5106_Blackwood_expansionapplic_20210205

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February 5, 2021
Ms. Donna J. Wilson
NC Department of Environmental Quality
Solid Waste Section
Division of Waste Management
1646 Mail Service Center
Raleigh, NC 27699
RE: Permit to Operate Application
Blackwood Associates, LLC
Newton Grove, North Carolina
Dear Ms. Wilson:
On behalf of Blackwood Associates, LLC please find enclosed a revised permit to operate
application for a wood material treatment and processing facility in Newton Grove, North
Carolina.
Thank you for your attention to this matter and if there are any questions regarding the
application or if you need additional information, please contact me. My email address is
[e-mail]. You may reach me at 812-676-8770.
Sincere) ,
Ryan Conrad
Enclosure

APPLICATION - PERMIT TO OPERATE
Blackwood Associates, LLC
Wood Material Treatment & Processing Facility
West Farms Wood Products
Newton Grove, North Carolina
February 5, 2021
Prepared for:
Ms. Donna J. Wilson
North Carolina Department of Environmental Quality
Prepared by:
Ryan Conrad
Blackwood Associates
699 E. Dillman Road
Bloomington, Indiana 47401

APPLICATION FOR PERMIT TO OPERATE
Blackwood Associates, LLC
Wood Material Treatment & Processing Facility
West Farms Wood Products
Newton Grove, NC
TABLE OF CONTENTS
Paqe
Facility Overview 2
Land Use and Regulatory Compliance 3
Site Design 4
Site Operations 5
Record Keeping and Reporting 6
Operating Plan 7-9
Attachments
Total Property Footprint — Drawing 1
Total Property Layout & Staging Area — Drawing 2
FEMA Flood Hazard Information Pages 1, 2 & 3
Water Table Test Pit #1
Water Table Test Pit #2
Copy of Deeds
Zoning & Water Supply Watershed Determination Letter
Braston Newton, Planning Director, Johnston County Planning Dept., dated March 13,
2019.
Fire Department Jurisdiction Letter
Jerry Blackman, Fire Chief, Meadow Volunteer Fire Department, dated March 18, 2019
Blackwood Associates, LLC - Organizational Chart
Blackwood Solutions, LLC - Organizational Chart
2

FACILITY OVERVIEW
Name of Facility: West Farms Wood Products
Address: 1683 Barefoot Road
Newton Grove, NC 28366
Office: 919-524-5737
Website: www.westfarmswoodproducts.com
Landowner: Ms. Jamie Feagans
BWS Real Estate, LLC
1370 That Road
Bloomington, Indiana 47403
Office: 812-676-6770
General Manager: Mr. Ryan Conrad
Office: 812-676-8770
Cell: 812-327-4934
Email: ryan(a)-bwoodsolutions.com
Administrative Contact: Mr. Ryan Conrad
Office: 812-676-8770
Cell: 812-327-4934
Email: ryan(a)bwoodsolutions.com
The West Farms Wood Products facility is an existing business which produces high quality pine
shavings used for animal bedding. Blackwood Associates, LLC purchased this facility in February
of 2019. Blackwood Associates plans to expand the operation to include the carbonization of
clean wood, grinding of used utility poles and collection of clean wood.
Carbonization of Clean Wood:
Clean wood and vegetation are carbonized in a device called a Carbonator. The biomass is
significantly reduced in volume and converted into a product called biochar. This occurs at a high
temperature in an oxygen deprived state known as thermal conversion. Carbon dioxide is
sequestered and stored in the biochar and will be sold to end use consumers of this product.
Grinding of Utility Poles:
We will collect and deliver used utility poles to this facility. These are used Duke Energy utility
poles which have been treated with creosote. The poles will be ground and sent to the Craven
County Wood Energy plant to be used as boiler fuel. The grindings will be placed into trailers by
the end of each operating day, and then transported to the plant. If grindings conveyed into trailers
are stored temporarily on -site they will be covered or stored under cover to avoid exposure to
rainwater in an effort to mitigate any stormwater runoff
Collection of Clean Wood:
We plan to receive untreated and unpainted clean wood, vegetation (stumps, trees, limbs). poles.
Yard trash, leaves and other high nitrogen wastes will not be accepted. The wood will be delivered
to this facility in trucks and on trailers. The clean wood will be accumulated in piles to be used as
feed stock for the Carbonator. The facility will accept material from the public and charge tipping
fees.
3

