W-9 Submission

identity

Name (as shown on your income tax return) *

Business name / disregarded entity name (if different)

Federal tax classification *

LLC tax classification *

Specify classification *

exemptions (if applicable)

Exempt payee code

FATCA exemption code

address

Street address *

City *

State *

ZIP *

taxpayer identification number

Social Security Number Employer Identification Number

SSN *

certification & signature

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 in the instructions for IRS Form W-9); and

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

Signature (type your full legal name) *

Date

Submitted