Payout Sheet | Form W-9 | Kicker AMA Arenacross

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Social 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 return

Today's Date *

Signature *

I agree to the above text being used as my electronic signature.