LAND USE AND REGULATORY COMPLIANCE
FEMA Floodplain Map:
FEMA Flood plain map is attached. The facility is not located in a 100-year flood plain.
Minimum Buffer Requirements:
The facility meets the following minimum buffer requirements from the waste boundary.
• 50 feet from all surface waters of the state as defined in G.S. 143-212.
• 50 feet from property lines.
• Wood grinder - a property line buffer of more than 50 feet will be in place to prevent
flying debris from leaving the property.
• 200 feet from residential dwellings and commercial or public buildings.
• 100 feet from water supply wells.
Zoning:
The site is in consistent with all applicable zoning ordinances. Refer to the attached letter from
Braston Newton, Planning Director, Johnston County Planning Department, dated March 13, 2019.
Watershed:
The site is not located in a water supply watershed. Refer to the attached letter from Braston
Newton, Planning Director, Johnston County Planning Department, dated March 13, 2019.
Water Table:
The permanent, seasonal or perched water table in more than 12 inches from the soil surface. Two
separate test pits were excavated on site. Refer to the attached photographs dated March 7, 2019.
Fire Protection:
The Meadow Volunteer Fire Department will respond to the site if a fire occurred. Refer to the
attached letter from Jerry Blackman, Fire Chief, Meadow Volunteer Fire Department, dated March
18, 2019.
4

SITE DESIGN
The West Farms Wood Products wood material treatment and processing facility is in the
northwestern portion of the site and occupies about 6.0 acres (see Total Property Layout & Staging
Area - Drawing 2). Access to the facility is provided by an all-weather road.
The facility is situated on the east central side of the 53-acre site, opposite the existing wood
shaving facility further to the east.
The remaining surrounding land is mostly wooded and undeveloped.
Buffers have been provided as follows: 50 feet from property lines, 1000 feet from the nearest
residence, 200 feet from the nearest well, and 1000 feet from streams.
Wood material treatment and processing operations consist of sorting and segregating incoming
material by type. Separate stockpiles will be established for clean wood and used utility pole
pieces.
Most of the area is used to segregate incoming clean wood material prior to carbonizing and used
utility pole pieces prior to grinding. Stockpiles averaging 15 feet high by 40 feet wide at the base
are utilized. The design layout calls for 20-foot fire lanes around and between the stockpiles.
5

SITE OPERATIONS
Though inflow of wood materials to the facility cannot be accurately predicted due to the
commercial nature of the operation and the cyclical nature of land development, inflow is initially
predicted to be 10,000 tons monthly or around 2,500 tons per week.
A storage and processing area (about 6.0 acres) is located in the eastern portion of the site for
processing operations (see Total Property Layout & Staging Area - Drawing 2). The design layout
allows for 20-foot fire lanes around and between storage piles. The wood material piles will be 15
feet tall and 40 feet wide.
The maximum tonnage for treated wood stored on -site will not exceed 2000 tons at any given time.
Blackwood will provide $200,000 (2000 x $100 / ton) of financial assurance required of a treatment
and processing facility. This will be provided through a financial assurance trust fund arrangement
established by the North Carolina Department of Environmental Quality.
The facility is operated to minimize dust, noise and vectors. Dust is controlled by the application of
water spray on facility roads during hot, dry weather. Material processing may be postponed during
periods of high wind to reduce dusting.
Noise during operation of the carbonator is not a problem as it is no louder than other conventional
equipment in operation at the site. Only a few pieces of conventional heavy equipment operate at
the facility and the site is relatively isolated. It is anticipated the CBI grinder will not be in regular
operation. It will be brought to the site on an as needed basis.
A

RECORD KEEPING AND REPORTING
Records are kept at the site regarding material received and processed and sold (biochar).
Records include customer or vendor name and address, type and volume of material received and
sold and the date of transaction.
Copies of all applicable permits (with supporting documentation from approved permit applications)
and of approved operating plans will be kept on site.
An annual report is prepared each year for the period July 1 st through June 30th and submitted to the
Division of Waste Management by August 1st. The annual report will document the total quantity
and types of material received, including material received from local governments, and the
quantities of biochar sold.
For reporting of volume -based transactions on a weight basis, processed volumes will be
converted using a factor of 400 pounds per cubic yard (0.2 tons / CY). The annual report will be
submitted on the reporting form provided by the Division of Waste Management for treatment and
processing facilities.
7

