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<br />FILE No.712 04/03 '00 15:08 <br /> <br />-'!:!,- <br /> <br />10: <br /> <br />FAX: <br /> <br />PAGE 2/ 2 <br /> <br />Request for Taxpayer <br />Identification Number and Certlftcatlon <br /> <br />cu.farm.~ <br />nl~HIIr. IJONOT <br />..... tit ..~.. <br /> <br />~. 1M T-..y <br />111111'I'III R-. ~ <br />Name (If . joint ICCQUm or you ~ your ".,.. see 8CleCific ~.A""" an paee 2.) <br />i Mounds View Economic Development Authority <br />eldir-. _. II diffInrlt frCI1'llllCMt. (See....... ~ an DIQlt 2.) <br /> <br />~ <br />-= <br />'C 0 <br />a. ChecIC IpClrCpnae tlclX: InclMl:lllllllScll propnMCt <br />: Addl'lD (r.um&:.. .... and .. or ~ no.1 <br />i 2401 Highwa 10 <br />CIty. .... II'lCt ZIP cadII <br />Mounds View, MN 55112-1429 <br /> <br />1i Identification Number <br />Enter your TIN In th. ~. DQX. For <br />incUvldLl8la. this Is YfM ICdII security number <br />(SSN). However; If you .... a rellident alien OR . <br />soItI proprietor, see the InstNCtlons on page 2. <br />For other entitIe8. it Is your employer <br />IdentlflcaUon numbOr (ElN). If you QO not hay. a <br />number. see Haw To Get . nN on page 2. <br />Noe.: It the KCDUnf 1$ In men tfNJn one name. <br />s'- the chait on page 2. faI' guid811nf1S en whcs8 <br />numcer fa enttIr. <br />Certiftcation <br /> <br /> <br /> <br />QI~ <br /> <br />o PeINrII1!p <br /> <br />o Other.. .......................---................ <br /> <br />~I name IU1d ~..... <br /> <br />UIl 8CCCNrft numt8(a) MM ~ , <br /> <br /> <br />. For PIIyMII.... FfWft...... <br />wtthhakIInv __ .. i1IDUI*anI <br />on page 2.) <br /> <br />OR <br />416008912 <br /> <br />... <br /> <br />Under penaIti_ ef perjury. I clll1ify that: <br />.. The number SIlOwn G1 thi1l fClnn is my ccrrect ta)cQaywo iden1lfIcaticn numblt (ar I am waiting far a numbllr tel be issuod fa - - I . <br />I am not subject to backup withI'lCIlCSlng beclWSe: (a. I ;un exempt fraM backup wiVlhaldinQ. or tilt 1 have not been natNci by 1he tntamIII <br />Revenue Service (IRS) that I am _ect to baclaJp withhalding as a telUlt of a failure to reIl(lr1 811 int...t or diYi~ gr (vi ow IRS hIllS <br />notlfted me that I am no tang.. IIUbject to backup witnl'lolding. .. <br />ce.tiftc:don 1~....Yau must crcu out item I above if ycu ..,. been nctifted by bIAS that yOU are currenUy IUbiICl to bacIcup. <br />witMOIdlng because you have failed to report all intllnlSt and d\YidIll'Ida on your tax l1IU'ft. Fer ,.... estalB transac:tiClns. Item a dOeI nat 8C)Iiy. <br />Fa mangage intlll8St plIiCS, acquiailian or abandonment at aec:ured property, cancellltian at debt. ccnuibu1ial'la to an IndtvIGuI& ..~ <br />anangement (IRA). and gEH18f'8lly, payments ather man interest and dlvlclendl. you are not requifod to sign the Cenification. but you must <br />provide your carTect T1N. (See the.ina1rUCticns on page 2.) <br /> <br />~~ J mlnatu~ ~ ~bI~ <br /> <br />Purpasa of Fonn.