EX-99.(A)(1)(G) 7 t1300350exa1g.htm EXHIBIT 99.(A)(1)(G)

 

Exhibit (a)(1)(G)

 

PAYER’S NAME: Wells Fargo Bank, N.A.

SUBSTITUTE

 

FORM W-9

 

Department of the Treasury
Internal Revenue Service

 

Part 1 – PLEASE PROVIDE YOUR TIN IN THE BOX AT RIGHT AND CERTIFY BY SIGNING AND DATING BELOW.

 

CHECK APPROPRIATE BOX:

 

¨ Individual/Sole Proprietor

 

Social Security Number or

Employer Identification Number

Payer’s Request for Taxpayer
Identification Number (“TIN”)

¨ Corporation

 

¨ Partnership

 

¨ Other

Part 3 –

Awaiting TIN

¨

   

Part 4 —
Exempt

¨

 

Please fill in your name and address below. Part 2 – Certification – Under penalties of perjury, I certify that:
   
Name

(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);

(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 (the “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;

(3)  I am a U.S. Person (including a U.S. resident alien); and

(4)  I am not a disregarded entity as defined in Treasury Regulation Section 1.1445-2(b)(2)(iii).

 

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.

 

I understand that this certification may be disclosed to the IRS by Purchaser and that any false statement I have made here could be punished by fine, imprisonment, or both.

 

SIGNATURE                                         DATE

 
Address (Number and Street)
 
City, State and Zip Code










NOTE: FAILURE TO COMPLETE AND RETURN THIS FORM MAY RESULT IN BACKUP WITHHOLDING OF A PORTION OF ANY PAYMENTS MADE TO YOU PURSUANT TO THE OFFER. PLEASE REVIEW THE ENCLOSED GUIDELINES FOR CERTIFICATION OF TAXPAYER IDENTIFICATION NUMBER ON SUBSTITUTE FORM W-9 FOR ADDITIONAL DETAILS.

 

YOU MUST COMPLETE THE FOLLOWING CERTIFICATE IF YOU CHECKED THE BOX IN PART 3 OF SUBSTITUTE FORM W-9.

 

 

CERTIFICATE OF AWAITING TAXPAYER IDENTIFICATION NUMBER

I certify under penalties of perjury that a Taxpayer Identification Number has not been issued to me, and either (1) I have mailed or delivered an application to receive a Taxpayer Identification Number to the appropriate Internal Revenue Service Center or Social Security Administration Office, or (2) I intend to mail or deliver an application in the near future. I understand that if I do not provide a Taxpayer Identification Number by the time of payment, a portion of all reportable payments made to me will be withheld.

 

Signature:                                                        Date:                        

 

 

 
 

  

 

 

GUIDELINES FOR CERTIFICATION OF TAXPAYER IDENTIFICATION
NUMBER ON SUBSTITUTE FORM W-9

 

GUIDELINES FOR DETERMINING THE PROPER IDENTIFICATION NUMBER TO GIVE THE PAYER. – Social Security numbers have nine digits separated by two hyphens: i.e., 000-00-0000. Employer identification numbers have nine digits separated by only one hyphen: i.e., 00-0000000. The table below will help determine the number to give the payer.

 

WHAT NAME AND NUMBER TO GIVE THE PAYER

 

For this type of account:   Give name and SSN of:
1. Individual   The individual
2. Two or more individuals (joint account)   The actual owner of the account or, if combined funds, the first individual on the account(1)
3. Custodian account of a minor (Uniform Gift to Minors Act)   The minor(2)
4. a. The usual revocable savings trust (grantor is also trustee)   The grantor-trustee(1)
  b. So-called trust account that is not a legal or valid trust under state law   The actual owner(1)
5. Sole proprietorship or disregarded entity owned by an individual   The owner(3)

 

