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(As shown on your income tax return). Name is required on this line; do not leave this line blank.

E-mail id is required on this line; do not leave this line blank.

(If different from above)

Check approppriate box for federal tax classification of the person whose name is entered on line. Check only one of the following seven boxes. Individual/Sole proprietor or single-member LCC C Corporation S Corporation Partnership Trust/Estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation,P=P corporation)
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner oof the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. Other

Exemptions (codes apply only to certain entities, not individuals)

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

(Applies to accounts maintained outside the U.S.)

(Number, Street, and Apt. or Suite No.)

Taxpayer Identification Number (TIN) 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 number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part 1, 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

Social security number

OR

Employer idenfication number

Signature

Date

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