DELIVERED

i CLEAR OF ANY CLAIMS AND/OR EXCEPTIONS

PAf.f. I / S

1 S 1 7 E - A L O A DRIVE CASA GRANDS. ARIZONA 851 22

M.IIN szn .tm.soa:)

FAX szo.B3fi.2iir.

ALTERNATE szo 431.5168

LORENZO'S
TRUCKING SERVICES
WWW.LORENZOSTRUCKIN6LLC.COM

ANNOUNCEMENT
DEAR VALUED CUSTOMER,
JS FREIGHT BROKERS WOULD LIKE TO INFORM YOU THAT WE HAVE CHANGED
OUR COMPANY NAME EFFECTIVE SEPTEMBER 1,2012 TO LORENZOS
TRUCKING SERVICES. OUR NAME HAS CHANGED, BUT THE SERVICE WE
PROVIDE WILL REMAIN. OUR ADDRESS,CONTACTS AND PHONE NUMBER WILL
REMAIN THE SAME ALONG WITH OUR INSURANCE.AUTHORiTY.TAX ID AND
LICENSE. FOR ANY QUESTIONS OR CONCERNS PLEASE FEEL FREE TO
CONTACT US. WE APOLOGIZE FOR ANY INCONVINIENCE THIS MAY CAUSE.
THANK YOU AND WE APPRECIATE YOUR BUSINESS AND WILL CONTINUE TO
STRIVE FOR THE BEST.

FEEL FREE TO CONTACT US AT 520-636-8083 OR JBGARCIA09@AOL.COM
YOU CAN ALSO VISIT US ONLINE AT WWW.LORENZOSTRUCKINGLLC.COM
THANK YOU!
LORENZOS TRUCKING SERVICES

1517 E. ALBA DRIVE CASA GRANDfc ARIZONA 85122
MAIN 520-836-8083 FAX 520-836-2115 ALTERNATIVE 520^31-5168
WWW.LORENZOSTRUCKINGLLC.COM

LORENZO'S
TRUCKING SERVICES
LORENZO'S TRUCKING SERVICES / CARRIER CONTRACT AGREEMENT

THIS AGREEMENT MADE THIS

20

DAY OF

BY AND BETWEEN

MC#
HEREINAFTER REFERRED TO AS "CARRIER1
AND LORENZO'S TRUCKING SERVICES, MC-663225. CARRIER REPRESENTS THAT IT IS A CONTRACT CARRIER,
HAVING APPROPRIATE REQUIRED AUTHORITY FROM ANY AND ALL GOVERNMENTAL AGENCIES AND DESIRES TO
RETAIN THE SERVICES OF LORENZO'S TRUCKING SERVICES TO OBTAIN GOODS AND MERCHANDISE FOR
TRANSPORTING AS ARE OFFERED BY LORENZO'S TRUCKING SERVICES. LORENZO'S TRUCKING SERVICES
DESIRES TO AVAIL ITSELF OF CARRIER'S MOTOR CARRIER SERVICE. NOW THEREFORE. IN CONSIDERATION OF
THE PREMISES AND THE MUTUAL COVENANTS HEREWITH CONTAINED, IT IS HEREBY AGREED AS FOLLOWS:

1. LORENZO'S TRUCKING SERVICES WILL TENDER A SERIES OF SHIPMENTS TO CARRIER. CARRIER AGREES
TO MAKE EQUIPMENT AVAILABLE ON AN "EXCLUSIVE USE" BASIS OR TO MEET THE "DISTINCT NEEDS" OF
LORENZO'S TRUCKING SERVICES.
2. CARRIER RESERVES THE RIGHT TO REFUSE TO TRANSPORT ANY SHIPMENT FOR ANY REASON IT DEEMS
REASONABLE BEFORE CONSIGNMENT; AFTER CONSIGNMENT, HOWEVER, CARRIER AGREES TO DELIVER EACH
SHIPMENT PURSUANT TO ITS DOT / FMCSA OBLIGATIONS.
3. THE RATE AND OTHER CHARGES TO APPLY TO EACH SHIPMENT TRANSPORTED UNDER THIS AGREEMENT
SHALL BE SET FORTH IN THE LORENZO'S TRUCKING SERVICES RATE CONFIRMATION SHEET, ISSUED BY
LORENZO'S TRUCKING SERVICES WITHIN TWENTY-FOUR (24) HOURS OF THE ORAL AGREEMENT. UNLESS
OBJECTED TO WITHIN TWENTY-FOUR (24) HOURS OF ITS RECEIPT, CARRIER SHALL BE CONCLUSIVELY
PRESUMED TO HAVE AGREED THAT THE TERMS AND CONDITIONS SET FORTH ON SUCH ARE FULLY AND
CORRECTLY STATED.
4. CARRIER AGREES TO HAVE INSURANCE CARRIER FORWARD A CERTIFICATE OF INSURANCE SHOWING
LIABILITY AND CARGO INSURANCE WITH LORENZO'S TRUCKING SERVICES NAMED AS ADDITIONAL INSURED.
CARRIER'S CARGO INSURANCE SHALL BE IN AN AMOUNT SUFFICIENT TO COMPENSATE LORENZO'S TRUCKING
SERVICES, OWNER, OR CONSIGNEE FOR LOSS OR DAMAGE TO PROPERTY TRANSPORTED, BUT IN NO EVENT IN
AN AMOUNT LESS THAN $100,000. CARRIER ALSO AGREES TO PROVIDE 30 DAYS NOTICE PRIOR TO THE
CANCELLATION OF INSURANCE. THE CERTIFICATE IS REQUIRED BEFORE CARRIER CAN BE DISPATCHED ON A
LOAD.
5. CARRIER SHALL BE LIABLE TO OWNER OF CARGO, CONSIGNEE, OR LORENZO'S TRUCKING SERVICES FOR
ANY LOSS OR DAMAGE TO THE PROPERTY OR CARGO WHILE IN THE POSSESSION OF OR UNDER THE CONTROL
OF CARRIER. CARRIER FURTHER AGREES TO INDEMNIFY AND SAVE HARMLESS LORENZO'S TRUCKING SERVICES
FROM AND AGAINST LOSS, DAMAGE, INJURY, INCLUDING DEATH, AND/OR CLAIMS, INCLUDING THE DEFENSE OF
ANY LAWSUITS WHICH ARISE BY THE GROSS NEGLIGENCE OF CARRIER IN CONNECTION WITH THE CARRIAGE OF
ANY AND ALL COMMODITIES OR OPERATION OF THE MOTOR VEHICLE EQUIPMENT UTILIZED BY CARRIER HEREIN
UNDER THIS AGREEMENT.
6. CARRIER AGREES TO RETAIN THIS LORENZO'S TRUCKING SERVICES CONTRACT CARRIER AGREEMENT
AND EACH OF LORENZO'S TRUCKING SERVICES RATE CONFIRMATION SHEET FOR A PERIOD OF THREE (3)
YEARS.

PAGE 4 / 5
1517 E. ALBA DRIVE CASA GRANDE. ARIZONA 85222
MAIN 520.836.8083 FAX 520.836.2115 ALTERNATE 520.431.5168

LORENZO'S
TRUCKING SERVICES
WORKERS COMPENSATION AGREEMENT
(CARRIER) MC#_
, SHALL
INDEMNIFY, DEFEND AND HOLD HARMLESS LORENZO'S TRUCKING SERVICE FROM AND AGAINST ALL LOSS,
DAMAGE, FINES, EXPENSE, ACTIONS, AND CLAIMS FOR INJURY TO CARRIERS EMPLOYEES, AGENTS, OR
SUBCONTRACTORS (INCLUDING INJURY RESULTING IN DEATH) ARISING OUT OF OR IN CONNECTION WITH THE
CARRIER'S DISCHARGE OF DUTIES AND RESPONSIBILITIES UNDER CARRIER CONTRACT AGREEMENT
BETWEEN LORENZO'S TRUCKING SERVICES AND CARRIER.

