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ASSET MANAGEMENT SPECIALISTS, INC.

220 Rittenhouse Circle Bristol, PA 19007 Office (866) 699-1734 **Please fax all application documents to:

215-486-3238

BUSINESS INFORMATION: (Please print legibly)
Business Name: Business Address: State: City: Phone: Mobile Phone: Fax Number: Email: Home Address: City: State: Contact Person:

TAX IDENTIFICATION INFORMATION Social Security Number: Or Employer Identification Number:

Please ensure the following documents are included with your application documents. (Check each as they are included)

□ □ □ □

Tax Identification Certificate (W-9) Drivers License Social Security Card Certificate of Insurance (Work Comp required on Sole Proprietors)

Fax all application documents to 215-486-3238 or email to vendormanagement@amsreo.com

INSURANCE INFORMATION: Insurance Company: Agent’s Name: Insurance Address: City: State & Zip Code: POLICY LIMITS: General Liability: Errors and Omissions: Workmans Comp CAPABILITIES: (Please check all you have experience with) Other: □ □ □ □ □ □ Lock change Winterization Lawn Maintenance Trash Removal Housekeeping Services Evictions □ □ □ □ □ □ Painting Pool Maintenance Repairs Construction Snow Removal Window Boarding Discount Rate: __________ Applicable licenses or certificates: REFERENCES: COMPANY NAME CONTACT NAME PHONE NUMBER Fax all application documents to 215-486-3238 or email to vendormanagement@amsreo.com .

with a disability that is service-connected. 124.R.sba.F.C. Has your business been certified as a small disadvantaged business consistent with the requirements of 13 C. Is your company at least 51 percent owned.pronet. Is your company at least 51 percent or more owned. Small Disadvantaged Business 2a.gov/?HTOWASP_CSRFTKN=4lBsssjOZvzktQs32s4HclOxGtSGdRC8siT72WCigu8s? 2e.Business Ownership Information Ownership: Business Name Business Address State Tax ID 1. If your business is owned by one or more disadvantaged individuals. Date Certification Number Certification Number .S. 4. Has your business avoided any material change in its disadvantaged ownership and control since its certification? 2c. as defined in 38 U.C 101(2). certification Number and expiration date of the certification for each DVE certification your company has obtained.S. Has your business avoided any material change in its disadvantaged ownership and control since its certification? 2. as defined in 38 U. managed and controlled by a veteran(s)? The definition of "veteran" is provided in 38 U.000 or less. what is the full and exact name under which your business appears in the PRO-Net database? 2f. after taking into account the exclusions at 13 C. National Certification Other Certification Exp.R. Provide the name of the certifying organization. If you answered yes to question 2d above. Is your business a current participant in the Small Business Administration (SBA) 8(a) program? 3.S. 4b.C. is the net worth of each individual upon whom the certification is based $750. Has your company been certified as a Disabled Veteran Business Enterprise (DVE) by a certifying organization(s)? 4c.104(c)(2)? 2d. Small Business 1a. Service-Disabled Veteran-Owned Business 4a. operated and controlled by a service-disabled veteran? Servicedisabled veteran means a veteran. 101(2). Subpart B? Contact Name City Zip Code Yes NO 2b. Date Exp. 124. Is your business currently identified as a certified small disadvantaged business in the PRO-Net database maintained by the SBA at http://www. 101(16). Veteran Owned Business 3a.F.

operated and controlled by a person with a permanent physical or mental impairment that substantially limits one or more of the major life activities and which has a significant impact on the company's ability to compete? Exp. Date Exp. Woman-Owned Business Enterprise (WBE) 6a.gov/hubzone/internet? 6.5. Have you provided an affidavit and supporting documentation to be considered eligible for this designation? 9. the certification number and the expiration date for each MBE certification you company has obtained: National Certification Regional Certification State Certification Local Certification Other Certification 8. Disabled Business Enterprise (DBE) 8a. Minority-Owned Business Enterprise (MBE) 7a. Date Exp. managed and controlled by one or more women of U.S. Date Exp. Has your company been certified as a Minority-Owned Business Enterprise (MBE) by any certifying organization(s)? 7c. Citizenship? 6b. Is your company at least 51 percent owned. HUBZone Qualified Business 5a. Date Exp. Date Certification Number Certification Number Certification Number Certification Number Certification Number 7b. Provide the name of the certifying organization. Is your company at least 51 percent owned. Date Exp. Date Exp.S. Date Exp. Date Certification Number Certification Number Certification Number Certification Number Certification Number 8b. US Citizen? Yes NO . Provide the name of the certifying organization. Date Exp. Citizenship? African American Minority Woman Owned Native American/Alaskan Asian Indian American Hispanic American Woman Owned Asian Pacific Island American Subcontinent Asian American Other Exp. managed and controlled by a member(s) of a minority group of U. Has your company been certified as a woman-owned enterprise (WBE) by one or more certifying organization(s)? 6c. Is your company at least 51percent of more owned. certification number and the expiration date of the certification for each WBE certification your company has obtained: National Certification Regional Certification State Certification Local Certification Other Certification 7.sba. Is your business currently on the List of Qualified HUBZone Small Business concerns maintained by the Small Business Administration at eweb1.