OPERATING PLAN
Blackwood Associates, LLC
Wood Material Treatment & Processing Facility
West Farms Wood Products
Newton Grove, NC
Owner: Ms. Jamie Feagans
Blackwood Associates, LLC
1370 That Road
Bloomington, Indiana 47403
Office: 812-676-6770
General Manager: Mr. Ryan Conrad
Office: 812-676-8770
Cell: 812-327-4934
Email: ryan(a)bwoodsolutions.com
Newton Grove Fire Department: 910-594-0211 (Fire Station)
Fire / Rescue Emergencies 911 (EMS)
Physical Address: 1683 Barefoot Road
Newton Grove, NC 28366
Operating Hours: Monday — Saturday: 7:00 am — 7:00 pm
Site Personnel: General Manager:
Supervises site operations and site personnel.
Also controls access and directs vehicles.
Equipment Operator:
Operate equipment associated with processing operations.
Office Manager:
Manages office and checks in trucks delivering material.
The facility accepts only the following solid wood material:
Land -clearing debris (stumps, trees, limbs), untreated and unpainted wood waste
(including dimension lumber), uncontaminated pallets and storm debris. Used utility
pole pieces.
T

All unscheduled vehicles entering the facility are directed to the nearby West Farms Wood
Products office, where pertinent information is recorded on a ticket and / or customer log, with the
hauler name, vehicle type and size, type of wood materials and weight noted. When the facility is
open to the public an attendant is on duty to prevent acceptance of unauthorized materials.
The office attendant then directs the vehicle driver to the site, where the General Manager directs
the vehicle to the appropriate off-loading area. The General Manager selects vehicles on a random
or targeted basis and conducts an inspection of materials as they are being off-loaded. The visual
inspection helps assure that received materials are compatible with the intent and goals of the
facility.
Off-loaded material is sorted by incoming material type and moved to the appropriate stockpile
area.
All non -conforming waste and non -recyclable material is stored on site in a designated (small)
area, then transferred to a roll -off container when enough volume accumulates. Any household
garbage or other putrescible wastes will be containerized daily and properly disposed of at least
weekly. Facility personnel are responsible for transporting all non -conforming wastes to an
appropriate and properly permitted solid waste disposal facility.
The following equipment is available for use at the facility:
2011 CBI 6400 Grinder
2011 John Deere 437C Trailer mounted log loader with grapple
2012 John Deere 650J LGP Bulldozer with 6-way blade
2013 Hyundai 740-9 Wheel Loader with cab and bucket
2015 International Pro -Star Day cab
2016 Neuenhauser Star Screener
2018 John Deere 311 Skid Steer with 3-yard bucket
2019 ROI Carbonator 500
Water Truck - 1500 Gallon
Truck Weight Scale
9

In the event of equipment failure, broken equipment will be repaired or replaced.
Access roads are of all-weather construction and are well maintained.
Stormwater is naturally diverted from the facility work area due to the slope of the site and runs off
into forested riparian buffers. There is presently no pooling of water at the site. Stormwater best
management practices are utilized to prevent soil and other pollutants from accessing surface
waters and to prevent excessive on -site erosion. Silt fences are presently in place to prevent silt
from leaving the site.
The facility staff can facilitate drainage and eliminate standing water to reduce the potential for
mosquito breeding. There is currently no pooling or standing water at the site. The materials being
processed are not likely to attract other vectors since they are not putrescible.
A sign is posted at the facility entrance showing the contact name and telephone number in case of
an emergency, acceptable materials accepted and the permit number.
Fire, ambulance and police telephone numbers are posted in a readily accessible place. The
facility personnel are trained in basic on -site fire response procedures and have access to heavy
equipment, water, water truck and extinguishers to aid in the early suppression of fire. Fire
suppression may include isolating and spreading burning material, application of water or chemical
suppressant, and / or covering with soil.
If market conditions become unfavorable, we will cease to accept material at the facility and
process and remaining material stockpiled on -site.
10