WE,

I HAVE READ, UNDERSTAND AND AGREE THE ABOVE STATEMENT
AS OF THIS.
DAY OF
, 20
.

CARRIER:

MCS:

SIGNATURE:,

PRINT NAME / OWNER:

DATE:

PAGE 3 / 5
1517 E. ALBA DRIVE CASA GRANDE, ARIZONA 85222
MAIN 520.836.8083 FAX 520.836.2115 ALTERNATE 520.431.5168

LORENZO'S
TRUCKING SERVICES
LORENZO'S TRUCKING SERVICES / CARRIER CONTRACT AGREEMENT

7. CARRIER SHALL NEITHER HAVE NOR CLAIM ANY LIEN RIGHTS ON OR AGAINST ANY PROPERTY
TRANSPORTED UNDER THIS AGREEMENT. HOWEVER, SHOULD A CONSIGNOR OR CONSIGNEE NOTIFY LORENZO'S
TRUCKING SERVICES OF A CLAIM FOR LOSS OR DAMAGE TO PROPERTY TRANSPORTED BY CARRIER UNDER
THIS UNDER THIS AGREEMENT, CARRIER AGREES THAT LORENZO'S TRUCKING SERVICES AND
CONSIGNOR/CONSIGNEE SHALL HAVE THE RIGHT TO SET-OFF AN AMOUNT SUFFICIENT TO COVER SUCH
DAMAGES, AND TO DEDUCT AND WITHHOLD SUCH AMOUNT FROM ANY FREIGHT CHARGE PAYMENTS DUE
CARRIER.
8. LORENZO'S TRUCKING SERVICES AGREES TO PAY CARRIER FOR SERVICES RENDERED WITHIN 30 DAYS
OF LORENZO'S TRUCKING SERVICES RECEIPT OF CARRIER'S INVOICE, CLEAR ORIGINAL SIGNED ORIGINAL BILL
OF LADING, PROOF OF DELIVERY, CURRENT INSURANCE ON FILE, SIGNED CONFIRMATION SHEET IS ON FILE FOR
SHIPMENT AND LOAD HAS BEEN DELIVERED CLEAR OF ANY CLAIMS AND/OR EXCEPTIONS.
9. CARRIER SHALL NOT SOLICIT TRAFFIC FROM ANY SHIPPER, CONSIGNEE, OR CUSTOMER OF LORENZO'S
TRUCKING SERVICES DURING THE TERM OF THIS AGREEMENT AND FOR A PERIOD OF ONE (1) YEAR AFTER. IF
CARRIER "BACK-SOLICITS" ANY OF LORENZO'S TRUCKING SERVICES SHIPPERS, CONSIGNEES, OR CUSTOMER
AND OBTAINS TRAFFIC, LORENZO'S TRUCKING SERVICES IS ENTITLED TO A COMMISSION FROM THE CARRIER OF
15% OF ALL TRANSPORTATION REVENUE RECEIVED ON SUCH TRAFFIC MOVEMENT.
10. THIS AGREEMENT SHALL CONTINUE IN FULL FORCE AND EFFECT FOR A PERIOD OF ONE (1) YEAR, WHICH
TERM SHALL THEREAFTER BE DEEMED AUTOMATICALLY RENEWED FOR SUCCESSIVE YEAR PERIODS; SUBJECT,
HOWEVER, TO THE RIGHT OF THE PARTIES HERETO TO CANCEL OR TERMINATE THE SAME UPON PRIOR WRITTEN
30 DAY NOTICE TO THE OTHER PARTY.
11. THE PARTIES AGREE THAT, SHOULD EITHER PARTY RESORT TO LEGAL ACTION TO ENFORCE THE TERMS OF
THIS AGREEMENT, THE PREVAILING PARTY IN SUCH LEGAL ACTION SHALL, IN ADDITION TO ALL OTHER RELIEF,
RECOVER ITS ACTUAL ATTORNEY'S FEES AND COURT COSTS.
12. IN THE EVENT THAT LEGAL ACTION TO ENFORCE THIS AGREEMENT SHALL BECOME NECESSARY, THE
PARTIES AGREE THAT THE LAWS OF THE STATE OF ARIZONA SHALL GOVERN IT, AND THAT JURISDICTION OVER
THE PARTIES AND SUBJECT MATTER OF THE DISPUTE SHALL BE APPROPRIATE IN MARICOPA COUNTY, ARIZONA.
13. THE PARTIES HERE TO AGREE THAT FACSIMILE SIGNATURES MAY BY AFFIXED TO THIS AGREEMENT, AND
THAT ONCE SO AFFIXED, SHALL BE DEEMED TO BE OF THE SAME FORCE AND EFFECT AS ORIGINAL
SIGNATURES.
IN WITNESS WHEREOF THE PARTIES HAVE EXECUTED THIS AGREEMENT, BY AND THROUGH THEIR DULY
AUTHORIZED REPRESENTATIVES, AS OF THE DATE SET FORTH ABOVE.

