Name *

As shown on your income tax return

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Taxpayer Certification *

Under penalties of perjury, I certify that: 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 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 I am a U.S. citizen or other U.S. person; and The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. | The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Sign Date *

MM

DD

YYYY

Electronic delivery

Uncheck to receive a mailed copy in addition to an electronic copy.

Only issue me electronic 1099 forms