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: Contact Person:

Business Address:
State:
City:

Phone: Mobile Phone:

Fax Number:

Email:

Home Address:

City: State:

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)

□ Lock change □ Painting

□ Winterization □ Pool Maintenance
□ Lawn Maintenance □ Repairs
□ Trash Removal □ Construction
□ Housekeeping Services □ Snow Removal
□ Evictions □ Window Boarding
Other:

Discount Rate: __________

Applicable licenses or certificates:

REFERENCES:

COMPANY NAME CONTACT NAME PHONE NUMBER

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Business Ownership Information
Ownership:
Business Name Contact Name
Business Address City
State Zip Code
Tax ID

1. Small Business Yes NO

1a. Has your business avoided any material change in its disadvantaged ownership and control since its
certification?

2. Small Disadvantaged Business

2a. Has your business been certified as a small disadvantaged business consistent with the requirements of 13 C.F.R.
124, Subpart B?

2b. Has your business avoided any material change in its disadvantaged ownership and control since its certification?

2c. If your business is owned by one or more disadvantaged individuals, is the net worth of each individual upon whom
the certification is based $750,000 or less, after taking into account the exclusions at 13 C.F.R. 124.104(c)(2)?

2d. Is your business currently identified as a certified small disadvantaged business in the PRO-Net database
maintained by the SBA at
http://www.pronet.sba.gov/?HTOWASP_CSRFTKN=4lBsssjOZvzktQs32s4HclOxGtSGdRC8siT72WCigu8s?

2e. If you answered yes to question 2d above, what is the full and exact name under which your business appears in the
PRO-Net database?

2f. Is your business a current participant in the Small Business Administration (SBA) 8(a) program?

3. Veteran Owned Business

3a. Is your company at least 51 percent owned, managed and controlled by a veteran(s)? The definition of "veteran" is
provided in 38 U.S.C 101(2).
4. Service-Disabled
Veteran-Owned Business
4a. Is your company at least 51 percent or more owned, operated and controlled by a service-disabled veteran? Service-
disabled veteran means a veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-connected, as defined
in 38 U.S.C. 101(16).

4b. Has your company been certified as a Disabled Veteran Business Enterprise (DVE) by a certifying organization(s)?

4c. Provide the name of the certifying organization, certification Number and expiration date of the certification for each
DVE certification your company has obtained.

National Certification Exp. Date Certification Number

Other Certification Exp. Date Certification Number
5. HUBZone Qualified Business

5a. Is your business currently on the List of Qualified HUBZone Small Business concerns maintained by the Small
Business Administration at eweb1.sba.gov/hubzone/internet?
6. Woman-Owned Business Enterprise (WBE)

6a. Is your company at least 51 percent owned, managed and controlled by one or more women of U.S. Citizenship?

6b. Has your company been certified as a woman-owned enterprise (WBE) by one or more certifying organization(s)?

6c. Provide the name of the certifying organization, certification number and the expiration date of the certification for
each WBE certification your company has obtained:

National Certification Exp. Date Certification Number

Regional Certification Exp. Date Certification Number
State Certification Exp. Date Certification Number
Local Certification Exp. Date Certification Number
Other Certification Exp. Date Certification Number

7. Minority-Owned Business Enterprise (MBE)

7a. Is your company at least 51 percent owned, managed and controlled by a member(s) of a minority group of U.S.
Citizenship?

African American Woman Owned

Minority Woman Owned Asian Pacific Island American
Native American/Alaskan Subcontinent Asian American
Asian Indian American Other
Hispanic American

7b. Has your company been certified as a Minority-Owned Business Enterprise (MBE) by any certifying organization(s)?

7c. Provide the name of the certifying organization, the certification number and the expiration date for each MBE
certification you company has obtained:
National Certification Exp. Date Certification Number
Regional Certification Exp. Date Certification Number
State Certification Exp. Date Certification Number
Local Certification Exp. Date Certification Number
Other Certification Exp. Date Certification Number
8. Disabled Business Enterprise (DBE)
8a. Is your company at least 51percent of more owned, 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?

8b. Have you provided an affidavit and supporting documentation to be considered eligible for this designation?