NET 15 DAYS (Prompt Payment) from last day of billing cycle. CONTRACTOR will accept all financial responsibility for any services completed by CONTRACTOR that is not covered in this agreement or that is not approved by AMS Management. PAYMENT FOR SERVICES.600 within 20 days after the date of the invoice. Inc Subcontractor Agreement This AGREEMENT for Services is made effective as of by and between ASSET MANAGEMENT SPECIALISTS. All payments made to CONTRACTOR in reference to this agreement will be tracked by AMS Invoice number unless agreed to prior to completion of work. PURCHASE ORDER \ INVOICE. the end of the discount period. When a discount for prompt payment is to be taken. All work order additions and or omissions must be approved by AMS Management. but not later than. DESCRIPTION OF SERVICES. and (2) the "discount for Prompt Payment" offer would overcome the requirement at that AMS shall not make invoice payments earlier than 7 days prior to the due date specified on the invoice. and services which have been deemed acceptable by AMS.” 1. Discounts for Prompt Payment are as approved by AMS.Asset Management Specialists. b. Example. COMPLETION DATE. or work as many hours as needed. 3. 4. It is not the intent of AMS to encourage or discourage use of the discount for prompt payment procedure. LEVITTOWN. payment will be made as close as possible to. INC (AMS) of 2021 HARTEL STREET. a discount of 4% . and services which have been deemed acceptable by AMS. supply as many workers as needed. the party who is contracting to receive services will be referred to as “AMS”. PERFORMANCE. The billing cycle is defined by a period beginning the first day to the last day of the month in which contracted services are completed. The billing cycle is defined by a period beginning the first day to the last day of the month in which contracted services are completed. to meet these completion schedules as well. CONTRACTOR is required to meet all reasonable completion schedules set forth by AMS therefore CONTRACTOR agrees to. the “Scope of Work”). All “Scope of Work” shall be completed and documented no later than 48 hours of the completion date on assigned service order (work order). NET 45 DAYS from last day of date of acceptance (Note: acceptance must occur prior to payment and the invoice should be mailed on the date it is submitted). Performance includes but is not limited to quality of services Fax all application documents to 215-486-3238 or email to vendormanagement@amsreo. and the party who will be providing the services will be referred to as “CONTRACTOR. In this AGREEMENT. The offer for a discount for prompt payment should appear prominently on the invoice (perhaps underlined).000 invoice should result in a payment of $9. CONTRACTOR will accept all financial responsibility for any services completed by CONTRACTOR that is not covered in this agreement or that is not approved by AMS.20 days offered on a $10. The discount for prompt payment procedure should help in at least two ways.com 5.PA 19057 and of . It may be helpful to discuss this with the designated paying office in order to get their recommended format. Beginning on effective date above. (1) The due date would be computed from the date of the invoice rather than the date of acceptance. In exchange for the Services AMS will pay CONTRACTOR according to the following schedule : a. All work order additions and or omissions must be approved by AMS. Payment will only be issued only upon completion of assigned work. Payment will only be issued only upon completion of assigned work. . CONTRACTOR will provide to AMS the services described in the attached Exhibit (collectively. 2.

It is understood by the parties that CONTRACTOR is an independent contractor with respect to AMS. CONTRACTOR agrees to participate in a minimum of one field training meeting with AMS and will also attend scheduled meetings with a notice of no less than 48 hours. or divulge. CONTRACTOR agrees to be financially responsible for the replacement of any damaged. State. In the event that the “Scope of Work” is canceled CONTRACTOR will be compensated for any work completed based on the breakdown of its services. CONTRACTOR will supply all material required to cover items. TERM. or stolen goods due to CONTRACTOR’s negligence. 11.com . CONTRACTOR and its employees. CONTRACTOR acknowledges that time is of the essence in the execution of this Subcontract and that failure of the CONTRACTOR to properly enforce the provision of this paragraph shall be considered a default giving AMS the right to terminate this agreement with cause.aspx#0 To rigidly adhere to starting and quitting times as established by Contractor. either directly or indirectly. disclose. 6. with no further compensation. AMS will not provide fringe benefits. and representatives will protect such information and treat it as strictly Fax all application documents to 215-486-3238 or email to vendormanagement@amsreo. If the work completed is not covered in CONTRACTOR’s agreement then AMS reserves the right to compensate CONTRACTOR based on a percentage scale of work completed up to the cancellation date. CANCELLATION / TERMINATION. or communicate in any manner. CONTRACTOR is responsible for furnishing all tools and equipment required to fulfill this agreement.completed and timely reporting as laid out by AMS policy and procedure for recording completed services. both at the site and by all material suppliers and CONTRACTORs. hours. health insurance benefits. CONTRACTOR will cooperate to the fullest extent with Contractor in supplying workmen who can and will work in harmony with other trades. and agrees: To comply with the Fair Labor Standards Act. method of payment and nondiscriminatory practices with regard to the hiring and use of labor. 13. Service Contract Act and all appropriate Federal. CONTRACTOR agrees to complete all typical punch items as required after installation. and not an employee of AMS. including the filing of any and all certificates of compliance required by any governmental agency or other authority. lost. CONFIDENTIALITY. AVAILABILITY. for the benefit of CONTRACTOR. also CONTRACTOR agrees to reimburse AMS for all cost incurred by AMS due to CONTRACTOR negligence. or any other employee benefit. LABOR.wdol. including liability. 10. 9. This AGREEMENT will renew automatically monthly upon completion by CONTRACTOR of the Services required by this Agreement. CONTRACTOR and its employees. CONTRACTOR will be responsible for protecting installed items by covering the items up immediately after installation. agents. and local acts concerning wages. A delivery notice will be issued to CONTRACTOR 24 hours prior to any delivery deemed to be after hours. TOOLS. paid vacation. workman’s compensation. The current wage determinations are found at the following link: www. 12. RELATIONSHIP OF PARTIES. 8. CONTRACTOR agrees to perform all items described in the “Scope of Work” prior to completion of this agreement. AMS reserves the right to terminate this agreement at any date. agents.gov/sca. use for the personal benefit of CONTRACTOR. RECEIPT OF GOODS. 7. or representatives will not at any time or in any manner. if AMS determines that CONTRACTOR is not performing its obligations to fully meet this agreement. PROTECTION \ PUNCH. AMS will not be responsible for any lost or stolen tools or equipment. any information that is proprietary to AMS. 14.

CONTRACTOR shall obtain and pay for all necessary permits. using knowledge and recommendations for performing the services which meet generally acceptable standards in CONTRACTOR’s community and region. CONTRACTOR will return to AMS all records. In the event of termination of cooperation between Asset Management Specialists. including consultations between or among the Contracting authorities: i. CONTRACTOR shall repair at its own expense and at the convenience of Owner any defects in workmanship or materials within two (2) years from the date of acceptance of the Work. expenses. building codes. Fax all application documents to 215-486-3238 or email to vendormanagement@amsreo. if any. notes. CONTRACTOR shall indemnify and defend Contractor from all loss. and assigns in failure to comply with such health and safety rules and regulations. unless the providing Authority expressly objects to this communication. 15. Inc and the contracting authorities the work plan. HEALTH AND SAFETY. CONTRACTOR agrees to indemnify and hold AMS harmless from all claims. damage or injury resulting directly or indirectly from CONTRACTOR’s noncompliance. costs. PERMITS AND REGULATIONS. rules and regulations. and judgments that may be asserted against AMS that result from the acts or omissions of CONTRACTOR and/or CONTRACTOR’s employees. employees. If consent is not obtained from the Providing Authority.confidential. ii. 17. without additional charge or expense to Contractor. CONTRACTOR shall provide its services and meet its obligations under this AGREEMENT in a timely and workmanlike manner. penalties and corrective measures that result from acts of commission or omission by the CONTRACTOR. Under this protocol the content of such communications. CONTRACTOR may use non-public information obtained solely for the purpose of achieving the goals of the “scope of work”. ordinances. Except for disclosures in accordance with this protocol. This provision will continue to be effective after the termination of this Contract.com . documentation and other items that were used. and any other non-public matters arising under the “scope of work”. Upon termination of this Contract. including the Board of Fire Underwriters. replace and/or repair Work and any work which may be damaged in removing or repairing Work. 19. expense. each Authority intends to keep confidential nonpublic communications information received. fees including attorney fees. the parties intend that such disclosure will not constitute a waiver of privilege or confidentiality of such information. This use includes communication to the issuer and the exchange of information between contracting authorities. and will provide a standard of care equal to. the parties will consult to discuss the reasons for withholding approval of such use and the circumstances. INDEMNIFICATION. State and local laws. under which the intended use by the receiver might be allowed. CONTRACTOR shall pay for all damage to the building resulting from defects in the Work and all expenses necessary to remove. created. 18. or controlled by CONTRACTOR during the term of this Contract. GUARANTEE. or representatives. WARRANTY. 16. CONTRACTOR must obtain the prior consent of the providing authority before disclosing non-public information received. CONTRACTOR shall defend. information obtained under this protocol will continue to be treated in the manner prescribed. agents. his agents. In the event that non-public information furnished pursuant to this protocol includes deliberative and consultative materials. indemnify and save harmless the Contractor from any and all expense incurred by the Contractor for fines. fees and licenses pertaining to Work and agrees to comply with all Federal. or superior to. care used by service providers similar to CONTRACTOR on similar projects. losses. CONTRACTOR shall be responsible to the Contractor for compliance with all health and safety rules and regulations.

