Important Note: the example use fictional information for educational purposes only.

Form W-9

Request for Taxpayer Identification Number and Certification

• Name (as shown on your income tax return). A name is required on this line; do not leave this line blank.
  Jane Doe
• Business name/disregarded entity name, if different from above.
  Jane Doe Designs
• Check the appropriate box for federal tax classification; check only one of the following seven boxes:
  [ ] Individual/sole proprietor or single-member LLC
  [X] C Corporation
  [ ] S Corporation
  [ ] Partnership
  [ ] Trust/estate
  [ ] Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
  [ ] Other (see instructions)
• Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
  [ ] Exempt payee code (if any)
  [ ] Exemption from FATCA reporting code (if any)
• Address (number, street, and apt. or suite no.): 1234 Main Street, Apartment 4B
• Requester's name and address (optional): ABC Company, 5678 Market Street
• City, state, and ZIP: Springfield, IL 62704
• List account number(s) here (optional): 112233
• Part I. Taxpayer Identification Number (TIN)
  Social security number: 123-45-6789
  OR
  Employer identification number