-A pflfSOn who is <br />required to file an information retum with <br />the IRS must get, your correct tupayer <br />idemific:ation numaer mN) to report. for <br />example, income ~cS to you. real estate <br />transac=ems. mortgage int81'8st you paid, <br />acqul.sltlon or abll/'ldC)N1'l8m of secured <br />property, cancellation of debt, or <br />contributiDns you mad. to an IRA. <br /> <br />Use Form W-9 to giv. your correct TIN <br />to tne person reque=l1lng it (the requester) <br />and. when applicable. to: <br /> <br />1. Certify the nN you are giving Is <br />eomtd (or you are waiting for a number to <br />D4t illaUed), <br /> <br />z.. Certify you arB not subject to backup <br />wRhholdlng, or <br /> <br />3. Claim exemption fram backup <br />wlttlholding if yOLl are an exempt payee. <br /> <br />. Note: /f a l1Jquester gives you Ii fcnn orner <br />than II W-9 fo teqUe<< your TIN, you must <br />USB the requests"'s l'onn /f If /5 sUbsUUlfia/ly <br />similar to '"/$ Form W.9. <br /> <br />wtNIt ,. Bactwp WlthholcAnl?~erscna <br />making certain ~aymems to you must <br />withhold and pay to the. IRS 31'K1 of sucn <br />payments unde, c8f'taln conditions. This' Is <br />called -baClCup withholding:' PaymentlS <br />that may be subject to backup withholding <br /> <br />Q~ <br /> <br />include interest, aiYide"ds. brOker and <br />baner exchange transactions, rents, <br />royalties. nonem!:llayee pay. and certain <br />payments from fishing bOat operators. Flea! <br />estate tranSaCtions lII'8 ncrt subJect to <br />back~ wnnnolding. <br /> <br />If you give tne requll8ter your correct <br />TIN, make the proper certifications. -and <br />report all your taxable Interest and <br />dividends on YQ~r tax nRLlrn. paymentS <br />you receive will not tle subject to backup <br />withnolding. Payments you rec.ive win be <br />subject to t:lac:IwP withholding It: <br /> <br />1. You do not tumisn your TIN to the <br />requester, Clr <br /> <br />2. The IRS tells the requester that you <br />furnished an incorrect TIN. or <br /> <br />3. 11'18 IRS tells you that you are subject <br />to backup withnoldlng beeause you did not <br />report an your inttlt'list and dividends on <br />your tax r~m 1for repClr1atl1e int8f8S1 IInct <br />dividendS only), or <br /> <br />4. You do not certify to the requester <br />that yau are not subject to. bacKUp <br />withholding unatlt' 3 i1tlove. (fer repcnable <br />intenlSt and cllvldend acccunn; epened <br />after 1983 only), or <br /> <br />D*~ <br /> <br />f.p - 2'} - .0 ( <br /> <br />5. You dO not certifY yaw TIN wnen <br />required. See the Pan IIIInttNCt10ns on <br />page Z far details. <br />Certain payees and payrMntI are <br />exempt from backup wiInhaIdIng. See tne <br />Part II instructiomJ and u. MPlU'It8 <br />'n.arucaOM for ... R..... at Fonn <br />w-e. <br /> <br />Penalties <br />Failure To Furnish 11N-6f you fall to <br />fumi:sn your correct TIN to . reqUtllll8r, yeu <br />ant subject to a penaltY of S!O for each <br />sud'l failure unless your faIIan .. due to <br />reua~. caIJU and nat to willful neglect. <br />Civil P....'" for F.... .........4lIIIon WIllI' <br />Aeapec;t fa WItftM~ you make a <br />faiN sta't8tne/'l! with flO rwaonabIe baSis <br />that resulW In no baC:lCUP withl'laldlng, you <br />are subJect to a $500 penIlly. <br />Crlmtn8. PenIStY for F......ne <br />InfDnnaUon.- Willfully faIaIfYfng <br />certiflcatlans or affIrmaUana mIIY lI\.lQ1ecl <br />you to criminal pena/tlee Including fines <br />and/or imprisonment. <br />MI8UM of llN~f the ~. <br />di$loaes or usee TINI In v1olallon at <br />Federal law. the requesW may tle sUbject <br />to civil and criminal penaItI8II. <br />