Form (Rev. January 2005)
Department of the Treasury Internal Revenue Service
Request for Taxpayer Identification Number and Certification
Give form to the requester. Do not send to the IRS.
Print or type See Specific Instructions on page 2.
Name (as shown on your income tax return)
Pro-Medic EMS LLC
Business name, if different from above
Check appropriate box:Individual/ Sole proprietor
Exempt from backup withholding Requester’s name and address (optional)
Address (number, street, and apt. or suite no.)
PO BOX 2190
City, state, and ZIP code
SAN JUAN, TX 78589
List account number(s) here (optional)
City of Hidalgo, TMFC DBA Dodge Arena 2600 N. 10th Street (HWY 336) Hidalgo, TX 78557
TaxpayerIdentification Number (TIN)
Social security number
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 your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employeridentification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.
Employer identification number
Under penalties of perjury, I certify that: 1. The number shown on this form is my correcttaxpayer 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 nolonger subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien). 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 interestpaid, 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. (See the instructions on page 4.)
Signature of U.S. person
Purpose of Form
A person whois required to file an information return with the IRS, must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. U.S. person. Use Form W-9 only if you are a U.S. person (including a residentalien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. Note. If a requester gives you a form other than Form W-9to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9. For federal tax purposes you are considered a person if you are: ● An individual who is a citizen or resident of the United States, ● A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, or ● Any estate (other than...
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