2021 Hartel Street. This is necessary because AMS’s Workers’ Compensation carrier will charge a premium for any subcontractor who has not provided proof of having their own Workers’ Compensation coverage. but not limited to. d.000 $1. as required by AMS.000. Under no circumstances should work start on a project prior to AMS receiving the certificate of insurance. AMS will be named as an additional insured. agents. Levittown. No worn attire with offensive language or symbols). in the form of a certificate of insurance. INJURIES. b. CONTRACTOR shall effectively secure and protect its Work and shall bear and be liable for all lesser damage of any kind which may occur to Work at any time prior to final completion and acceptance by Owner.000 (i) General Liability Insurance. Additionally. If the CONTRACTOR provides professional services. AMS will not pay for a subcontractor to purchase or maintain the required insurance. must be provided to AMS with the signed Subcontractor Service Agreement. CONTRACTOR waives any rights to recovery from AMS for any injuries that CONTRACTOR (and/ CONTRACTOR’S employees) may sustain while performing services under this Agreement and that are a result of the negligence of CONTRACTOR or CONTRACTOR‘s employees. CONTRACTOR acknowledges CONTRACTOR's obligation to obtain appropriate insurance coverage for the benefit of CONTRACTOR (and CONTRACTOR’s employees. 22. or roofing. CONDUCT AND APPEARANCE.000. to include Contractual Liability. c. the CONTRACTOR must provide documentation of insurance which shall be obtained and maintained during the period of performance of all services. electrical work. CONTRACTOR.com a. plumbing. Insurance Coverage Insurance Limit(s) $1.e. 23. PA 19057 Fax all application documents to 215-486-3238 or email to vendormanagement@amsreo. the following conditions apply: Failure to provide documentation of Workers’ Compensation and Employers’ Liability insurance will result in your payment for any work being reduced by 1%. or comparable Occurrence Limit coverage. 21. clean all of his materials and remove from the site all dirt.000 (iii) Workers’ Compensation and Employers Statutory Liability Requirements Proof of insurance coverage. (i.000. Appearances by CONTRACTOR’s workers shall meet the guidelines set forth by AMS. CONTRACTOR shall.000 must be included on the certificate of insurance. . SECURITY AND CLEAN-UP. Upon signing the agreement to provide services for AMS. then proof of Professional Liability insurance with a limit of $1. The Certificate Holder on the certificate of insurance should be listed as follows: Asset Management Specialist. such as. debris and rubbish caused by CONTRACTOR in the execution of the Work.20. INSURANCE REQUIREMENTS. if any). General Aggregate (ii) Automobile Liability limits Combined Single Limit $1. or representatives shall conduct themselves in a professional manner at all times while representing AMS and AMS Clients. and all its employees. Inc.000.

com . SEVERABILITY. which shall be subject to the same process for resolution as a dispute initiated by an AMS billing contact. improper adherence to AMS policy and procedure. f. However. the disputed transaction shall be permanently removed from the account as an amount due. If your insurance policies expire during the period of performance on a project. vii. Unless waived by a party providing notice. The party receiving such notice shall have 10 working days from the effective date of such notice to cure the default(s). A Dispute shall be defined as an event where the validity of the transaction itself is in question specific to whether the transaction actually occurred or was the result of a assignment by a valid AMS representative. A CONTRACTOR dispute shall only be accepted by AMS when initiated by the AMS billing contact on record or contact on record within the same hierarchy. Dispute \ Audit Process. ENTIRE AGREEMENT. iii.e. In the event the dispute is found in AMS’s favor. CONTRACTOR may issue a request to AMS. This notice shall describe with sufficient detail the nature of the default. then such provision will be deemed to be written. if a party defaults by failing to substantially perform any provision. A CONTRACTOR dispute must be received within ten (10) days of the receipt of AMS billing contact’s disputes designated for account questions. In addition to any and all other rights a party may have available according to law. and enforced as so limited. viii. a request to validate signature on assigned services. but that by limiting such provision it would become valid and enforceable. the remaining provisions will continue to be valid and enforceable. the other party may terminate the AGREEMENT by providing written notice to the defaulting party. term or condition of this AGREEMENT (including without limitation the failure to make a monetary payment when due). the failure to cure the default(s) within such time period shall result in the automatic termination of this Contract. g. AMS Disputes reasons shall include but not limited to – suspected duplicate transactions. v. If a court finds that any provision of this AGREEMENT is invalid or unenforceable. construed. lack of supporting documentation for completed services or questionable transaction activity. Fax all application documents to 215-486-3238 or email to vendormanagement@amsreo. CONTRACTOR disputes shall be initiated by contacting AMS billing contact in writing through electronic or mail submission designated for account questions. 26. and there are no other promises or conditions in any other agreement whether oral or written concerning the subject matter of this AGREEMENT. If the CONTRACTOR is unable to provide a written response within the ten (10) day window. ii. 25. the Transaction shall be considered invalid and a systematic chargeback to the CONTRACTOR will occur. This AGREEMENT supersedes any prior written or oral agreements between the parties. If any provision of this AGREEMENT will be held to be invalid or unenforceable for any reason. iv. If the CONTRACTOR is able to supply sufficient proof of completed services no later than the expiration of the ten (10) day window. REMEDIES. This AGREEMENT contains the entire agreement of the parties. a certificate of insurance for your renewed coverage will be required. the allowable time to clear a dispute may vary slightly by type of dispute. AMS Billing Contact / Accounting Department will clear dispute liabilities in accordance with the timeframes. When proactively researching potential AMS dispute issues. which is normally shall not exceed ninety (90) days from the central processing date. suspected fraud. the chargeback will be reversed and the disputed amount will be reapplied to the account. 24. vi. i. Any account’s unpaid amount not reconciled against an open valid dispute shall be considered past due and subject to Suspension at ninety ( 90) days past due.