National Flood Hazard Layer FIRMette
Legend
�= FEMA 9
35° 18'8.43"N
i cci I.VVVV
0 250 500 1,000 1,500 2,000 Rev. May2019 Blackwood Associates, LLC
SEE FIS REPORT FOR DETAILED LEGEND AND INDEX MAP FOR FIRM PANEL LAYOUT
Without Base Flood Elevation (BFE)
Zone A. V. A99
SPECIAL FLOOD With BFE or Depth Zone AE, AO, AH, VE, AR
HAZARD AREAS Regulatory Floodway
0.2% Annual Chance Flood Hazard, Areas
of 1% annual chance flood with average
depth less than one foot or with drainage
areas of less than one square mile zone x
Future Conditions 1% Annual
Chance Flood Hazard zone x
Area with Reduced Flood Risk due to
)THEIR AREAS OF Levee. See Notes. Zone x
FLOOD HAZARD Area with Flood Risk due to Leveezone o
NO SCREEN Area of Minimal Flood Hazard zone x
Q Effective LOMRs
OTHER AREAS Area of Undetermined Flood Hazard zone o
GENERAL - — - - Channel, Culvert, or Storm Sewer
STRUCTURES I I I I I I I Levee, Dike, or Floodwall
Cross Sections with 1% Annual Chance
17•5 Water Surface Elevation
eo- - - Coastal Transect
---513----- Base Flood Elevation Line (BFE)
Limit of Study
Jurisdiction Boundary
-- --- Coastal Transect Baseline
OTHER _ Profile Baseline
FEATURES Hydrographic Feature
Digital Data Available N
No Digital Data Available + _
MAP PANELS Unmapped V'
Q The pin displayed on the map is an approximate
point selected by the user and does not represent
an authoritative property location.
This map complies with FEMA's standards for the use of
digital flood maps if it is not void as described below.
The basemap shown complies with FEMA's basemap
accuracy standards
The flood hazard information is derived directly from the
authoritative NFHL web services provided by FEMA. This map
was exported on 5/10/2019 at 1:09:59 PM and does not
reflect changes or amendments subsequent to this date and
time. The NFHL and effective information may change or
become superseded by new data over time.
This map image is void if the one or more of the following map
elements do not appear: basemap imagery, flood zone labels,
legend, scale bar, map creation date, community identifiers,
FIRM panel number, and FIRM effective date. Map images for
unmapped and unmodernized areas cannot be used for
regulatory purposes.

Drawing 1:
Total Property
Footprint

Total Property Layout & Staging Area — Drawing 2
LEFT: Zoom out
RIGHT: Close up
Blue Box: Staging
and Processing
Area. Approx 6ac.
BLUE LINE: Total
Property
BLACK: Driveway
and easement
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44
A Flood Hazard Layer F1RMettb #FEMA
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Area with Reduced Flood Risk due to
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Area wllh Fla ad Rio due to Lov,9a1— r.
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GENERAL Channel, culvert, or Storm sower
STRUCTURES III !I)I Leven, Dike, or FOodwall
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FEATURES
HydrographlcFeat ure
DItotai Data Available 14
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MAP PANELS®
Unmapped
I? The pin dlsplayed on the map Is an approxlma!A
polntseiected by the user and does not ropreso
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This map complies with FEIAA'sstandards for the use of
digital Ilofld mops It It Is not vold as described below.
The basemap shaven complies with FEMA's ba.semap
accuracy standards
The Rood hazard Information Ls derived directly from the
n„rhn.anrivn Nash —h —1— —Irrr•rl by FFMA. This maD

Johnston County
PLANNING AND ZONING DEPARTMENT
"Here to Serve..."
March 13 2019
Mr. Robert Stancombe
West Farms Wood Products
1683 Barefoot Road
Newton Grove, NC 28336
'-� T
Subject: Zoning and Water Supply -Watershed Determination
1683 Barefoot Rd, Newton Grove, NC. ,� �. J �,... ••
0�' `�
Dear Mr. Stancombe�. vo ' � .
The proposed wood material treatment and processing facility at the property referenced above is
consistent with all applicable zoning ordinances. This property is not located in a water supply -
watershed district.
If there are any questions or concerns regarding.this letter, please cdntact me at [phone].
Should you have any questions, please contact me at 919-989-5150 or [e-mail].
Sincerely'
f01-
ston Newton's
Planning Director
309 E. Market Street, Smithfield, NC 27577
Telephone [phone] * Fax [phone]
www.johnstonnc.com/planning

May 8, 2019
Mr. Bob Stancombe
West Farms Wood Products
1683 Barefoot Road
Newton Grove, NC 28336
RE: Fire Department Jurisdiction Letter
Parcel Identification Number(s): 09J16085A
09116008E
09116008E
Dear Mr. Stancombe
The proposed wood material treatment and processing facility at the property referenced above
is in the jurisdiction of the Meadow Volunteer Fire Department. Our department located at 7409
NC Highway 50 South in Benson, NC 27504 would respond if a fire were to occur at this facility.
If there are any questions regarding this letter, please contact me at [phone].