9. US Citizen? Yes NO
Asset Management Specialists, Inc
Subcontractor Agreement

This AGREEMENT for Services is made effective as of by and between ASSET

MANAGEMENT SPECIALISTS, INC (AMS) of 2021 HARTEL STREET, LEVITTOWN,PA 19057 and
of
. In this AGREEMENT, the party who is contracting to receive services will be referred to as “AMS”, and
the party who will be providing the services will be referred to as “CONTRACTOR.”
1. DESCRIPTION OF SERVICES. Beginning on effective date above, CONTRACTOR will provide to AMS the
services described in the attached Exhibit (collectively, the “Scope of Work”).

2. COMPLETION DATE. All “Scope of Work” shall be completed and documented no later than 48 hours of
the completion date on assigned service order (work order).

3. PAYMENT FOR SERVICES. In exchange for the Services AMS will pay CONTRACTOR according to the
following schedule :

a. 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). 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. Payment will only be issued only upon completion of assigned work, and
services which have been deemed acceptable by AMS. All work order additions and or omissions
must be approved by AMS. 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.

b. NET 15 DAYS (Prompt Payment) from last day of billing cycle. 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. When a discount for prompt payment is to be taken, payment will be made as close
as possible to, but not later than, the end of the discount period. Discounts for Prompt Payment
are as approved by AMS. Example, a discount of 4% - 20 days offered on a $10,000 invoice should
result in a payment of $9,600 within 20 days after the date of the invoice. The discount for
prompt payment procedure should help in at least two ways. (1) The due date would be
computed from the date of the invoice rather than the date of acceptance, 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. The offer for a
discount for prompt payment should appear prominently on the invoice (perhaps underlined). It
may be helpful to discuss this with the designated paying office in order to get their
recommended format. It is not the intent of AMS to encourage or discourage use of the
discount for prompt payment procedure. Payment will only be issued only upon completion of
assigned work, and services which have been deemed acceptable by AMS. All work order
additions and or omissions must be approved by AMS Management. 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.

4. PURCHASE ORDER \ INVOICE. 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.

5. PERFORMANCE. CONTRACTOR is required to meet all reasonable completion schedules set forth by AMS
therefore CONTRACTOR agrees to, supply as many workers as needed, or work as many hours as needed,
to meet these completion schedules as well. Performance includes but is not limited to quality of services

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 completed and timely reporting as laid out by AMS policy and procedure for recording completed
services.

6. PROTECTION \ PUNCH. CONTRACTOR will be responsible for protecting installed items by covering the
items up immediately after installation. CONTRACTOR will supply all material required to cover items.
CONTRACTOR agrees to perform all items described in the “Scope of Work” prior to completion of this
agreement. CONTRACTOR agrees to complete all typical punch items as required after installation.

7. TOOLS. CONTRACTOR is responsible for furnishing all tools and equipment required to fulfill this
agreement. AMS will not be responsible for any lost or stolen tools or equipment.

8. TERM. This AGREEMENT will renew automatically monthly upon completion by CONTRACTOR of the
Services required by this Agreement.

9. CANCELLATION / TERMINATION. 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. 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. AMS reserves the right to
terminate this agreement at any date, with no further compensation, if AMS determines that
CONTRACTOR is not performing its obligations to fully meet this agreement, also CONTRACTOR agrees to
reimburse AMS for all cost incurred by AMS due to CONTRACTOR negligence.

10. RELATIONSHIP OF PARTIES. It is understood by the parties that CONTRACTOR is an independent

contractor with respect to AMS, and not an employee of AMS. AMS will not provide fringe benefits,
including liability, workman’s compensation, health insurance benefits, paid vacation, or any other
employee benefit, for the benefit of CONTRACTOR.

11. LABOR. 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, Service Contract Act and all appropriate Federal,
State, and local acts concerning wages, hours, method of payment and nondiscriminatory
practices with regard to the hiring and use of labor, both at the site and by all material suppliers
and CONTRACTORs, including the filing of any and all certificates of compliance required by any
governmental agency or other authority. The current wage determinations are found at the
following link: www.wdol.gov/sca.aspx#0

To rigidly adhere to starting and quitting times as established by Contractor.

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.

12. AVAILABILITY. 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.

13. RECEIPT OF GOODS. CONTRACTOR agrees to be financially responsible for the replacement of any
damaged, lost, or stolen goods due to CONTRACTOR’s negligence. A delivery notice will be issued to
CONTRACTOR 24 hours prior to any delivery deemed to be after hours.