JOSE GARCIA
PHN: 520.836.8083 FAX 520.836.2115
LORENZO'S TRUCKING SERVICES

CARRIER:

MC#
SIGNATURE:
PRINT NAME/TITLE:

ALL DOCUMENTS MUST BE FAXED TO 620.836.2115

DATE:
PAGES/5

1517 E. ALBA DRIVE CASA GRANDE. ARIZONA 85222

MAIN 520.836.8083

FAX 520.836.2115

ALTERNATE 520.431.S168

LORENZO'S
TRUCKING SERVICES
DEAR CARRIER.
THANK YOU FOR PARTNERING WITH LORENZOS TRUCKING SERVICES TO BETTER
SERVE YOU & EXPEDITE PAYMENT, WE MUST HAVE YOUR COMPANY'S COMPLETE
INFORMATION IN OUR SYSTEM.WE ASK THAT YOU PLEASE FILL OUT COMPLETELY
AND PRINT LEGIBLY. THANK YOU.
DBA Name:

Legal Name:
Address:

City:.

Zip:

State:

Phone:

Fax:

Cell:

E-Mail:
Ace Contact:

Dispatch Contact:

FED ID#

USDOT#

MC#

_How Many:_

Type Of Equipment:.

Size:

Lanes/ States:
Additional Info:
Notes:
Date Entered:

Entered By:

Time:

WE ALSO REQUIRE THE FOLLOWING DOCUMENTS FILLED OUT & FAXED BACK TO
COMPLETE THE SET UP PROCESS:
-CARRIERS CURRENT CARGO & LIABILITY INSURANCE
-CARRIERS MC/ICC AUTHORITY
-CARRIERS W9 TAX FORM
-LORENZOS CARRIER PACKET FILLED OUTRAGES 2-5
"ALL DOCUMENTS MUST BE FAXED TO 520-836-2115**
PAGE 2/5
1517 E. ALBA DRIVE CASA GRANDE. AZ 85122
MAIN:520-836-8083 FAX:520-836-2115 ALT:520-431-5168

Lorenzos Trucking Services
1517 E. Alba Dr.
Casa Grande AZ 85122
Phn: 520-836-8083 Fax:520-836-2115
E-Mail ibgarcia09@aol.com
MC# 663225

Request for.

To Whom It May Concern please add Lorenzos
Trucking Services as a certificate Holder.Fax back to
520-836-2115

Thank You
AP Department

Commercial Certificate of Liability Insurance
Agency BRIAN COX INSURANCE
Name 2°° s LEROUX ST STE. 1

Issue Date

&
FLAGSTAFF, AZ 86001
Address

is.