For this type of account:   Give name and EIN of:
6. Disregarded entity not owned by an individual   The owner
7. A valid trust, estate, or pension trust   Legal entity(4)
8. Corporation or LLC electing corporate status on IRS   The corporation
  Form 8832 or IRS Form 2553    
9. Association, club, religious, charitable, educational, or other tax-exempt organization   The organization
10. Partnership or multi-member LLC   The partnership
11. A broker or registered nominee   The broker or nominee
12. Account with the Department of Agriculture in the name of a public entity (such as state or local government, school district, or prison)  that receives agricultural program payments   The public entity

(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 second name line. You may use either your SSN or EIN (if you have one). If you are a sole proprietor, 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.)

 

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.

 

 
 

 

 

GUIDELINES FOR CERTIFICATION OF TAXPAYER IDENTIFICATION
NUMBER ON SUBSTITUTE FORM W-9

PAGE 2

 

OBTAINING A NUMBER

 

If you don’t have a Taxpayer Identification Number or you don’t know your number, obtain Form SS-5, Application for a Social Security Number Card, or Form SS-4, Application for Employer Identification Number, at the local office of the Social Security Administration or the Internal Revenue Service and apply for a number.

 

PAYEES EXEMPT FROM BACKUP WITHHOLDING

 

Payees specifically exempted from backup withholding include the following:

 

·A corporation.

 

·A financial institution.

 

·An organization exempt from tax under section 501(a), or an individual retirement plan or a custodial account under section 403 (b)(7) if the account satisfies the requirements of section 401(f)(2).

 

·The United States or any agency or instrumentality thereof.

 

·A State, the District of Columbia, a possession of the United States, or any subdivision or instrumentality thereof.

 

·A foreign government, a political subdivision of a foreign government, or any agency or instrumentality thereof.

 

·An international organization or any agency, or instrumentality thereof.

 

·A registered dealer in securities or commodities registered in the United States or a possession of the United States.

 

·A real estate investment trust.

 

·A common trust fund operated by a bank under section 584(a).

 

·An entity registered at all times during the tax year under the Investment Company Act of 1940.

 

·A foreign central bank of issue.

 

·A futures commission merchant registered with the Commodity Futures Trading Commission.

 

·A middleman known in the investment community as a nominee or custodian.

 

Exempt payees described above should file Substitute Form W-9 to avoid possible erroneous backup withholding. FILE THIS FORM WITH THE PAYER, FURNISH YOUR TAXPAYER IDENTIFICATION NUMBER, CHECK THE BOX IN PART 4, SIGN AND DATE THE FORM, AND RETURN IT TO THE PAYER.

 

Certain payments that are not subject to information reporting are also not subject to backup withholding. For details, see the Treasury regulations under sections 6041, 6041A(a), 6045, and 6050A of the Internal Revenue Code.

 

PRIVACY ACT NOTICE – Section 6109 of the Internal Revenue Code requires most recipients of dividend, interest, or other payments to give taxpayer identification numbers to payers who must report the payments to IRS. IRS uses the numbers for identification purposes. Payers must be given the numbers whether or not recipients are required to file tax returns. Payers must generally withhold a portion of taxable interest, dividend, and certain other payments to a payee who does not furnish a taxpayer identification number to a payer. Certain penalties may also apply.

 

 
 

 

PENALTIES

 

(1) PENALTY FOR FAILURE TO FURNISH TAXPAYER IDENTIFICATION NUMBER – If you fail to furnish your taxpayer identification number to a payer, 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.

 

(2) CIVIL PENALTY FOR FALSE INFORMATION WITH RESPECT TO WITHHOLDING – If you make a false statement with no reasonable basis which results in no imposition of backup withholding, you are subject to a penalty of $500.

 

(3) CRIMINAL PENALTY FOR FALSIFYING INFORMATION – Falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

 

FOR ADDITIONAL INFORMATION CONTACT YOUR TAX CONSULTANT OR THE INTERNAL REVENUE SERVICE.