Payout Sheet | Form W-9 Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocial Security Number (#s only) *Tax Payer Identification Number (if for a business)Certification: Under the penalties of perjury, I certify that:The number shown on this form is my correct taxpayer identification number, or I am waiting for a number to be issued to me. *The above statement is true.I am not subject to backup withholding because (a) I am exempt from backup withholding or (b) I have not been notified by The IRS that I am subject to backup withholding as a failure to report all interest or dividends or ( c ) the IRS has notified me that I am no longer subject to backup withholding *The above statements are true.The above statements are true, except: I have been notified by the IRS that I am currently subject to backup withholding because you have failed to report all interest or dividends on my returnToday's Date *Signature *I agree to the above text being used as my electronic signature.Submit