Form W-9
(Rev. October 2018)
Department of the Treasury
Internal Revenue Service

Request for Taxpayer Identification
Number and Certification


▶ Go to www.irs.gov/FormW9 for instructions.

Check appropriate box for federal tax classification of the person whose name is entered in the Name textbox. Select only one of the following seven radio buttons.

Note: Select from the drop-down list, for LLC (Limited liability company), for the tax classification of the single-member owner. Do not select LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal taxes purposes. Otherwise, a single-member LLC that is disregarded from the owner should select the appropriate radio button for the tax classification of its owner.
Affiliated With Company(required to select one option)

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



(Applies to accounts maintained outside the U.S.)
Yes
No

Part I 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 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.

Select the Taxpayer Identification Number you are entering:


Part II Certification

Under penalties of perjury, I certify that:

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. 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

3. I 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.


Notification of Cozen O’Connor’s Federal Contractor Status

Cozen O'Connor ("Cozen") is a federal contractor and/or subcontractor. As a vendor or supplier to Cozen, your company may be a federal subcontractor required to comply with applicable Executive Orders, laws and regulations enforced by the U.S. Department of Labor, Office of Federal Contract Compliance Programs. Accordingly, we are notifying you of the following:

To the extent applicable, contractors and subcontractors shall abide by the requirements of 41 CFR §§ 60-1.4(a), 60-300.5(a) and 60-741.5(a). These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity or national origin. Moreover, these regulations require that covered prime contractors and subcontractors take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disability. The Executive Order 13496 Employee Notice Clause set forth in 29 Code of Federal Regulations Part 471 Appendix A to Subpart A is hereby incorporated by reference.

Payment Method (required to select one option)


11/7/2024

E-mail address entered will be used for secure electronic delivery of 1099s, please see confirmation e-mail for more information.