GOVERNING LAW. This AGREEMENT may be modified or amended in writing.com . AMENDMENT. return receipt requested. Neither party may assign or transfer this AGREEMENT without the prior written consent of the non-assigning party. 28. 29. 30.27. NOTICE. This AGREEMENT shall be construed in accordance with the laws of the State of Pennsylvania. ASSIGNMENT. if the writing is signed by the party obligated under the amendment. to the address set forth in the opening paragraph or to such other address as one party may have furnished to the other in writing. which approval shall not be unreasonably withheld. Service Provider: CONTRACTOR By: ________________________________________ Authorized Representative (SIGN) Date:____________ ________________________________________ Authorized Representative (PRINT) ________________________________________ CONTRACTOR “company name” (PRINT) Fax all application documents to 215-486-3238 or email to vendormanagement@amsreo. Any notice or communication required or permitted under this AGREEMENT shall be sufficiently given if delivered in person or by certified mail.

220 Rittenhouse Circle Bristol. I understand that electing this payment option discounts my invoice by 4%. (name)_______________________ ________of (company)__________________________________ request expedited payment (Net 15 days) . Authorized Representative (Sign) Date: Authorized Representative (Print) Fax all application documents to 215-486-3238 or email to vendormanagement@amsreo.3238 Prompt Payment To request Net 15 payment terms as outlined on Page 1 of the Subcontractor Agreement. your elected payment terms will be Net 45 days as outlined on Page 1 of the Subcontractor Agreement. PA 19007 Phone 866.486.com .1734 Fax 215.699. I. If your application is submitted without this page. by default. please submit this form with your application documents.

What type of services does your business provide (ie. How many years of experience do you have in the home business? 7. Are you willing to work nights and/or weekends? 2. Home cleanouts. lawn maintenance.) 4. How many employees work for your company? Number of field employees: Number of office staff: 5. Do you complete all of your work in-house or do you sub-out as well? If you sub-out. What are some major clients you have worked for in the past? 8.com . How many crews of workers do you have at your disposal? Fax all application documents to 215-486-3238 or email to vendormanagement@amsreo.SUB CONTRACTOR QUESTIONNAIRE Business Name: Address: State: City: Phone: Mobile Phone: Fax Number: Email: Contact Person: 1. what percentage of work do you sub-out? 6. What COUNTIES can you operate in on a regular basis? 3. home cleaning. home repairs. etc.

size. debris removal dump truck)? 10. Do you have experience with using computers (email.9. How many lawns/inspections can your company do PER DAY? 14. and make of the following equipment your company uses. What type of trucks do these crews have to use (ie. How many cleanouts/trashouts can your company do PER DAY? 15. Please list the type. Lawn care pick-up. Does your company have workmans comp and general liability insurance for 1 million? Fax all application documents to 215-486-3238 or email to vendormanagement@amsreo. Edger Weed whacker 15 cyd dump truck or trailer Cell phones on trucks Commerical lawn mowers Generators Compressors 13.com . Is your company capable of the following? (Check boxes) □ □ □ □ □ □ □ Pressure test plumbing system Trim Bushes Have a contact for vehicle removal Board windows Re-glaze broken windows Install earthquake stripping (California only) Regular email communication 12. uploading digital photos)? 11. internet. Are there any specialized skill sets within your company? __________ __________ 16.