14. CONFIDENTIALITY. CONTRACTOR and its employees, agents, or representatives will not at any time or in
any manner, either directly or indirectly, use for the personal benefit of CONTRACTOR, or divulge,
disclose, or communicate in any manner, any information that is proprietary to AMS. CONTRACTOR and
its employees, agents, and representatives will protect such information and treat it as strictly

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

 confidential. This provision will continue to be effective after the termination of this Contract. Upon
termination of this Contract, CONTRACTOR will return to AMS all records, notes, documentation and
other items that were used, created, or controlled by CONTRACTOR during the term of this Contract.
CONTRACTOR may use non-public information obtained solely for the purpose of achieving the goals of
the “scope of work”. This use includes communication to the issuer and the exchange of information
between contracting authorities, unless the providing Authority expressly objects to this communication.

CONTRACTOR must obtain the prior consent of the providing authority before disclosing non-public
information received. If consent is not obtained from the Providing Authority, the parties will consult to
discuss the reasons for withholding approval of such use and the circumstances, if any, under which the
intended use by the receiver might be allowed.

Except for disclosures in accordance with this protocol, each Authority intends to keep confidential non-
public communications information received. Under this protocol the content of such communications,
and any other non-public matters arising under the “scope of work”, including consultations between or
among the Contracting authorities:

i. In the event that non-public information furnished pursuant to this protocol includes
deliberative and consultative materials, the parties intend that such disclosure will not
constitute a waiver of privilege or confidentiality of such information.

ii. In the event of termination of cooperation between Asset Management Specialists, Inc
and the contracting authorities the work plan, information obtained under this protocol
will continue to be treated in the manner prescribed.

15. INDEMNIFICATION. CONTRACTOR agrees to indemnify and hold AMS harmless from all claims, losses,
expenses, fees including attorney fees, costs, and judgments that may be asserted against AMS that result
from the acts or omissions of CONTRACTOR and/or CONTRACTOR’s employees, agents, or
representatives.

16. HEALTH AND SAFETY. CONTRACTOR shall be responsible to the Contractor for compliance with all health
and safety rules and regulations. CONTRACTOR shall defend, indemnify and save harmless the Contractor
from any and all expense incurred by the Contractor for fines, penalties and corrective measures that
result from acts of commission or omission by the CONTRACTOR, his agents, employees, and assigns in
failure to comply with such health and safety rules and regulations.

17. WARRANTY. CONTRACTOR shall provide its services and meet its obligations under this AGREEMENT in a
timely and workmanlike manner, using knowledge and recommendations for performing the services
which meet generally acceptable standards in CONTRACTOR’s community and region, and will provide a
standard of care equal to, or superior to, care used by service providers similar to CONTRACTOR on similar
projects.

18. GUARANTEE. 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. CONTRACTOR
shall pay for all damage to the building resulting from defects in the Work and all expenses necessary to
remove, replace and/or repair Work and any work which may be damaged in removing or repairing Work.

19. PERMITS AND REGULATIONS. CONTRACTOR shall obtain and pay for all necessary permits, fees and
licenses pertaining to Work and agrees to comply with all Federal, State and local laws, ordinances,
building codes, rules and regulations, including the Board of Fire Underwriters, without additional charge
or expense to Contractor. CONTRACTOR shall indemnify and defend Contractor from all loss, expense,
damage or injury resulting directly or indirectly from CONTRACTOR’s noncompliance.

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

20. SECURITY AND CLEAN-UP. 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. CONTRACTOR shall, as required by AMS, clean all of his materials
and remove from the site all dirt, debris and rubbish caused by CONTRACTOR in the execution of the
Work.

21. CONDUCT AND APPEARANCE. CONTRACTOR, and all its employees, agents, or representatives shall
conduct themselves in a professional manner at all times while representing AMS and AMS Clients.
Appearances by CONTRACTOR’s workers shall meet the guidelines set forth by AMS. (i.e. No worn attire
with offensive language or symbols).

22. INJURIES. CONTRACTOR acknowledges CONTRACTOR's obligation to obtain appropriate insurance

coverage for the benefit of CONTRACTOR (and CONTRACTOR’s employees, if any). 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.

