Common use of Signature of U.S Clause in Contracts

Signature of U.S. Person: Date: Is your organization (association, club, religious, charitable, educational, Or other group) tax exempt under IRS Code Section 501(a)? YES or NO Are you a Real Estate Agent? YES or NO Is your business a *DMBE Certified Women Owned Business (WB)? YES or NO Is your business a *DMBE Certified Small Business (SB)? YES or NO Is your business a *DMBE Certified Minority Business (MB)? YES or NO African American Native American Subcontinent-Asian American Hispanic American Asian-Pacific American Other *DMBE = The Commonwealth of Virginia Department of Minority Business Enterprise @▇▇▇.▇▇▇▇.▇▇▇▇▇▇▇▇.▇▇▇ PLEASE PRINT: Contact Person: Title: Contact Phone: Contact Fax: A person who is required to file an information return with the IRS Exempt from backup withholding. If you are exempt, enter your name as described above, then check the AExempt from backup withholding@ box in the line following the business name6, . distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. must get 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 ▇▇▇. sign and date the form. Individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup

Signature of U.S. Person: Date: Is your organization (association, club, religious, charitable, educational, Or other group) tax exempt under IRS Code Section 501(a)? YES or NO Are you a Real Estate Agent? YES or NO Is your business a *DMBE Certified Women Owned Business (WB)? YES or NO Is your business a *DMBE Certified Small Business (SB)? YES or NO Is your business a *DMBE Certified Minority Business (MB)? YES or NO African American Native American Subcontinent-Asian American Hispanic American Asian-Pacific American Other *DMBE = The Commonwealth of Virginia Department of Minority Business Enterprise @▇▇▇.▇▇▇▇.▇▇▇▇▇▇▇▇.▇▇▇ PLEASE PRINT: Contact Person: Title: Contact Phone: Contact Fax: A person who is required to file an information return with the IRS Exempt from backup withholding. If you are exempt, enter your name as described above, then check the AExempt from backup withholding@ box in the line following the business name6, . distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. must get 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. sign and date the form. Individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup