+orm

"!#

(Massachusetts $ubstitute "!# %orm) !e # ,pril -../

&equest for 'a(pa)er *dentification +umber and Certification

Completed form should be ,i-en to the requestin, department or the department )ou are currentl) doin, business with.

+ame ( 0ist legal name, if joint names, list first 1 circle the name of the person whose TI' you enter in 2art I3 $ee $pecific *nstruction on page -) .usiness name, if different from abo e# ($ee $pecific *nstruction on page -)

2lease print or t)pe

$heck the appropriate box: Indi idual4"ole proprietor 0e,al ddress: number, street, and apt# or suite no# Cit), state and 1*2 code

5 $orporation 5 2artnership 5 6ther 733333333333333333333333333333333333333333333333

&emittance ddress: if different from legal address number, street, and apt# or
suite no#

Cit), state and 1*2 code

2hone 8 (

+ax 8 (

*mail address:

2art I

Taxpayer Identification 'umber (TI')

$ocial securit) number

*nter your TI' in the appropriate box# +or indi iduals, this is your social security number (""')# 3owe-er, for a resident alien, sole proprietor, or disre,arded entit), see the 2art * instruction on pa,e 2# +or other entities, it is your employer identification number (*I')# If you do not ha e a number, see 3ow to ,et a '*+ on page -# +ote: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter#

3 3
4& 5mplo)er identification number

3
67+$

Vendors: Dunn and Bradstreet Universal Numbering System (DUNS))

2art **

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 ha e not been notified by the Internal !e enue "er ices (I!") that I am subject to backup withholding as a result of a failure to report all interest or di idends, or (c) the I!" has notified me that I am no longer subject to backup withholding, and 3. I am an U#"# person (including an U#"# resident alien)# 4# I am currently a $ommonwealth of %assachusetts&s state employee: (check one): 'o(((( )es ((((( If yes , in compliance with the "tate *thics $ommission requirements. Certification instructions: )ou must cross out item 2 abo e if you ha e been notified by the I!" that you are currently subject to backup withholding because you ha e failed to report all interest and di idends on your tax return# +or real estate transactions, item 2 does not apply#

+orm M ! "!# (!e # ,pril -../)

$i,n 3ere

uthori8ed $i,nature 9
conditions# This is called =backup withholding#> 2ayments that may be subject to backup withholding include interest, di idends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators# !eal estate transactions are not subject to backup withholding# If you gi e the re9uester your correct TI', make the proper certifications, and report all your taxable interest and di idends on your tax return, payments you recei e will not be subject to backup withholding# 2a)ments )ou recei-e will be sub>ect to bac<up withholdin, if: 1. )ou do not furnish your TI' to the re9uester, or 2. )ou do not certify your TI' when re9uired (see the 2art II instructions on page - for details), or 3. The I!" tells the re9uester that you furnished an incorrect TI', or 4. The I!" tells you that you are subject to backup withholding because you did not report all your interest and di idends only), or

6ate 9
;. )ou do not certify to the re9uester that you are not subject to backup withholding under ? abo e (for reportable interest and di idend accounts opened after @/;A only)# $ertain payees and payments are exempt from backup withholding# "ee the 2art II instructions on page -#

2urpose of %orm
, person who is re9uired to file an information return with the I!" must get your correct taxpayer identification number (TI') to report, for example, income paid to you, real estate transactions, mortgage interest you paid, ac9uisition or debt, or contributions you made to an I!,# 7se %orm "!# onl) if )ou are a 7.$. person (including a resident alien), to gi e your correct TI' to the person re9uesting it (the re9uester) and , when applicable, to: 1. $ertify the TI' you are gi ing is correct (or you are waiting for a number to be issued)# 2. $ertify you are not subject to backup withholding *f )ou are a forei,n person, use the appropriate %orm "!:# "ee 2ub ;1;, :ithholding of Tax on 'onresident ,liens and +oreign $orporations# "hat is bac<up withholdin,= 2ersons making certain payments to you must withhold a designated percentage, currently -;< and pay to the I!" of such payments under certain

2enalties
%ailure to furnish '*+# If you fail to furnish your correct TI' to a re9uester, you are subject to a penalty of BC. for each such failure unless your failure is due to reasonable cause and not to willful neglect# Ci-il penalt) for false information with respect to withholdin,# If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a BC.. penalty# Criminal penalt) for falsif)in, information # :illfully falsifying certifications or affirmations may subject you to criminal penalties including fines and4or imprisonment# Misuse of '*+s# If the re9uester discloses or uses TI's in iolation of +ederal law, the re9uester may be subject to ci il and criminal penalties#

$pecific *nstructions
+ame# If you are an indi idual, you must generally enter the name shown on your social security card# Dowe er, if you ha e changed your last name, for instance, due to marriage without informing the "ocial "ecurity ,dministration of the name change, enter your first name, the last name shown on your social security card, and your new last name# If the account is in joint names, list first and then circle the name of the person or entity whose number you enter in 2art I of the form# $ole proprietor# *nter your indi-idual name as shown on your social security card on the ='ame> line# )ou may enter your business, trade, or =doing business as (EF,)> name on the =Fusiness name> line# 0imited liabilit) compan) (00C)# If you are a single3member 00$ (including a foreign 00$ with a domestic owner) that is disregarded as an entity separate from its owner under Treasury regulations section A.@#GG.@3A, enter the owner?s name on the @+ameA line# *nter the 00$&s name on the =Fusiness name> line# Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8# Other entities# *nter your business name as shown on re9uired +ederal tax documents on the ='ame> line# This name should match the name shown on the charter or other legal document creating the entity# )ou may enter any business, trade, or EF, name on the =Fusiness name> line#

3ow to ,et a '*+#

If you do not ha e a TI', apply for one immediately# To apply for an ""', get %orm $$!;, ,pplication for a "ocial "ecurity $ard, from your local "ocial "ecurity ,dministration office# Het %orm "!B, ,pplication for I!" Indi idual Taxpayer Identification 'umber, to apply for an ITI' or %orm $$!4, ,pplication for *mployer Identification 'umber, to apply for an *I'# )ou can get +orms :3G and ""3? from the I!" by calling @3;..3T,I3+6!% (@3;..3;-/3 AJGJ) or from the I!"&s Internet :eb "ite www.irs.,o-# If you do not ha e a TI', write =,pplied +or> in the space for the TI', sign and date the form, and gi e it to the re9uester# +or interest and di idend payments, and certain payments made with respect to readily tradable instruments, generally you will ha e J. days to get a TI' and gi e it to the re9uester before you are subject to backup withholding on payments# The J.3day rule does not apply to other types of payments# )ou will be subject to backup withholding on all such payments until you pro ide your TI' to the re9uester# +ote: Writing Applied For means that you ha e already applied for a !I" or that you intend to apply for one soon#

"hat +ame and +umber to Di-e the &equester

%or this t)pe of account: 1. 2. Indi idual Two or more indi iduals (joint account) $ustodian account of a minor (Uniform Hift to %inors ,ct) a# The usual re ocable sa ings trust (grantor is also trustee) b# "o3called trust account that is not a legal or alid trust under state law "ole proprietorship Di-e name and $$+ of: The indi idual The actual owner of the account or, if combined funds, the first indi idual on the account @ The minor The grantor3trustee @

3. 4.

The actual owner

;.

The owner A Di-e name and 5*+ of: The owner A 0egal entity ? The corporation The organiKation

%or this t)pe of account: E. B. "ole proprietorship , alid trust, estate, or pension trust :. $orporate #. ,ssociation, club, religious, charitable, educational, or other tax3exempt organiKation 1F. 2artnership 11. , broker or registered nominee 12. ,ccount with the Eepartment of ,griculture in the name of a public entity (such as a state or local go ernment, school district, or prison) that recei es agricultural program payments

2art **

! Certification

To establish to the paying agent that your TI' is correct or you are a U#"# person, or resident alien, sign +orm :3/# +or a joint account, only the person whole TI' is shown in 2art I should sign (when re9uired)# !eal estate transactions. )ou must sign the certification# )ou may cross out item - of the certification#
6unn and .radstreet 7ni-ersal +umberin, $)stem (67+$) number requirement C The United "tates 6ffice of %anagement and Fudget (6%F) re9uires all endors that recei e federal grant funds ha e their EU'" number recorded with and subse9uently reported to the granting agency# If a

The partnership The broker or nominee The public entity

2art *

! 'a(pa)er *dentification
+umber ('*+)

5nter )our '*+ in the appropriate bo(.

If you are a resident alien and you do not ha e and are not eligible to get an ""', your TI' is your I!" indi idual taxpayer identification number (ITI')# *nter it in the

+orm M ! "!# (!e # ,pril -../) 2age 2

$i,n 3ere

uthori8ed $i,nature 9
conditions# This is called =backup withholding#> 2ayments that may be subject to backup withholding include interest, di idends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators# !eal estate transactions are not subject to backup withholding# If you gi e the re9uester your correct TI', make the proper certifications, and report all your taxable interest and di idends on your tax return, payments you recei e will not be subject to backup withholding# 2a)ments )ou recei-e will be sub>ect to bac<up withholdin, if: 1. )ou do not furnish your TI' to the re9uester, or 2. )ou do not certify your TI' when re9uired (see the 2art II instructions on page - for details), or 3. The I!" tells the re9uester that you furnished an incorrect TI', or 4. The I!" tells you that you are subject to backup withholding because you did not report all your interest and di idends only), or

6ate 9
;. )ou do not certify to the re9uester that you are not subject to backup withholding under ? abo e (for reportable interest and di idend accounts opened after @/;A only)# $ertain payees and payments are exempt from backup withholding# "ee the 2art II instructions on page -#

2urpose of %orm
, person who is re9uired to file an information return with the I!" must get your correct taxpayer identification number (TI') to report, for example, income paid to you, real estate transactions, mortgage interest you paid, ac9uisition or debt, or contributions you made to an I!,# 7se %orm "!# onl) if )ou are a 7.$. person (including a resident alien), to gi e your correct TI' to the person re9uesting it (the re9uester) and , when applicable, to: 1. $ertify the TI' you are gi ing is correct (or you are waiting for a number to be issued)# 2. $ertify you are not subject to backup withholding *f )ou are a forei,n person, use the appropriate %orm "!:# "ee 2ub ;1;, :ithholding of Tax on 'onresident ,liens and +oreign $orporations# "hat is bac<up withholdin,= 2ersons making certain payments to you must withhold a designated percentage, currently -;< and pay to the I!" of such payments under certain

2enalties
%ailure to furnish '*+# If you fail to furnish your correct TI' to a re9uester, you are subject to a penalty of BC. for each such failure unless your failure is due to reasonable cause and not to willful neglect# Ci-il penalt) for false information with respect to withholdin,# If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a BC.. penalty# Criminal penalt) for falsif)in, information # :illfully falsifying certifications or affirmations may subject you to criminal penalties including fines and4or imprisonment# Misuse of '*+s# If the re9uester discloses or uses TI's in iolation of +ederal law, the re9uester may be subject to ci il and criminal penalties#

$pecific *nstructions
+ame# If you are an indi idual, you must generally enter the name shown on your social security card# Dowe er, if you ha e changed your last name, for instance, due to marriage without informing the "ocial "ecurity ,dministration of the name change, enter your first name, the last name shown on your social security card, and your new last name# If the account is in joint names, list first and then circle the name of the person or entity whose number you enter in 2art I of the form# $ole proprietor# *nter your indi-idual name as shown on your social security card on the ='ame> line# )ou may enter your business, trade, or =doing business as (EF,)> name on the =Fusiness name> line# 0imited liabilit) compan) (00C)# If you are a single3member 00$ (including a foreign 00$ with a domestic owner) that is disregarded as an entity separate from its owner under Treasury regulations section A.@#GG.@3A, enter the owner?s name on the @+ameA line# *nter the 00$&s name on the =Fusiness name> line# social security number box# If you entity do notthat ha e Caution : A disregarded domestic an ITI', see 3ow tomust ,et ause '*+the below# has a foreign owner appropriate Form # sole proprietor and you ha e an If you W-8 are a *I', you may enter either your ""' or *I'#as Other entities # *nter your business name Dowe I!" prefers that use your shown er, on the re9uired +ederal taxyou documents on ""'# the ='ame> line# This name should match the name shown on the charter or other legal If you are an 00C that is disre,arded as an document creating the entity# enter entit) separate from its owner)ou (seemay Limited any business, trade, or EF, name on are the liability company (LLC) abo e), and =Fusiness name> owned by an indi line# idual, enter your ""' (or =pre300$> *I', if desired)# If the owner of a 2art * ! 00$ 'a(pa)er *dentification disregarded is a corporation, partnership, ('*+) etc#, enter the+umber owner&s *I'#