Filed in JOHNSTON COUNTY, NC CRAIG OLIVE, Register of Deeds Filed 04/29/2019 12:43:08 PM
DEED BOOK: 5337 PAGE: 338-342 INSTRUMENT # 2019610075
Real Estate Excise Tax: $550.00 Deputy/Assistant Register of Deeds: LaWanda Neal
Submitted electronically by Huggins, Davis & Associates, LLP in compliance
with North Carolina statutes governing recordable documents and the terms
of the submitter agreement with the Johnston County Register of Deeds.
Excise Tax $550.00
Recording Time Book and Page
Tax Lot No. Parcel Identifier No. 09I16008E & 09I16008F
Verified by County on the _ day of
by
20_
Mail after recording to Katherine H. Davis, Attorney, P.O. Box 1571, Lumberton, NC 28359
This instrument was prepared by Katherine H. Davis, Attorney
PREPARATION OF THIS INSTRUMENT
The Property being conveyed is not the DOES NOT CERTIFY TITLE UNLESS
primary residence of the grantor(s) ACCOMPANIED BY CERTIFYING LETTER
Brief Description for the index
NORTH CAROLINA GENERAL WARRANTY DEED
THIS DEED made the;�3ay of April 2019 by and between
GRANTOR
SHIRLEY WOOD BEASLEY, Life Tenant
4011 Eldridge Rd
Newton Grove, NC 28366-8669
DEBORAH B. PILKENTON, unmarried
4011 Eldridge Rd
Newton Grove, NC 28366-8669
CAROLYN JEAN BEASLEY WALDRON, and husband
PAUL TRAVIS WALDRON
206 Enochs Rd
Newbern, TN 38059
DANIEL LEE BEASLEY, JR and wife,
JOAN L. BEASLEY
36 Clearwater Harbour
Sanford, NC 27332
ABIGAIL BEASLEY VIERRA and husband
DAVID J. VIERRA
4005 Eldridge Rd
Newton Grove, NC 28366
GRANTEE
BWS REAL ESTATE, LLC
An Indiana Limited Liability Company
1370 W. THAT ROAD
BLOOMINGTON, IN 47403
Enter in appropriate block for each party: name address and if appropriate character of entity, e.g., corporation or partnership.
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and assigns, and shall
include singular, plural, masculine, feminine or neuter as required by context.
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee, the receipt of which is hereby acknowledged, has and
N. C. Bar Assoc. Form No. 3 © 1977
Printed by Agreement with the N.C. Bar Assoc.
Chicago Title Insurance Company

DEED B: 5337 P: 339
by these presents does grant, bargain, sell and convey unto the Grantee in fee simple, all that certain lot or parcel of land situated in
City of MEADOW Township, JOHNSTON County, North Carolina and more particularly described as
follows:
Being all of Lot FOUR (4), containing 52.064 acres and Lot FIVE (5), containing 14.124 acres, according to a
map entitled "Heirs Division Survey and Map for Shirley Wood Beasley" prepared by Peacock Land Surveying,
dated July 22, 2002, and recorded in Map Book 62, Page 326, Johnston County Registry, which map is
incorporated herein by reference and to which map reference is made for a more complete and accurate
description.
BEING a portion of that 178.8 acre tract of land owned by Wade H. Wood (74 E 270, Johnston County Clerk of
Superior Court) and devised under his Last Will and Testament to Grace W. Wood for her lifetime and then to
Shirley Wood Beasley for her lifetime and then to his grandchildren Deborah Grace Beasley, Carolyn Jean
Beasley, Daniel Lee Beasley, Jr. and Florence Abigail Beasley.
The property heremabove described was acquired by Grantor by instrument recorded in Book 1224, Page 317, ROBESON County
Registry.
A map showing the above described property is recorded in Map Book 62, Page 326.
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto belonging to the Grantee in
fee simple.
And the Grantor covenants with the Grantee, that Grantor is seized of the premises in fee simple, has the right to convey the same in fee
simple, that title is marketable and free and clear of all encumbrances, and that Grantor will warrant and defend the title against the
lawful claims of all persons whomsoever except for the exceptions hereinafter stated.
Title to the property heremabove described is subject to the following exceptions:
SUBJECT TO ALL EASEMENTS AND RESTRICTIONS OF RECORD.
SUBJECT TO TAXES FOR THE YEAR 2019.
IN WITNESS WHEREOF, the Grantor has hereunto set his hand and seal, or if corporate, has caused this instrument to be signed
in its corporate name by its duly authorized officers and its seal to be hereunto affixed by authority of its Board of Directors, the
day and year first above written.
(SEAL)
SHi L,E,{ IAD BEASLEY
Vf (SEAL)
DEBORAH B. PILKENTON
STATE OF NORTH CAROLINA
JOHNSTON COUNTY
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1 CJut� t Se a Notary Public for said County and
State, do hereby certify that SHIRLEY WOOD BEASLEY personally appeared before me this day
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and acknowledged the due execution of the foregoing instrument
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this day and acknowledged the due execution of the foregoing instrument
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N. C. Bar Assoc. Form No.
3 © 1977
Printed by Agreement with the N.C. Bar Assoc.
Chicago Title Insurance Company