23. INSURANCE REQUIREMENTS. Upon signing the agreement to provide services for AMS, the
CONTRACTOR must provide documentation of insurance which shall be obtained and
maintained during the period of performance of all services.

Insurance Coverage Insurance Limit(s)

(i) General Liability Insurance, or comparable Occurrence Limit $1,000,000

coverage, to include Contractual Liability.
AMS will be named as an additional insured. General Aggregate $1,000,000

(ii) Automobile Liability limits Combined Single Limit $1,000,000

(iii) Workers’ Compensation and Employers Statutory

Liability Requirements

Proof of insurance coverage, in the form of a certificate of insurance, must be provided to AMS with the
signed Subcontractor Service Agreement. Under no circumstances should work start on a project prior to
AMS receiving the certificate of insurance.

Additionally, the following conditions apply:

a. Failure to provide documentation of Workers’ Compensation and Employers’ Liability insurance

will result in your payment for any work being reduced by 1%. 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.
b. If the CONTRACTOR provides professional services, such as, but not limited to, electrical work,
plumbing, or roofing, then proof of Professional Liability insurance with a limit of $1,000,000
must be included on the certificate of insurance.
c. AMS will not pay for a subcontractor to purchase or maintain the required insurance.
d. The Certificate Holder on the certificate of insurance should be listed as follows: Asset
Management Specialist, Inc, 2021 Hartel Street, Levittown, PA 19057

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 e. If your insurance policies expire during the period of performance on a project, a certificate of
insurance for your renewed coverage will be required.

24. REMEDIES. In addition to any and all other rights a party may have available according to law, if a party
defaults by failing to substantially perform any provision, term or condition of this AGREEMENT (including
without limitation the failure to make a monetary payment when due), the other party may terminate the
AGREEMENT by providing written notice to the defaulting party. This notice shall describe with sufficient
detail the nature of the default.

f. The party receiving such notice shall have 10 working days from the effective date of such notice
to cure the default(s). Unless waived by a party providing notice, the failure to cure the
default(s) within such time period shall result in the automatic termination of this Contract.

g. Dispute \ Audit Process. 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.

i. CONTRACTOR disputes shall be initiated by contacting AMS billing contact in

writing through electronic or mail submission designated for account
questions.
ii. AMS Disputes reasons shall include but not limited to – suspected duplicate
transactions, suspected fraud, a request to validate signature on assigned
services, improper adherence to AMS policy and procedure, lack of supporting
documentation for completed services or questionable transaction activity.
iii. 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.
A CONTRACTOR dispute must be received within ten (10) days of the receipt of
AMS billing contact’s disputes designated for account questions.
iv. When proactively researching potential AMS dispute issues, CONTRACTOR may
issue a request to AMS, which shall be subject to the same process for
resolution as a dispute initiated by an AMS billing contact.
v. If the CONTRACTOR is unable to provide a written response within the ten (10)
day window, the Transaction shall be considered invalid and a systematic
chargeback to the CONTRACTOR will occur.
vi. If the CONTRACTOR is able to supply sufficient proof of completed services no
later than the expiration of the ten (10) day window, the chargeback will be
reversed and the disputed amount will be reapplied to the account.
vii. In the event the dispute is found in AMS’s favor, the disputed transaction shall
be permanently removed from the account as an amount due.
viii. AMS Billing Contact / Accounting Department will clear dispute liabilities in
accordance with the timeframes, which is normally shall not exceed ninety (90)
days from the central processing date. However, the allowable time to clear a
dispute may vary slightly by type of dispute. 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.

25. ENTIRE AGREEMENT. This AGREEMENT contains the entire agreement of the parties, and there are no
other promises or conditions in any other agreement whether oral or written concerning the subject
matter of this AGREEMENT. This AGREEMENT supersedes any prior written or oral agreements between
the parties.

26. SEVERABILITY. If any provision of this AGREEMENT will be held to be invalid or unenforceable for any
reason, the remaining provisions will continue to be valid and enforceable. If a court finds that any
provision of this AGREEMENT is invalid or unenforceable, but that by limiting such provision it would
become valid and enforceable, then such provision will be deemed to be written, construed, and enforced
as so limited.

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 27. AMENDMENT. This AGREEMENT may be modified or amended in writing, if the writing is signed by the
party obligated under the amendment.

