Request for Taxpayer Identification Number and Certification

Request for Taxpayer Completed form should be Form W-9 given to the requesting Identification Number and Certification department or the department (Massachusetts Substitute W-9 Form) you are currently doing Rev. April 2009 business with. Name ( List legal name, if joint names, list first & circle the name of the person whose TIN you enter in Part I-See Specific Instruction on page 2)

Business name, if different from above. (See Specific Instruction on page 2)

t Check the appropriate box: Individual/Sole proprietor Corporation Partnership Other► r o

t Legal Address: number, street, and apt. or suite no. Remittance Address: if different from legal address number, street, and apt. or n i suite no. r p e

s City, state and ZIP code City, state and ZIP code a

e l P Phone # ( ) - Fax # ( ) - Email address: Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. For individuals, this is your social Social security number security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instruction on - - page 2. For other entities, it is your employer identification number (EIN). If OR you do not have a number, see How to get a TIN on page 2. Employer identification number Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter. -

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

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 Services (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 an U.S. person (including an U.S. resident alien). 4. I am currently a Commonwealth of Massachusetts’s state employee: (check one): No Yes If yes, in compliance with the State Ethics Commission requirements. 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.

Form MA- W-9 (Rev. April 2009) Sign Here Authorized Signature ► Date ►

Purpose of Form conditions. This is called “backup withholding.” 5. You do not certify to the requester that you are A person who is required to file an information Payments that may be subject to backup not subject to backup withholding under 4 above return with the IRS must get your correct withholding include interest, dividends, broker and (for reportable interest and dividend accounts taxpayer identification number (TIN) to report, for barter exchange transactions, rents, royalties, opened after 1983 only). nonemployee pay, and certain payments from example, income paid to you, real estate Certain payees and payments are exempt from transactions, mortgage interest you paid, fishing boat operators. Real estate transactions are not subject to backup withholding. backup withholding. See the Part II instructions acquisition or debt, or contributions you made to on page 2. an IRA. If you give the requester your correct TIN, make Penalties Use Form W-9 only if you are a U.S. person the proper certifications, and report all your (including a resident alien), to give your correct taxable interest and dividends on your tax return, Failure to furnish TIN. If you fail to furnish your TIN to the person requesting it (the requester) payments you receive will not be subject to correct TIN to a requester, you are subject to a and , when applicable, to: backup withholding. Payments you receive will penalty of $50 for each such failure unless your be subject to backup withholding if: 1. Certify the TIN you are giving is correct (or failure is due to reasonable cause and not to willful neglect. you are waiting for a number to be issued). 1. You do not furnish your TIN to the requester, or 2. Certify you are not subject to backup Civil penalty for false information with respect to withholding. If you make a false statement withholding 2. You do not certify your TIN when required with no reasonable basis that results in no backup (see the Part II instructions on page 2 for withholding, you are subject to a $500 penalty. If you are a foreign person, use the details), or appropriate Form W-8. See Pub 515, Criminal penalty for falsifying information. Withholding of Tax on Nonresident Aliens and 3. The IRS tells the requester that you furnished Willfully falsifying certifications or affirmations Foreign Corporations. an incorrect TIN, or may subject you to criminal penalties including What is backup withholding? Persons making 4. The IRS tells you that you are subject to fines and/or imprisonment. certain payments to you must withhold a backup withholding because you did not Misuse of TINs. If the requester discloses or uses designated percentage, currently 28% and pay to report all your interest and dividends only), or the IRS of such payments under certain TINs in violation of Federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions What Name and Number to How to get a TIN. If you do not have a Give the Requester Name. If you are an individual, you must TIN, apply for one immediately. To apply for an generally enter the name shown on your social SSN, get Form SS-5, Application for a Social security card. However, if you have changed Security Card, from your local Social Security For this type of account: Give name and SSN of: your last name, for instance, due to marriage Administration office. Get Form W-7, Application 1. Individual The individual without informing the Social Security for IRS Individual Taxpayer Identification Number, 2. Two or more The actual owner of the Administration of the name change, enter your to apply for an ITIN or Form SS-4, Application for individuals (joint account or, if combined first name, the last name shown on your social Employer Identification Number, to apply for an account) funds, the first security card, and your new last name. EIN. You can get Forms W-7 and SS-4 from the individual on the IRS by calling 1-800-TAX-FORM (1-800-829- account 1 If the account is in joint names, list first and 3676) or from the IRS’s Internet Web Site 3. Custodian account of The minor 2 then circle the name of the person or entity www.irs.gov. a minor (Uniform Gift whose number you enter in Part I of the form. to Minors Act) If you do not have a TIN, write “Applied For” in 1 Sole proprietor. Enter your individual name 4. a. The usual The grantor-trustee the space for the TIN, sign and date the form, as shown on your social security card on the revocable savings and give it to the requester. For interest and “Name” line. You may enter your business, trust (grantor is dividend payments, and certain payments made trade, or “doing business as (DBA)” name on also trustee) with respect to readily tradable instruments, 1 the “Business name” line. b. So-called trust The actual owner generally you will have 60 days to get a TIN and account that is not Limited liability company (LLC). If you are a give it to the requester before you are subject to a legal or valid single-member LLC (including a foreign LLC backup withholding on payments. trust under state with a domestic owner) that is disregarded as law an entity separate from its owner under The 60-day rule does not apply to other types of 5. Sole proprietorship The owner 3 Treasury regulations section 301.7701-3, enter payments. You will be subject to backup the owner’s name on the “Name” line. Enter withholding on all such payments until you the LLC’s name on the “Business name” line. provide your TIN to the requester. For this type of account: Give name and EIN of: 3 Caution: A disregarded domestic entity that Note: Writing “Applied For” means that you have 6. Sole proprietorship The owner 4 has a foreign owner must use the appropriate already applied for a TIN or that you intend to 7. A valid trust, estate, or Legal entity Form W-8. apply for one soon. pension trust 8. Corporate The corporation Other entities. Enter your business name as Part II - Certification 9. Association, club, The organization shown on required Federal tax documents on religious, charitable, the “Name” line. This name should match the To establish to the paying agent that your TIN is educational, or other name shown on the charter or other legal correct or you are a U.S. person, or resident tax-exempt organization document creating the entity. You may enter alien, sign Form W-9. 10. Partnership The partnership any business, trade, or DBA name on the 11. A broker or registered The broker or nominee For a joint account, only the person whole TIN is “Business name” line. shown in Part I should sign (when required). nominee 12. Account with the The public entity Part I - Taxpayer Identification Real estate transactions. You must sign the Department of Number (TIN) certification. You may cross out item 2 of the Agriculture in the name certification. of a public entity (such Enter your TIN in the appropriate as a state or local box. Dunn and Bradstreet Universal Numbering government, school System (DUNS) number requirement – district, or prison) that If you are a resident alien and you do not The United States Office of Management and Budget receives agricultural have and are not eligible to get an SSN, your (OMB) requires all vendors that receive federal grant program payments TIN is your IRS individual taxpayer funds have their DUNS number recorded with and identification number (ITIN). Enter it in the subsequently reported to the granting agency. If a

