NCC192265_W-9_20191120

NC Office of the STATE
State Controller SUB
{IRS Forrn W-9 will not be
accepted in lieu of this farm) Request for Tw
50cial Security Number (55N),
OR
ED'Employer identification Number (b1N),
OR
II Taxpayer Ictentification Nwriber ([TIN)
2.
OF NORTH CAROUNA
STITU TF W-9 FORM
xpayer Identification Number
A. Legal Name (as shown on your income tax return):
1 ^
1-1 FL
S. Business Name/OBA/Disregarded Entity Nanre, if different from
Legal Name:
"6, Legal Address
"Address Line 1:
Address Line z:
City
County
8. Contact Name:
9. Phone Number; G
10. Fax Number: ff
11. EmaI!Addresr l --
Please select the appropriate Taxpayer Identification Nlnnber (EIN, SSrV,
or MN) type and enter your 9-digit ID number. The U.S. 'Taxpayer
Identification Number is being requested per U.S. Tax Law, Failure to
Provide this information In a timely manner could prevent or delay
payment to you or require The State of NC to withhold 2S% for backup
withholding tax.
3. Dunn & Bradstreet Universal Numbering System (DUNS) (see
Instructions(
Contact Information .................
7. Remittance Address {Location specifically used for payment that is
U .f A different from Legal Address, if applicable}
Address Line 1;
State Zip (9 digit)
C,
12. Entity Type
Individual/Sole Proprietor/Singh"-member LLCC Corporation
Address Line Z:
City — —� state
County
Partnership ®Trust/Estate 0Oil
Grri4ed liability company. I OW tax dassification {C=Cccrpnration,
S=Seorporatian, P=Partnership!--.'
--
'13. Entity
_ Classiflcatfon
ti011 yY.��.W�
I Medical Services
_ t'""'1 Legal/Attarney
Ll Services
0 NC Local Govt
® Federal Govt
zip (9 digit)
14, Exemptions (see
instructions)
Exempt payee code (if any);
Note; Check the appropriate box in the line above for the tax classification of the single ®NC State Agency
member owner. Do not check Iif the LLC is classified as a single -member Ithat Is Exemption (ram FATCA
disregarded from the owner unless the owner of the LLC is another LLC that is not ® Other Govt reporting code (if anyt
disregarded from the owner for 0 5- federal tax purpos4S. Otherwise, a Single -member LLC
that is disregarded from the owner should check the appropriate box for the tax classification Other {specify)
of its owner.
Urrder perli7itiCS of perjury, 1 certify that:—
i The number .shown pr1 this form is my correct taxpayer identifrcatiun nurrnher (or I aryl waiting for a number to be issued to me), and
1. 1 am not subject to backup withholding because: [aJ 1 am exempt from hackup withholding, or (b) I hnvc not been notified by the Internal Revinue Service
IIRSj that 1 871 subjectto backup withholding because of a railure to report all interest or dividends, or (c) the IRS has notified me th,,rt I am no longer
subject to backup withholding, and
3. 1 am a U.S. citizen or olhee U.S, person (defi meta lalfir it general instructions), and
4, the FATCA code[sj entered on this form (if amyl indicting that I am emirlpt from r-ATCA rrportilig is correct.
Certificatmn Instructians: Please refer to the MS Fora W 9 lorded on the IRS Webs'rte
,Printed Name'. _..__
W Authorized Li 1
Signature:
—
Please complete the Mod'ficat
Printed Title; Q._\-- ,2-
Date:
o C; rshn, �Ir!2rJr,a Record;" sprfionbelow If them havco bs:nn any GhanF;e's tar thF, fmllm,.,7npE:.., 1rlgOrifir,Eitimt iVunrhar fr?N;,