Payout Sheet - W9 Form

Name

Email

Phone Number

Address

Social Secuirty Number

Tax Payer ID Number (If for a Business)

Certification: Under the penalties of perjury, I certify that:

I am not subject to backup withholding because (a) I am exempt from backup withholding or (b) I have not been notified by The IRS that I am subject to backup withholding as a failure to report all interest or dividends or ( c ) the IRS has notified me that I am no longer subject to backup withholding

The above statements are true, except: I have been notified by the IRS that I am currently subject to backup withholding because you have failed to report all interest or dividends on my return

Today's Date

Signature (Type Name)

Submit