Form MA- W-9 (Rev. April 2009) Page 2 Sign Here Authorized Signature ► Date ►

Purpose of Form conditions. This is called “backup withholding.” 5. You do not certify to the requester that you are A person who is required to file an information Payments that may be subject to backup not subject to backup withholding under 4 above return with the IRS must get your correct withholding include interest, dividends, broker and (for reportable interest and dividend accounts taxpayer identification number (TIN) to report, for barter exchange transactions, rents, royalties, opened after 1983 only). nonemployee pay, and certain payments from example, income paid to you, real estate Certain payees and payments are exempt from transactions, mortgage interest you paid, fishing boat operators. Real estate transactions are not subject to backup withholding. backup withholding. See the Part II instructions acquisition or debt, or contributions you made to on page 2. an IRA. If you give the requester your correct TIN, make Penalties Use Form W-9 only if you are a U.S. person the proper certifications, and report all your (including a resident alien), to give your correct taxable interest and dividends on your tax return, Failure to furnish TIN. If you fail to furnish your TIN to the person requesting it (the requester) payments you receive will not be subject to correct TIN to a requester, you are subject to a and , when applicable, to: backup withholding. Payments you receive will penalty of $50 for each such failure unless your be subject to backup withholding if: 1. Certify the TIN you are giving is correct (or failure is due to reasonable cause and not to willful neglect. you are waiting for a number to be issued). 1. You do not furnish your TIN to the requester, or 2. Certify you are not subject to backup Civil penalty for false information with respect to withholding. If you make a false statement withholding 2. You do not certify your TIN when required with no reasonable basis that results in no backup (see the Part II instructions on page 2 for withholding, you are subject to a $500 penalty. If you are a foreign person, use the details), or appropriate Form W-8. See Pub 515, Criminal penalty for falsifying information. Withholding of Tax on Nonresident Aliens and 3. The IRS tells the requester that you furnished Willfully falsifying certifications or affirmations Foreign Corporations. an incorrect TIN, or may subject you to criminal penalties including What is backup withholding? Persons making 4. The IRS tells you that you are subject to fines and/or imprisonment. certain payments to you must withhold a backup withholding because you did not Misuse of TINs. If the requester discloses or uses designated percentage, currently 28% and pay to report all your interest and dividends only), or the IRS of such payments under certain TINs in violation of Federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions What Name and Number to How to get a TIN. If you do not have a Give the Requester Name. If you are an individual, you must TIN, apply for one immediately. To apply for an generally enter the name shown on your social SSN, get Form SS-5, Application for a Social security card. However, if you have changed Security Card, from your local Social Security For this type of account: Give name and SSN of: your last name, for instance, due to marriage Administration office. Get Form W-7, Application 1. Individual The individual without informing the Social Security for IRS Individual Taxpayer Identification Number, 2. Two or more The actual owner of the Administration of the name change, enter your to apply for an ITIN or Form SS-4, Application for individuals (joint account or, if combined first name, the last name shown on your social Employer Identification Number, to apply for an account) funds, the first security card, and your new last name. EIN. You can get Forms W-7 and SS-4 from the individual on the IRS by calling 1-800-TAX-FORM (1-800-829- account 1 If the account is in joint names, list first and 3676) or from the IRS’s Internet Web Site 3. Custodian account of The minor 2 then circle the name of the person or entity www.irs.gov. a minor (Uniform Gift whose number you enter in Part I of the form. to Minors Act) If you do not have a TIN, write “Applied For” in 1 Sole proprietor. Enter your individual name 4. a. The usual The grantor-trustee the space for the TIN, sign and date the form, as shown on your social security card on the revocable savings and give it to the requester. For interest and “Name” line. You may enter your business, trust (grantor is dividend payments, and certain payments made trade, or “doing business as (DBA)” name on also trustee) with respect to readily tradable instruments, 1 the “Business name” line. b. So-called trust The actual owner generally you will have 60 days to get a TIN and account that is