3ow to ,et a '*+#

If you do not ha e a TI', apply for one immediately# To apply for an ""', get %orm $$!;, ,pplication for a "ocial "ecurity $ard, from your local "ocial "ecurity ,dministration office# Het %orm "!B, ,pplication for I!" Indi idual Taxpayer Identification 'umber, to apply for an ITI' or %orm $$!4, ,pplication for *mployer Identification 'umber, to apply for an *I'# )ou can get +orms :3G and ""3? from the I!" by calling @3;..3T,I3+6!% (@3;..3;-/3 AJGJ) or from the I!"&s Internet :eb "ite www.irs.,o-# If you do not ha e a TI', write =,pplied +or> in the space for the TI', sign and date the form, and gi e it to the re9uester# +or interest and di idend payments, and certain payments made with respect to readily tradable instruments, generally you will ha e J. days to get a TI' and gi e it to the re9uester before you are subject to backup withholding on payments# The J.3day rule does not apply to other types of payments# )ou will be subject to backup withholding on all such payments until you pro ide your TI' to the re9uester#
contractor has multiple EU'" numbers theyou ha e +ote : Writing Applied For means that contractor shouldfor pro the number already applied a ide !I" or primary that you intendlisted to with the +ederal go ernment&s $entral $ontractor apply for one soon# !egistration ($$!) at 4www#ccr#go # ,ny entity that does not e Certification a EU'" number can apply for one on3 2art ** ha ! line at http:44www#dnb#com4us4 under the E'F 'umber Tab# To establish toE3U3' the paying agent that your TI' is

"hat +ame and +umber to Di-e the &equester

%or this t)pe of account: 1. 2. Indi idual Two or more indi iduals (joint account) $ustodian account of a minor (Uniform Hift to %inors ,ct) a# The usual re ocable sa ings trust (grantor is also trustee) b# "o3called trust account that is not a legal or alid trust under state law "ole proprietorship Di-e name and $$+ of: The indi idual The actual owner of the account or, if combined funds, the first indi idual on the account @ The minor The grantor3trustee @

3. 4.

The actual owner

;.

The owner A Di-e name and 5*+ of:

%or this t)pe of account:

@

0ist first and circle the name of the person whose number you furnish# If only one person on a joint account has an ""', that person&s number must be furnished#
A

$ircle the minor&s name and furnish the minor&s ""'#

correct or you are a U#"# person, or resident 2ri-ac) ct +otice alien, sign +orm :3/# "ection J@./ of the only Internal enue $ode +or a joint account, the !e person whole TI' is re9uires to gi e your correct TI' to persons shown inyou 2art I should sign (when re9uired)# who must file information returns with the I!" to !eal estate transactions . )ou sign the report interest, di idends, and must certain other certification# )ou may cross out item -you of the income paid to you, mortgage interest paid, certification# the ac9uisition or abandonment of secured property, cancellation of debt, or contributions 6unn and .radstreet 7ni-ersal +umberin, you made to an I!, or %",# The I!" uses the $)stem (67+$) number requirement C to help numbers for identification purposes and The United "tates 6ffice of %anagement and Fudget erify the accuracy of your tax return# The I!" (6%F) re9uires all endors that recei e federal grant may pro ide this information to the fundsalso ha e their EU'" number recorded with and Eepartment Lustice for cigranting il and criminal subse9uentlyof reported to the agency# If a litigation, and to cities, states, and the Eistrict of contractor has multiple EU'" numbers the $olumbia should to carry out their laws number listed contractor pro ide thetax primary
with the +ederal go ernment&s $entral $ontractor )ou must pro ide at your TI' whether or not you !egistration ($$!) 4www#ccr#go # ,ny entity that

)ou must show your indi idual name, but you may also enter your business or =EF,> name# )ou may use either your ""' or *I' (if you ha e one)#
?

# 0ist first and circle the name of the legal trust, estate, or pension trust# (Eo not furnish the TI' of the personal representati e or trustee unless the legal entity itself is not designated in the account title#)

5nter )our in the +ote: $ee the'*+ chart on thisappropriate page for further clarification of name and !I" combinations# bo(.
If you are a resident alien and you do not ha e and are not eligible to get an ""', your TI' is your I!" indi idual taxpayer identification number (ITI')# *nter it in the social security number box# If you do not ha e an ITI', see 3ow to ,et a '*+ below# If you are a sole proprietor and you ha e an

+ote: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed# If you have questions on completing this form, please contact the Office of the State Comptroller. ( !") #"$%&' (.

)pon completion of this form, please send it to the Common*ealth +orm M ! "!# (!e of # ,pril -../)
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+orm M ! "!# (!e # ,pril -../)