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Form W�9 Request for Taxpayer Give Form to the
<br /> (Rev December2011) Identification Number and Certification requester.Do not
<br /> Department ot the Treasury Send to the IRS.
<br /> Internal Revenue Service
<br /> Name(as shown on your income tax return)
<br /> City of Zephyrhills
<br /> Business name/disregarded entity name,if different from above
<br /> N
<br /> N
<br /> m
<br /> (II
<br /> �' Check appropriate box for federal tax classification:
<br /> c
<br /> � C ❑ Individual/sole proprietor ❑ C Corporation ❑ S Corporation ❑ Partnership � TrusVestate
<br /> ao
<br /> �� � Limited liability company Enter the tax classification(C=C corporation,S=S corporation,P=partnership)► ✓❑Exempt payee
<br /> � ----------------------------
<br /> r y
<br /> C C
<br /> a � �✓ Other(see instructions)► MuniCi alit
<br /> ;E Address(number,street,and apt.or suite no.) Requester's name and address(optional)
<br /> u
<br /> a 5335 8th Street Humana JCI Supplier
<br /> � City,state,and ZIP code
<br /> �, 640 Eden Park Dr
<br /> � Zephyrhills, Florida 33542 Cincinnati,OH 45202
<br /> List account number(s)here(optiona�)
<br /> Taxpayer ldentification Number(TIN)
<br /> Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line Social security number
<br /> to avoid backup withholding.For individuals,this is your social security number(SSN).However,for a � —�LJ —�
<br /> resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other
<br /> entities,it is your employer identification number(EIN).If you do not have a number,see How to gei a
<br /> TIN on page 3.
<br /> Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose Empioyer identification number
<br /> number to enter
<br /> 5 9 — 6 0 0 0 4 5 5
<br /> Certification
<br /> Under penalties of perjury,I certify that:
<br /> 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
<br /> 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
<br /> 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
<br /> no longer subject to backup withholding,and
<br /> 3. I am a U.S.citizen or other U.S.person(defined below).
<br /> 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
<br /> 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
<br /> interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
<br /> generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
<br /> instructions on page 4
<br /> Sign Signature of L '
<br /> Here U.S. erson►r"�
<br /> p ..� Date► i I�g zG���
<br /> General Instructions Note.If a requester gives you a form other than Form W-9 to request
<br /> your TIN,you must use the requester's form if it is substantially similar
<br /> Section references are to the Internal Revenue Code unless otherwise to this Form W-9.
<br /> noted.
<br /> Definition of a U.S.person.For federal tax purposes,you are
<br /> Purpose of Form considered a U.S.person if you are:
<br /> A person who is required to file an information return with the IRS must •An individual who is a U.S.citizen or U.S.resident alien,
<br /> obtain your correct taxpayer identification number(fIN)to report,for •A partnership,corporation,company,or association created or
<br /> example,income paid to you,real estate transactions,mortgage interest organized in the United States or under the laws of the United States,
<br /> you paid,acquisition or abandonment of secured property,cancellation .An estate(other than a foreign estate),or
<br /> of debt,or contributions you made to an IRA.
<br /> Use Form W-9 only if you are a U.S.person(including a resident
<br /> •A domestic trust(as defined in Regulations section 301 7701-7).
<br /> alien),to provide your correct TIN to the person requesting it(the Special rules for partnerships.Partnerships that conduct a trade or
<br /> requester)and,when applicable,to: business in the United States are generally required to pay a withholding
<br /> 1 Certify that the TIN you are giving is correct(or you are waiting for a tax on any foreign partners'share of income from such business.
<br /> Further,in certain cases where a Form W-9 has not been received,a
<br /> number to be issued), partnership is required to presume that a partner is a foreign person,
<br /> 2.Certify that you are not subject to backup withholding,or and pay the withholding tax.Therefore,if you are a U.S.person that is a
<br /> 3 Claim exemption from backup withholding if you are a U.S.exempt partner in a partnership conducting a trade or business in the United
<br /> payee.If applicable,you are also certifying that as a U.S.person,your States,provide Form W-9 to the partnership to establish your U.S.
<br /> allocable share of any partnership income from a U.S.trade or business status and avoid withholding on your share ot partnership income.
<br /> is not subject to the withholding tax on foreign partners'share of
<br /> effectively connected income.
<br /> Cat.No.10231X Form W-9(Rev 12-2011)
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