not Limited liability company (LLC). If you are a give it to the requester before you are subject to a legal or valid single-member LLC (including a foreign LLC backup withholding on payments. trust under state with a domestic owner) that is disregarded as law an entity separate from its owner under The 60-day rule does not apply to other types of 5. Sole proprietorship The owner 3 Treasury regulations section 301.7701-3, enter payments. You will be subject to backup the owner’s name on the “Name” line. Enter withholding on all such payments until you the LLC’s name on the “Business name” line. provide your TIN to the requester. For this type of account: Give name and EIN of: 1 Cautionsocial security: A disregarded number box. domestic If you entitydo not that have Notecontractor: Writing has multiple “Applied DUNS For” meansnumbers that the you have List first and circle the name of the person whose hasan ITIN, a foreign see How owner to must get a use TIN the below. appropriate alreadycontractor applied should for provide a TIN the or primarythat you number intend listed to number you furnish. If only one person on a joint with the Federal government’s Central Contractor Form W-8. apply for one soon. account has an SSN, that person’s number must be If you are a sole proprietor and you have an Registration (CCR) at /www.ccr.gov . Any entity that furnished. OtherEIN, you entities may enter. Enter either your your business SSN orname EIN. as does not have a DUNS number can apply for one on- Part II - Certification 2 shownHowever, on therequired IRS prefers Federal that tax you documents use your on line at http://www.dnb.com/us/ Circle the minor’s name and furnish the minor’s SSN. SSN. Tounder establish the DNB to D-U-N the paying Number agent Tab. that your TIN is the “Name” line. This name should match the 3 You must show your individual name, but you may correct or you are a U.S. person, or resident Ifname you areshown an LLCon the that charter is disregarded or other legal as an also enter your business or “DBA” name. You may alien,Privacy sign ActForm Notice W-9. entitydocument separate creating from the its entity. owner You(see may Limited enter use either your SSN or EIN (if you have one). liabilityany business, company trade, (LLC) or DBA above), name and on arethe ForSection a joint 6109 account, of the onlyInternal the Revenueperson whole Code TIN is 4 “Business name” line. . List first and circle the name of the legal trust, estate, owned by an individual, enter your SSN (or shownrequires in you Part to I shouldgive your sign correct (when TIN required). to persons or pension trust. (Do not furnish the TIN of the “pre-LLC” EIN,Taxpayer if desired). Identification If the owner of a who must file information returns with the IRS to disregardedPart I - LLC is a corporation, partnership, reportReal estate interest, transactions dividends,. Youand mustcertain sign other the personal representative or trustee unless the legal etc., enter theNumber owner’s EIN. (TIN) incomecertification. paid toYou you, may mortgage cross out interest item 2 you of the paid, entity itself is not designated in the account title.) thecertification. acquisition or abandonment of secured EnterNote: Seeyour the TIN chart in on the this appropriate page for further Note: If no name is circled when more than one name property, cancellation of debt, or contributions is listed, the number will be considered to be that of box.clarification of name and TIN combinations. Dunn and Bradstreet Universal Numbering you made to an IRA or MSA. The IRS uses the the first name listed. numbersSystem (DUNS) for identification number requirement purposes and – to help If you are a resident alien and you do not The United States Office of Management and Budget verify the accuracy of your tax return. The IRS have and are not eligible to get an SSN, your (OMB) requires all vendors that receive federal grant If you have questions on completing this form, may also provide this information to the TIN is your IRS individual taxpayer funds have their DUNS number recorded with and please contact the Office of the State Comptroller. Department of Justice for civil and criminal identification number (ITIN). Enter it in the subsequently reported to the granting agency. If a (617) 973-2468. litigation, and to cities, states, and the District of social security number box. If you do not have contractor has multiple DUNS numbers the Columbia to carry out their tax laws an ITIN, see How to get a TIN below. contractor should provide the primary number listed Upon completion of this form, please with the Federal government’s Central Contractor If you are a sole proprietor and you have an Registration You must provide (CCR) atyour /www.ccr.gov TIN whether . Any or notentity you that send it to the CommonwealthForm MA- W-9 (Rev. of April 2009) Page 2 Form MA- W-9 (Rev. April 2009)