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PayPal Account Email:

Verify PayPal Account Email:

Make Checks Payable to:

Name (as shown on your income tax return)*:

Business Name (if different):

Tax Classification*: Select Tax ClassificationCorporationLLCLLPNon-ProfitSole PropreitorshipOther

Tax Class - Other:

Enter your Taxpayer Identification Number (TIN) in the appropriate box. The TIN provided must match the name given in the Name field to avoid backup withholding. For individuals, this is your social security number (SSN). For other entities, it is your employer identification number (EIN).For more details, click here.

Social Security Number / Employer Identification number*:

Please contact your Account Manager if you wish to change your tax information.

Check here if the contact address listed above is the same as the address on your tax return

Address1*:

Address2:

City*:

State*: Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming---US Territories---American SamoaGuamMarshall IslandsMicronesia (Federated States of)PalauPuerto RicoU.S. Minor Outlying IslandsU.S. Virgin IslandsNorthern Mariana IslandsArmed Forces Americas AAArmed Forces Pacific APArmed Forces Canada AEOthers---Canada---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNova ScotiaNorthwest TerritoriesOntarioPrince Edward IslandQuebecSaskatchewanYukon Territory---Mexico---AguascalientesBaja CaliforniaBaja California SurCampecheCoahuilaColimaChiapasChihuahuaDistrito FederalDurangoGuanajuatoGuerreroHidalgoJaliscoMichoacanMorelosNayaritNuevo LeonOaxacaPueblaQueretaroQuintana RooSan Luis PotosiSinaloaSonoraTabascoTamaulipasTlaxcalaVeracruzYucatanZacatecas

Postal Code*:

Under penalties of perjury, I certify that:

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

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

I am a U.S. citizen or other U.S. person (defined here).

Certification Instructions: You must contact your account manager 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 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 here.