28. GOVERNING LAW. This AGREEMENT shall be construed in accordance with the laws of the State of
Pennsylvania.

29. NOTICE. Any notice or communication required or permitted under this AGREEMENT shall be sufficiently
given if delivered in person or by certified mail, return receipt requested, 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.

30. ASSIGNMENT. Neither party may assign or transfer this AGREEMENT without the prior written consent of
the non-assigning party, which approval shall not be unreasonably withheld.

Service Provider: CONTRACTOR

By: ________________________________________ Date:____________

Authorized Representative (SIGN)

________________________________________

Authorized Representative (PRINT)

________________________________________

CONTRACTOR “company name” (PRINT)

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 220 Rittenhouse Circle
Bristol, PA 19007
Phone 866.699.1734
Fax 215.486.3238

Prompt Payment

To request Net 15 payment terms as outlined on Page 1 of the Subcontractor Agreement, please submit
this form with your application documents.

If your application is submitted without this page, by default, your elected payment terms will be Net 45
days as outlined on Page 1 of the Subcontractor Agreement.

I, (name)_______________________ ________of (company)__________________________________

request expedited payment (Net 15 days) . I understand that electing this payment option discounts my
invoice by 4%.

Authorized Representative (Sign) Date:

Authorized Representative (Print)

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SUB CONTRACTOR QUESTIONNAIRE

Business Name: Contact Person:

Address:
State:
City:

Phone: Mobile Phone:

Fax Number:

Email:

1. Are you willing to work nights and/or weekends?

2. What COUNTIES can you operate in on a regular basis?

3. What type of services does your business provide (ie. Home cleanouts, lawn
maintenance, home repairs, home cleaning, etc.)

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 percentage of work do you sub-out?

6. How many years of experience do you have in the home business?

7. What are some major clients you have worked for in the past?

8. How many crews of workers do you have at your disposal?

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

 9. What type of trucks do these crews have to use (ie. Lawn care pick-up, debris removal dump
truck)?

10. Do you have experience with using computers (email, internet, uploading digital photos)?

11. 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. Please list the type, size, and make of the following equipment your company uses.

Edger
Weed whacker
15 cyd dump truck or trailer
Cell phones on trucks
Commerical lawn mowers
Generators
Compressors

13. How many lawns/inspections can your company do PER DAY? __________
14. How many cleanouts/trashouts can your company do PER DAY? __________

15. Are there any specialized skill sets within your company?

16. 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.com

Form
(Rev. October 2007)
W-9 Request for Taxpayer Give form to the
requester. Do not
Department of the Treasury
Identification Number and Certification send to the IRS.
Internal Revenue Service
Name (as shown on your income tax return)
See Specific Instructions on page 2.

Business name, if different from above

Print or type

Check appropriate box: Individual/Sole proprietor Corporation Partnership

Exempt
Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) ©
payee
Other (see instructions) ©

Address (number, street, and apt. or suite no.) Requester’s name and address (optional)

City, state, and ZIP code

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. or
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number
number to enter.
Part II Certification
Under penalties of perjury, I certify that:
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), and
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 (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
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 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. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition 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 Signature of
Here U.S. person © Date ©