for a resident alien. person (including a resident alien).Form (Rev. it is your employer identification number (EIN).S. Special rules for partnerships. payments other than interest and dividends.S. The person who gives Form W-9 to the partnership for purposes of establishing its U. acquisition or abandonment of secured property. or (c) the IRS has notified me that I am no longer subject to backup withholding.S. 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. or association created or organized in the United States or under the laws of the United States. and 2. you must use the requester’s form if it is substantially similar to this Form W-9. If you do not have a number. corporation. trade or business is not subject to the withholding tax on foreign partners’ share of effectively connected income. to: 1. See the instructions on page 4. citizen or other U.S. and 3. 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. see How to get a TIN on page 3. in certain cases where a Form W-9 has not been received. For individuals. for example.S. C=corporation. sole proprietor. For real estate transactions. or contributions you made to an IRA. Sign Here Signature of U. when applicable.S. you are not required to sign the Certification. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases: ● The U. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me). Use Form W-9 only if you are a U. cancellation of debt. Note. If applicable.7701-7). acquisition or abandonment of secured property. The TIN provided must match the name given on Line 1 to avoid backup withholding. P=partnership) Other (see instructions) Address (number. person. For mortgage interest paid. see the chart on page 4 for guidelines on whose number to enter. company. or ● A domestic trust (as defined in Regulations section 301. street. or suite no. 10231X W-9 (Rev. ● A partnership. item 2 does not apply. exempt payee. real estate transactions. person Date General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Definition of a U. Form Cat.S. If a requester gives you a form other than Form W-9 to request your TIN. or 3. provide Form W-9 to the partnership to establish your U. a partnership is required to presume that a partner is a foreign person. 2. Further. For other entities. Enter the tax classification (D=disregarded entity.S. or disregarded entity. see the Part I instructions on page 3. citizen or U. Note.) Exempt payee Requester’s name and address (optional) City. or Employer identification number Part II Certification Under penalties of perjury. and ZIP code List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Social security number Enter your TIN in the appropriate box. if different from above Check appropriate box: Individual/Sole proprietor Corporation Partnership Limited liability company. Therefore.S. cancellation of debt.S. owner of a disregarded entity and not the entity.S. 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. your allocable share of any partnership income from a U. but you must provide your correct TIN.S.S. I am a U.S. Claim exemption from backup withholding if you are a U. contributions to an individual retirement arrangement (IRA). to provide your correct TIN to the person requesting it (the requester) and. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report. person if you are: ● An individual who is a U. No. For federal tax purposes. Do not send to the IRS. Certify that you are not subject to backup withholding. income paid to you. you are considered a U. I certify that: 1. this is your social security number (SSN). if you are a U. state. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued). person (defined below). Name (as shown on your income tax return) Print or type See Specific Instructions on page 2. Certification instructions. October 2007) Department of the Treasury Internal Revenue Service W-9 Request for Taxpayer Identification Number and Certification Give form to the requester. you are also certifying that as a U. and generally. mortgage interest you paid. ● An estate (other than a foreign estate). I am not subject to backup withholding because: (a) I am exempt from backup withholding. 10-2007) . Business name. and pay the withholding tax. person. However. and apt. resident alien. status and avoid withholding on your share of partnership income.S. person that is a partner in a partnership conducting a trade or business in the United States. If the account is in more than one name.

you must attach a statement to Form W-9 that specifies the following five items: 1. enter the LLC’s name on the “Name” line and any business. 4.S. 2. 3. the name of the person or entity whose number you entered in Part I of the form. Withholding of Tax on Nonresident Aliens and Foreign Entities). However. Note. You may enter your business. “C” for corporation. 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. the last name shown on your social security card. 5.S.-China treaty (dated April 30. Sole proprietor. 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. or “doing business as (DBA)” name on the “Business name” line.7701-3. then check the “Exempt payee” box in the line following the business name. This is called “backup withholding. enter the owner’s name on the “Name” line. grantor or other owner of a grantor trust and not the trust. Example. enter your first name. If you are a nonresident alien or a foreign entity not subject to backup withholding. use the appropriate Form W-8 (see Publication 515. trust (other than a grantor trust) and not the beneficiaries of the trust. See the instructions below and the separate Instructions for the Requester of Form W-9. broker and barter exchange transactions. For an LLC classified as a partnership or a corporation.S. What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. You are requested to check the appropriate box for your status (individual/sole proprietor. and then circle. Exempt Payee If you are exempt from backup withholding. corporation. the requester may be subject to civil and criminal penalties. royalties. make the proper certifications. 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).S. if you have changed your last name. 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. The treaty country. or DBA name on the “Business name” line. rents.” Payments that may be subject to backup withholding include interest. dividends. Civil penalty for false information with respect to withholding. law. For a single-member LLC (including a foreign LLC with a domestic owner) that is disregarded as an entity separate from its owner under Regulations section 301. Payments you receive will be subject to backup withholding if: 1. 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). you are subject to a $500 penalty. resident alien for tax purposes. Enter the LLC’s name on the “Business name” line.). trade. trade. If you are a U. Generally. do not use Form W-9. Nonresident alien who becomes a resident alien. due to marriage without informing the Social Security Administration of the name change. you must generally enter the name shown on your income tax return. and report all your taxable interest and dividends on your tax return. 4.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN.” 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. Real estate transactions are not subject to backup withholding. Enter your individual name as shown on your income tax return on the “Name” line.S. sign and date the form. However. Generally. The treaty article addressing the income. this must be the same treaty under which you claimed exemption from tax as a nonresident alien.S. The IRS tells the requester that you furnished an incorrect TIN. Also see Special rules for partnerships on page 1. You may enter any business. Misuse of TINs. only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U. tax on certain types of income. “P” for partnership) in the space provided. or 5.Form W-9 (Rev. trade. or DBA name on the “Business name” line. 2. enter your name as described above and check the appropriate box for your status. etc. Criminal penalty for falsifying information. Instead.S. and certain payments from fishing boat operators. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. nonemployee pay. list first. give the requester the appropriate completed Form W-8. Foreign person. Specific Instructions Name If you are an individual. Under U. and ● The U. Penalties Failure to furnish TIN. tax on certain types of income. If you are a foreign person. 10-2007) Page 2 ● The U. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.S. tax-exempt interest. If the account is in joint names. Check the “Limited liability company” box only and enter the appropriate code for the tax classification (“D” for disregarded entity. for instance. If you make a false statement with no reasonable basis that results in no backup withholding. If the requester discloses or uses TINs in violation of federal law. The type and amount of income that qualifies for the exemption from tax. paragraph 2 of the first Protocol to the U. This name should match the name shown on the charter or other legal document creating the entity. If you fail to furnish your correct TIN to a requester.S. . this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. You do not certify your TIN when required (see the Part II instructions on page 3 for details). You do not furnish your TIN to the requester. Enter your business name as shown on required federal tax documents on the “Name” line. Article 20 of the U. most tax treaties contain a provision known as a “saving clause. However. Other entities. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U. and your new last name. Limited liability company (LLC). 3. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Certain payees and payments are exempt from backup withholding.