Dist.Q2

FARMERS

Agent _3i_

(MM/DD/YY)!

11/09/12

This certificate is issuwt as a natter of information only and confers no rights
•poa UK certificate holder. This certificate does net affnnatively or nejativdy
amenl, extend or alter the coverage afforded by the policies shown below.
This certificate of insurance does not constitute a contract betwera the issuing
insurerd), authorized representative or producer, and the certificate holder.

Insured LORENZO'S TRUCKING LLC.
DBA: LORENZO'S TRUCKING SERVICES
&
1517 E ALBA
Address CASA GRANDE, AZ 85122

Companies Providing Coverage (NAIC #):
Company Letter A Truck Insurance Exchange 21709
Company Letter B Farmers Insurance Exchange 21652
Company Letter C Mid-Century Insurance Company 21687
Company Le ttfr D

v
.
l\arnt:

Coverages
This jg to certify that the policies of Insurance Jisced below have been Issued to the insured named above for the policy period
indicated. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this
certificate may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions
and conditions of such oolicies. Limits shown may have been reduced bv paid claims.
Pufcy Effective
Policy Expiation
Co. Add'l
Policy Limits
Pokey Number Dau(Ut/DD/YY) fete (HH/DO/YV)
Ltr, Insrd. Type of Insurance
Genera] Liability
Each Occurrence
$ 1,000,000
11/09/12
604776860
11/09/13
C
_X_ Commercial General Liab.
Damage To Rented
Premiss (Ea. Occur.)
Medical Expenses
(Any one person)
Personal & Adv. Injury

$
$

$

Genera! Aggregate Limit Applies
Per Location

Automobile Liability
Any Auto

C

604776860

11/09/12

11/09/13

-X— Scheduled Autos
-X— Hired Autos
X
Non-Owned Autos

General Aggregate

$ 2,000,000

Prod./Comp. Ops. Aggr.

$

Combined Single Limit $ 1,000,000
(Each accldentf
Bodily Injury
(Per person;
Bodily Injury
(Per accident)
Property Damage
(rer accident;
Auto Only-Ea. Accident

$
$
$

$
Other Than Each Accident s
Auto Only.

Garage Liability
Any Auto

Aggregate

Umbrella Liability
Retention $

Limit

$

s

Statutory

Workers' Compensation and
Employers Liability

Each Accident
Disease - Ea. Employee
Disease - Policy Limit

$
$
$

Description of Operations/Vehiclcs/Restrictions/Special items:

ALSO CARRIES $100,000 IN CARGO INSURANCE - POLICY 604776860- EFFECTIVE 11/09/2012 - EXPIRES 11/09/2013

Certificate Holder
ne

UNIVERSAL FOREST PRODUCTS INC ITS
AFFILIATES & SUBSIDIARIES

Address

Cancellation
Should any of the above described policies be cancelled
before the expiration date thereof, notice wlil be delivered in
accordance with the policy provisions.

g SUITE 100

Authorized ReprtSenta
56-2492 10-11

C249Z201

PAGE 1 OF Z

W-9

Request for Taxpayer
Identification Number and Certification

Give Form to the
requester. Do not
send to the IRS.

Ar]ifri"-s (ruiniht-ii. street.  t . or suitu no )

Oily, stiilii. ,inii ZIP cndu

1 ,^t .11 i ' i1, inl number is) hcic (optional)

Taxpayer Identification Number (TIN)
L:ntcr your I IN in the appropriate box. The I IN provided must match the name given on the "Name" line
to avoid backup withholding. For individuals, this is your social security number (SSN). I lowever, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. I or other
entities, it is your employer identification number (FIN). If you do not have a number, see How to gef a
UN on page 3.

Social security number

Note. If the account is in more than one name-, sno the chart on page 4 for guidelines on whose
ae
number to enter.