General Instructions Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
Section references are to the Internal Revenue Code unless
otherwise noted. ● An individual who is a U.S. citizen or U.S. resident alien,
● A partnership, corporation, company, or association created or
Purpose of Form organized in the United States or under the laws of the United
A person who is required to file an information return with the States,
IRS must obtain your correct taxpayer identification number (TIN) ● An estate (other than a foreign estate), or
to report, for example, income paid to you, real estate ● A domestic trust (as defined in Regulations section
transactions, mortgage interest you paid, acquisition or 301.7701-7).
abandonment of secured property, cancellation of debt, or
Special rules for partnerships. Partnerships that conduct a
contributions you made to an IRA.
trade or business in the United States are generally required to
Use Form W-9 only if you are a U.S. person (including a pay a withholding tax on any foreign partners’ share of income
resident alien), to provide your correct TIN to the person from such business. Further, in certain cases where a Form W-9
requesting it (the requester) and, when applicable, to: has not been received, a partnership is required to presume that
1. Certify that the TIN you are giving is correct (or you are a partner is a foreign person, and pay the withholding tax.
waiting for a number to be issued), Therefore, if you are a U.S. person that is a partner in a
partnership conducting a trade or business in the United States,
2. Certify that you are not subject to backup withholding, or provide Form W-9 to the partnership to establish your U.S.
3. Claim exemption from backup withholding if you are a U.S. status and avoid withholding on your share of partnership
exempt payee. If applicable, you are also certifying that as a income.
U.S. person, your allocable share of any partnership income from The person who gives Form W-9 to the partnership for
a U.S. trade or business is not subject to the withholding tax on purposes of establishing its U.S. status and avoiding withholding
foreign partners’ share of effectively connected income. on its allocable share of net income from the partnership
Note. If a requester gives you a form other than Form W-9 to conducting a trade or business in the United States is in the
request your TIN, you must use the requester’s form if it is following cases:
substantially similar to this Form W-9.
● The U.S. owner of a disregarded entity and not the entity,
Cat. No. 10231X Form W-9 (Rev. 10-2007)
Form W-9 (Rev. 10-2007)
● The U.S. grantor or other owner of a grantor trust and not the
trust, and
● The U.S. trust (other than a grantor trust) and not the
beneficiaries of the trust.
Foreign person. If you are a foreign person, do not use Form
W-9. Instead, use the appropriate Form W-8 (see Publication
515, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
Nonresident alien who becomes a resident alien. Generally,
only a nonresident alien individual may use the terms of a tax
treaty to reduce or eliminate U.S. tax on certain types of income.
However, most tax treaties contain a provision known as a
“saving clause.” 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.S.
resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an
exemption from U.S. tax on certain types of income, you must
attach a statement to Form W-9 that specifies the following five
items:
1. The treaty country. Generally, this must be the same treaty
under which you claimed exemption from tax as a nonresident
alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax under the
terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows
an exemption from tax for scholarship income received by a
Chinese student temporarily present in the United States. Under
U.S. law, this student will become a resident alien for tax
purposes if his or her stay in the United States exceeds 5
calendar years. However, paragraph 2 of the first Protocol to the
U.S.-China treaty (dated April 30, 1984) allows the provisions of
Article 20 to continue to apply even after the Chinese student
becomes a resident alien of the United States. 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.
If you are a nonresident alien or a foreign entity not subject to
backup withholding, give the requester the appropriate
completed Form W-8.
What is backup withholding? Persons making certain payments
to you must under certain conditions withhold and pay to the
IRS 28% of such payments. This is called “backup withholding.”
Payments that may be subject to backup withholding include
interest, tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay, and
certain payments from fishing boat operators. Real estate
transactions are not subject to backup withholding.
You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make the
proper certifications, and report all your taxable interest and
dividends on your tax return.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part II
instructions on page 3 for details),
3. The IRS tells the requester that you furnished an incorrect
TIN,
Page 2
4. 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), or
5. 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).
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Instructions for the Requester of Form W-9.
Also see Special rules for partnerships on page 1.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, 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.
Civil penalty for false information with respect to
withholding. If you make a false statement with no reasonable
basis that results in no backup withholding, you are subject to a
$500 penalty.
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal
penalties including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in
violation of federal law, the requester may be subject to civil and
criminal penalties.
Specific Instructions
Name
If you are an individual, you must generally enter the name
shown on your income tax return. However, if you have changed