DEED B: 5337 P: 340
NORTH CAROLINA GENERAL WARRANTY DEED
Page - 3 -
In witness whereof, the Grantor(s) have hereunto set their name and seal.
Cr 4pfy ��4Li✓►, P ce (SEAL)
CAR LYN JEAN BEASLIkY WALDRON
u� E�•✓f iq� r `.t (SEAL)
PAUL TRAVIS WALDRON
A q TENNESSEE, County
STATE
TENNE.98S 1, a Notary Public of the County and State aforesaid, certify that
Norggy CAROLYN JEAN BEASLEY WALDRON
q C Grantor, personally appeared before me this day and acknowledged the
execution of the foregoing instrument. Witness my hand and official
Commis o stamp or seal, this QL"+�l day of A p_t k 2019.
OCtober2o,2020 My fission pire 0 -, D
Notary Public
SEAL -STAMP
TENNESSEE, IL County
G�PSiT YOgL
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STATE '�
Paul Travis Waldron
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Grantor, personally appeared before me this day and acknowledged the
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DEED B: 5337 P: 341
NORTH CAROLINA GENERAL WARRANTY DEED
Page-4-
In witness whereof, the Grantor(s) have hereunto set their name and seal.
— XW4 (SEAL)
DANIEL LEE BEASLEY, JR.
(SEAL)
JOA L. TEXSLEY
SEAL -STAMP
NORTH CAROLINA
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Jr�xtT.r nt r Ct�M COUNTY
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DEED B: 5337 P: 342 END OF DOCUMENT
NORTH CAROLINA GENERAL WARRANTY DEED
Page - 5 -
In witness whereof, the Grantor(s) have hereunto set their name and seal.
(SEAL)
ABIG IL BEAS LEY VIERRA
GV/" (SEAL)
DAVID J. VIERRA
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F NORTH CAROLINA
JOHNSTON COUNTY
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1, a Notary Public of the County and State aforesaid, certify that
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ABIGAIL BEASLEY VIERRA
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Grantor, personally appeared before me this day and acknowledged the
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execution of the foregoing instrument. Witness my hand and official
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stamp or seal, this day of '�rA 2019.
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Request for Taxpayer
Give Form to the
Form
Identification Number and Certification
requester. Do not
;Rev. October2018)
Department of the Treasury
send to the IRS.
ntemal
Revenue Service
► Go to www.irs.gov/FormV* for instructions and the latest information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Blackwood Associates, LLC
2 Business name/disregarded entity name, if different from above
M
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
4 Exemptions (codes apply only to
following seven boxes.
certain entities, not individuals; see
a
instructions on page 3):
o
ElIndividual/sole proprietor or ElC Corporation ElS Corporation ElPartnership ElTrust/estate
w
c
single -member LLC
Exempt payee code (if any)
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✓❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ►
p r
Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check
Exemption from FATCA reporting
+• rn
C
LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is
LLC
code if any)
(
a
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another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
❑ Other (see instructions) ►
(Applies to accounts maintained outside the U.S.)
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5 Address (number, street, and apt. or suite no.) See instructions.
Requester's name and address (optional)
a
PO Box 336
6 City, state, and ZIP code
Bloomington, IN 47402
7 List account number(s) here (optional)
Identification Number
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Under penalties of perjury, I certify that:
Social security number
_11E
or
identification number
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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. 1 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. 1 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 for Part 11, later.
Sin
9 Signature of
Here U.S. person ► Date ►
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
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.
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
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,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)

Blackwood Associates, LLC
President
(Jamie Feagans)
Finance Sales & production Operations Human
Marketing Resources