If you do not have a TIN. An entity registered at all times during the tax year under the Investment Company Act of 1940.irs. If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited liability company (LLC) on page 2). For interest and dividend payments. 13. Note. 11. If you are a resident alien and you do not have and are not eligible to get an SSN. 7. or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2). .Form W-9 (Rev. any IRA. see Exempt Payee on page 2. to apply for an EIN. All exempt payees except for 9 Exempt payees 1 through 13. A foreign central bank of issue. Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8. Other payees that may be exempt from backup withholding include: 6. You can get Forms W-7 and SS-4 from the IRS by visiting www. exempt payees 2 1 through 7 Part I. Part II. the following payments made to a corporation (including gross proceeds paid to an attorney under section 6045(f). 4. Enter it in the social security number box. 4. A financial institution. dividend. If you are subject to backup withholding and you are merely providing your correct TIN to the requester. or Form SS-4. An organization exempt from tax under section 501(a). Application for Employer Identification Number. person. To apply for an SSN. enter the owner’s SSN (or EIN. you must cross out item 2 in the certification before signing the form. 3. and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. a person registered under the Investment Advisers Act of 1940 who regularly acts as a broker Exempt payees 1 through 5 Generally. see How to get a TIN below. A dealer in securities or commodities required to register in the United States. but you do not have to sign the certification. An international organization or any of its agencies or instrumentalities. Corporations are exempt from backup withholding for certain payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester. you should still complete this form to avoid possible erroneous backup withholding. You must sign the certification or backup withholding will apply. a possession of the United States. However. Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. Signature requirements. . and give it to the requester. enter the entity’s EIN. Exempt payees.ssa. your TIN is your IRS individual taxpayer identification number (ITIN). 10-2007) Page 3 Generally. Complete the certification as indicated in 1 through 5 below. A common trust fund operated by a bank under section 584(a). . or instrumentalities. For a joint account. or 5. the IRS prefers that you use your SSN. even if the attorney is a corporation) and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments. dividend. or resident alien. A corporation. broker. The United States or any of its agencies or instrumentalities. If you are exempt from backup withholding. See the chart on page 4 for further clarification of name and TIN combinations. Application for a Social Security Card. Also. write “Applied For” in the space for the TIN. agencies. get Form SS-5. However. You can apply for an EIN online by accessing the IRS website at www. .gov or by calling 1-800-TAX-FORM (1-800-829-3676). or 15. and 5 below indicate otherwise. Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon. such as interest and dividends. A futures commission merchant registered with the Commodity Futures Trading Commission. the District of Columbia. or any of their political subdivisions or instrumentalities. if the owner has one). Use Form W-7. Application for IRS Individual Taxpayer Identification Number. 2. 9. and its instructions. and certain payments made with respect to readily tradable instruments. the District of Columbia. attorneys’ fees. A trust exempt from tax under section 664 or described in section 4947. If the LLC is classified as a corporation or partnership. If you do not have an ITIN. A state. Do not enter the disregarded entity’s EIN. Interest. Miscellaneous Income. Note. 14. The following payees are exempt from backup withholding: 1. Note. You may be requested to sign by the withholding agent even if items 1. How to get a TIN. sign and date the form. If you are asked to complete Form W-9 but do not have a TIN.irs. sign Form W-9. or a possession of the United States. A foreign government or any of its political subdivisions. The chart below shows types of payments that may be exempt from backup withholding. 8.000 1 2 See Form 1099-MISC. you may enter either your SSN or EIN. 10. Interest. Certification To establish to the withholding agent that you are a U.S. The 60-day rule does not apply to other types of payments.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a Business. IF the payment is for . Interest and dividend payments Broker transactions THEN the payment is exempt for . Barter exchange transactions and patronage dividends Payments over $600 required to be reported and direct 1 sales over $5. 1 through 15. You must give your correct TIN. 12. 1. and payments for services paid by a federal executive agency. individuals (including sole proprietors) are not exempt from backup withholding. to apply for an ITIN. The chart applies to the exempt payees listed above. A real estate investment trust. 2. 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. A middleman known in the investment community as a nominee or custodian. You may also get this form by calling 1-800-772-1213. If you are a sole proprietor and you have an EIN.gov. only the person whose TIN is shown in Part I should sign (when required). apply for one immediately. and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. . from your local Social Security Administration office or get this form online at www.