your last name, for instance, due to marriage without informing
the Social Security Administration of the name change, enter
your first name, the last name shown on your social security
card, and your new last name.
If the account is in joint names, list first, and then circle, the
name of the person or entity whose number you entered in Part I
of the form.
Sole proprietor. Enter your individual name as shown on your
income tax return on the “Name” line. You may enter your
business, trade, or “doing business as (DBA)” name on the
“Business name” line.
Limited liability company (LLC). Check the “Limited liability
company” box only and enter the appropriate code for the tax
classification (“D” for disregarded entity, “C” for corporation, “P”
for partnership) in the space provided.
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 301.7701-3, enter the
owner’s name on the “Name” line. Enter the LLC’s name on the
“Business name” line.
For an LLC classified as a partnership or a corporation, enter
the LLC’s name on the “Name” line and any business, trade, or
DBA name on the “Business name” line.
Other entities. Enter your business name as shown on required
federal tax documents on the “Name” 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” line.
Note. You are requested to check the appropriate box for your
status (individual/sole proprietor, corporation, etc.).
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, sign and date the form.
Form W-9 (Rev. 10-2007) Page 3
Generally, individuals (including sole proprietors) are not exempt Part I. Taxpayer Identification
from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends. Number (TIN)
Note. If you are exempt from backup withholding, you should Enter your TIN in the appropriate box. If you are a resident
still complete this form to avoid possible erroneous backup alien and you do not have and are not eligible to get an SSN,
withholding. your TIN is your IRS individual taxpayer identification number
The following payees are exempt from backup withholding: (ITIN). Enter it in the social security number box. If you do not
have an ITIN, see How to get a TIN below.
1. An organization exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(b)(7) if the account If you are a sole proprietor and you have an EIN, you may
satisfies the requirements of section 401(f)(2), enter either your SSN or EIN. However, the IRS prefers that you
use your SSN.
2. The United States or any of its agencies or If you are a single-member LLC that is disregarded as an
instrumentalities, entity separate from its owner (see Limited liability company
3. A state, the District of Columbia, a possession of the United (LLC) on page 2), enter the owner’s SSN (or EIN, if the owner
States, or any of their political subdivisions or instrumentalities, has one). Do not enter the disregarded entity’s EIN. If the LLC is
4. A foreign government or any of its political subdivisions, classified as a corporation or partnership, enter the entity’s EIN.
agencies, or instrumentalities, or Note. See the chart on page 4 for further clarification of name
5. An international organization or any of its agencies or and TIN combinations.
instrumentalities. 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
Other payees that may be exempt from backup withholding for a Social Security Card, from your local Social Security
include: Administration office or get this form online at www.ssa.gov. You
6. A corporation, may also get this form by calling 1-800-772-1213. Use Form
7. A foreign central bank of issue, W-7, Application for IRS Individual Taxpayer Identification
8. A dealer in securities or commodities required to register in Number, to apply for an ITIN, or Form SS-4, Application for
the United States, the District of Columbia, or a possession of Employer Identification Number, to apply for an EIN. You can
the United States, apply for an EIN online by accessing the IRS website at
www.irs.gov/businesses and clicking on Employer Identification
9. A futures commission merchant registered with the Number (EIN) under Starting a Business. You can get Forms W-7
Commodity Futures Trading Commission, and SS-4 from the IRS by visiting www.irs.gov or by calling
10. A real estate investment trust, 1-800-TAX-FORM (1-800-829-3676).
11. An entity registered at all times during the tax year under If you are asked to complete Form W-9 but do not have a TIN,
the Investment Company Act of 1940, write “Applied For” in the space for the TIN, sign and date the
form, and give it to the requester. For interest and dividend
12. A common trust fund operated by a bank under section payments, and certain payments made with respect to readily
584(a), tradable instruments, generally you will have 60 days to get a
13. A financial institution, TIN and give it to the requester before you are subject to backup
14. A middleman known in the investment community as a withholding on payments. The 60-day rule does not apply to
nominee or custodian, or other types of payments. You will be subject to backup
withholding on all such payments until you provide your TIN to
15. A trust exempt from tax under section 664 or described in the requester.
section 4947.
Note. Entering “Applied For” means that you have already
The chart below shows types of payments that may be applied for a TIN or that you intend to apply for one soon.
exempt from backup withholding. The chart applies to the Caution: A disregarded domestic entity that has a foreign owner
exempt payees listed above, 1 through 15. must use the appropriate Form W-8.
IF the payment is for . . . THEN the payment is exempt Part II. Certification
for . . .
To establish to the withholding agent that you are a U.S. person,
Interest and dividend payments All exempt payees except or resident alien, sign Form W-9. You may be requested to sign
for 9 by the withholding agent even if items 1, 4, and 5 below indicate
Broker transactions Exempt payees 1 through 13. otherwise.
Also, a person registered under For a joint account, only the person whose TIN is shown in