Em ployer

identification number
-

f

Certification
Under penalties of perjury, I certify that:
1. I he 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 arn not subject to backup withholding because; fa) I am exempt from backup withholding, or (b) I have not been notified by the Internal Hevenue
Service (IRS) that I am subject to backup withholding as a result of a failuto 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).
Certification instructions. You must cross out item 2 above if you have boon notified by tho IMS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. F or real estate transactions, item 2 does not apply. For mortgage
interest paid, aoquisition 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 on page 4.

Sign
Here

Signature of
U.S. person

General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.

Purpose of Form
A person who is required to file an information return with the IMS must
obtain your correct taxpayer identification number (TIN) to report, for
example, income paid to you, real estate transactions, mortgage interest
you paid, acquisition or abandonment of secured property, cancellation
of debt, or contributions you made to an IRA.
Use Form W-'J only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (tho
requester) and. when applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued),
?.. 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 ot any partnership income from a U.S. trade or business
is not subject to the withholding tax on foreign partners' shate of
effectively connected income.

Note. If 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. I or 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 ./VU1 7).
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to pay a withholding
tax on any foreign partners' share of income from such business.
Further, in certain cases where a Form W-9 has not been received, a
partnership is required to presume that a partner is a foreign person,
and pay the withholding tax. Therefore, if you arc 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 withholding on your share of partnership income.

l-orm W-9

(Hov. 12-2011)

Paqc 3

Other entities. Enter your business name as shown on required federal
lax documents on the "Name'1 line. 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 the "Business name/
disregarded entity name" line.

Exempt Payee
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status, then
check the "Exempt payee" box in the line following the "Business name/
disregarded entity name," sign and date the form.
Generally, individuals (including sole proprietors) are not exempt from
backup withholding. Corporations are exempt from backup withholding
for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should still
complete this form to avoid possible erroneous backup withholding.
The following payees are exempt from backup withholding:
1. An organization exempt from tax under section 501 (a), any IRA, or a
custodial account under section 403(b)(/) if the account satisfies the
requirements of section 4Q1(f)(2),
2. The United States or any of its agencies or instrumentalities,
3. A state, the District of Columbia, a possession of the United States,
or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions, agencies,
or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding include:
6. A corporation,
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register in the
United States, the District of Columbia, or a possession of the United
States,
9. A futures commission merchant registered with the Commodity
Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year under the
Investment Company Act of 1940,
12. A common trust fund operated by a bank under section 584(a),
13. A financial institution,
14. A middleman known in the investment community as a nominee or
custodian, or
15. A trust exempt from tax under section 664 or described in section
494/.
I he following chart shows types of payments that may be exempt
from backup withholding. The chart applies to the exempt payees listed
above, 1 through 15.
IF the payment is for . . .

THEN the payment is exempt
for ...

Interest and dividend payments

AN exempt payees except
for 9

Broker transactions

Exempt payees 1 through 5 and 7
through 13. Also, C corporations.

Barter exchange transactions and
patronage dividends

Exempt payees 1 through 5

Payments over $000 required to be Generally, exempt payees
reported and direct sales over
1 through 7 '
$5.000 '

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 I TIN, 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. However, the IRS prefers that you use your SSN.
If you are a single-member LEG that is disregarded as an entity
separate from its owner (see Limited Liability Company (L I.C) on page ?),
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 the chart on page 4 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 Social Security Administration office or get this
form online at www.ss3.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. You can get Forms W-7 and SS-4 from the IRS by visiting
IRS.gov or by calling 1 -800-TAX-FORM (1 -800-829-3676).
If you are asked to complete Form W-9 but do not have a TIN, 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 domestic 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, below, and items 4 and 5 on page 4
indicate 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 the "Name" line must sign. Exempt payees, see
Exempt Payee on page 3.
Signature requirements. Complete the certification as indicated in
items 1 through 3, below, and items 4 and 5 on page 4.
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 ? 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.



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Source Exif Data:

File Type                       : PDF
File Type Extension             : pdf
MIME Type                       : application/pdf
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