consumer. Partnership or multi-member LLC 11. to federal and state agencies to enforce federal nontax criminal laws. or pension trust 8. and U. or other IRS personal property to the Treasury Inspector General for Tax Administration at 1-800-366-4484. “Other payments” include payments made in the course of the requester’s trade or business for rents. but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN.S. the number will be considered to be that of the first name listed. estate. or other tax-exempt organization 10. dividend. or similar secret access information for their credit card. If you receive an unsolicited email claiming to be from the IRS. Corporate or LLC electing corporate status on Form 8832 9. cancellation of debt. but you do not have to sign the certification. Victims of identity theft who are experiencing economic harm or a system problem. logo. the first 1 individual on the account 2 The minor The grantor-trustee The actual owner 3 1 1 The owner Give name and EIN of: The owner Legal entity The corporation The organization 4 The partnership The broker or nominee The public entity List first and circle the name of the person whose number you furnish. royalties. The IRS does not initiate contacts with taxpayers via emails. 4. or prison) that receives agricultural program payments 1 Give name and SSN of: The individual The actual owner of the account or. the District of Columbia. Archer MSA or HSA contributions or distributions. So-called trust account that is not a legal or valid trust under state law 5.gov to learn more about identity theft and how to reduce your risk. dividends. forward this message to phishing@irs. Sole proprietorship or disregarded entity owned by an individual For this type of account: 6. school district. 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. the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers. to commit fraud or other crimes. educational. or to federal law enforcement and intelligence agencies to combat terrorism. Other payments. and certain other income paid to you. mortgage interest you paid. Certain penalties may also apply. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund. Mortgage interest paid by you. charitable. without your permission. You must show your individual name and you may also enter your business or “DBA” name on the second name line. Association. the acquisition or abandonment of secured property. and pension distributions. estate. Real estate transactions. a. payments to a nonemployee for services.gov/idtheft or 1-877-IDTHEFT(438-4338). and ● Be careful when choosing a tax preparer. Account with the Department of Agriculture in the name of a public entity (such as a state or local government. 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. The IRS may also provide this information to the Department of Justice for civil and criminal litigation. Circle the minor’s name and furnish the minor’s SSN. medical and health care services (including payments to corporations). goods (other than bills for merchandise). or other financial accounts.gov or contact them at www. To reduce your risk: ● Protect your SSN. 10-2007) Page 4 3. if combined funds. passwords. or Archer MSA or HSA. . Secure Your Tax Records from Identity Theft Identity theft occurs when someone uses your personal information such as your name. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. You may cross out item 2 of the certification. Individual 2. Protect yourself from suspicious emails or phishing schemes. Coverdell ESA. You may also report misuse of the IRS name. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title. Custodian account of a minor (Uniform Gift to Minors Act) 4. may be eligible for Taxpayer Advocate Service (TAS) assistance. You must sign the certification. and to cities. Call the IRS at 1-800-829-1040 if you think your identity has been used inappropriately for tax purposes. Two or more individuals (joint account) 3. You may use either your SSN or EIN (if you have one).gov. but the IRS encourages you to use your SSN. Visit the IRS website at www. IRA. 5. What Name and Number To Give the Requester For this type of account: 1. and certain other payments to a payee who does not give a TIN to a payer. religious. Payers must generally withhold 28% of taxable interest. A broker or registered nominee 12.) Also see Special rules for partnerships on page 1. club. List first and circle the name of the trust. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. 2 3 4 Note. acquisition or abandonment of secured property. states. We may also disclose this information to other countries under a tax treaty. qualified tuition program payments (under section 529).Form W-9 (Rev. or pension trust. You must give your correct TIN. or contributions you made to an IRA. You must give your correct TIN. You must provide your TIN whether or not you are required to file a tax return. If no name is circled when more than one name is listed. or are seeking help in resolving tax problems that have not been resolved through normal channels. The usual revocable savings trust (grantor is also trustee) b. bank.irs. and gross proceeds paid to attorneys (including payments to corporations). social security number (SSN). that person’s number must be furnished. You can forward suspicious emails to the Federal Trade Commission at: spam@uce. ● Ensure your employer is protecting your SSN. Disregarded entity not owned by an individual 7. payments to certain fishing boat crew members and fishermen. A valid trust. or other identifying information. possessions to carry out their tax laws. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest. cancellation of debt. Also. If only one person on a joint account has an SSN.