the Investment Advisers Act of Part I should sign (when required). Exempt payees, see Exempt
1940 who regularly acts as a Payee on page 2.
broker Signature requirements. Complete the certification as indicated
Barter exchange transactions Exempt payees 1 through 5 in 1 through 5 below.
and patronage dividends 1. Interest, dividend, and barter exchange accounts
opened before 1984 and broker accounts considered active
Payments over $600 required Generally, exempt
2
payees during 1983. You must give your correct TIN, but you do not
to be reported and direct 1 through 7 have to sign the certification.
1
sales over $5,000
2. Interest, dividend, broker, and barter exchange
1 accounts opened after 1983 and broker accounts considered
See Form 1099-MISC, Miscellaneous Income, and its instructions.
2 inactive during 1983. You must sign the certification or backup
However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 6045(f), even if the attorney is a
withholding will apply. If you are subject to backup withholding
corporation) and reportable on Form 1099-MISC are not exempt from and you are merely providing your correct TIN to the requester,
backup withholding: medical and health care payments, attorneys’ fees, and you must cross out item 2 in the certification before signing the
payments for services paid by a federal executive agency. form.
Form W-9 (Rev. 10-2007) Page 4
3. Real estate transactions. You must sign the certification. Secure Your Tax Records from Identity Theft
You may cross out item 2 of the certification.
Identity theft occurs when someone uses your personal
4. Other payments. You must give your correct TIN, but you information such as your name, social security number (SSN), or
do not have to sign the certification unless you have been other identifying information, without your permission, to commit
notified that you have previously given an incorrect TIN. “Other fraud or other crimes. An identity thief may use your SSN to get
payments” include payments made in the course of the a job or may file a tax return using your SSN to receive a refund.
requester’s trade or business for rents, royalties, goods (other
than bills for merchandise), medical and health care services To reduce your risk:
(including payments to corporations), payments to a ● Protect your SSN,
nonemployee for services, payments to certain fishing boat crew ● Ensure your employer is protecting your SSN, and
members and fishermen, and gross proceeds paid to attorneys ● Be careful when choosing a tax preparer.
(including payments to corporations).
Call the IRS at 1-800-829-1040 if you think your identity has
5. Mortgage interest paid by you, acquisition or been used inappropriately for tax purposes.
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529), IRA, Victims of identity theft who are experiencing economic harm
Coverdell ESA, Archer MSA or HSA contributions or or a system problem, or are seeking help in resolving tax
distributions, and pension distributions. You must give your problems that have not been resolved through normal channels,
correct TIN, but you do not have to sign the certification. may be eligible for Taxpayer Advocate Service (TAS) assistance.
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.
What Name and Number To Give the Requester
Protect yourself from suspicious emails or phishing
For this type of account: Give name and SSN of: schemes. Phishing is the creation and use of email and
websites designed to mimic legitimate business emails and
1. Individual The individual
websites. The most common act is sending an email to a user
2. Two or more individuals (joint The actual owner of the account or,
account) if combined funds, the first
falsely claiming to be an established legitimate enterprise in an
individual on the account
1
attempt to scam the user into surrendering private information
3. Custodian account of a minor The minor
2 that will be used for identity theft.
(Uniform Gift to Minors Act)
1
The IRS does not initiate contacts with taxpayers via emails.
4. a. The usual revocable savings The grantor-trustee Also, the IRS does not request personal detailed information
trust (grantor is also trustee) through email or ask taxpayers for the PIN numbers, passwords,
1
b. So-called trust account that is The actual owner or similar secret access information for their credit card, bank, or
not a legal or valid trust under other financial accounts.
state law
5. Sole proprietorship or disregarded The owner
3
If you receive an unsolicited email claiming to be from the IRS,
entity owned by an individual forward this message to phishing@irs.gov. You may also report
Give name and EIN of:
misuse of the IRS name, logo, or other IRS personal property to
For this type of account:
the Treasury Inspector General for Tax Administration at
6. Disregarded entity not owned by an The owner 1-800-366-4484. You can forward suspicious emails to the
individual Federal Trade Commission at: spam@uce.gov or contact them at
4
7. A valid trust, estate, or pension trust Legal entity www.consumer.gov/idtheft or 1-877-IDTHEFT(438-4338).
8. Corporate or LLC electing The corporation
corporate status on Form 8832 Visit the IRS website at www.irs.gov to learn more about
9. Association, club, religious, The organization identity theft and how to reduce your risk.
charitable, educational, or other
tax-exempt 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 The public entity
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
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),
but 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.) Also see Special rules for partnerships on page 1.

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.

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,
dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return.
The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal
nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividend, and certain other
payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.