Form W-9 Request for Taxpayer Give Form to the

Identification Number and Certification

(Rev. December 2014) requester. Do not

Department of the Treasury send to the IRS.

Internal Revenue Service

1 ,Name (as shown on your Income tax return). Name Is required on this line; do not leave this line blank.

Northwestern Indiana Regional Planning Commission

C\i 2 Business name/disregarded entity name, IIdifferent from above




"c'. 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to

instructions on page 3):

0 D Individual/sole proprietor or D C Corporation D S Corporation D Partnership D Trust/estate certain entities, not individuals; see


ID UI single-member LLC


c. D Limited liability company . Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Exempt payee code (If any)

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Note.For a single-member LLC that ts disregarded, do not check LLC;check the appropriate box in the line above for Exemption from FATCA reporting

the tax classifli;:atlon .of Iha single-member owner. code (if any)

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·c .5 0 Other (see instructions) Gov't Agency (Applies lo eccounts maintained outside the U.S )

!e 5 Address (number, street, and apt. or suite no.) Requester"s name and address {optionaQ


IcD. 6100 Southport Road





6 Glly, state, and ZIP ccida

- l

Portage, IN 46368

7 List account number(s) here (optional)

Taxpayer Identification Number (TlN)

Enter you TIN in.the app.roriate box. h TIN provided must.match te name given on line 1 to avoid I Social security number I

[[[]-ITJ -I I I I I

backup withholding. For md1v1duals, this 1s generally 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.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.





I Employer identification number



Under penalties of perjury, I certify that:

3 5 8 2 8 4 4

  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); and

  4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.


    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 3.

    General Instructions

    Section references are to the Internal Revenue Code unless otherwise noted.

    Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at

    Purpose of Form

    An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

    Use Form W-9 only if you are a U.S. person (including a resident alien) , to provide your correct TIN.

    If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

    By signing the filled-out form, you:

    1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

    2. Certify that you are not subject to backup withholding, or

    3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

    4. . Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. Sae What is FATCA reporting? on page 2 for further information.


Cat. No. 10231X Form W-9 (Rav. 12-2014)