Affidavit of residence form
Use the following instructions to accurately complete the Affidavit of Residence form:
- Name of Corporation.
- Social Security number or Taxpayer Identification Number of the deceased shareowner.
- Your name.
- Your address.
- Your relationship to the deceased shareowner (i.e. executor, administrator, survivor in joint tenancy).
- Deceased shareowner's name as it appears on the face of the certificate/ or registration.
- Date of deceased person's death.
- Permanent address of deceased person at the time of death.
- State where deceased person lived at the time of death.
- Number of years deceased person lived in this state.
- Your signature.
- Notary's stamp and signature.
Broker authorization form
Use the following instructions to accurately complete the DRS form:
- Only check this space, if now, or in the near future you want to move your book entry shares electronically to your Broker/Dealer. If you check this space, items 5-7 must also be completed.
- Check this space to change the Broker/Dealer information on your account records at Computershare. If you check this space, items 5-7 must also be completed.
- If you check this space, Computershare will electronically transfer a specified number of your whole book entry shares to your current Broker/Dealer, as indicated on our records. If we do not currently maintain this information on our records you are required to provide it by completing items 5-7.
- Provide the number of whole book entry shares you wish to electronically transfer to your Broker/Dealer.
- The full name of your Broker/Dealer.
- A number used by your Broker/Dealer when clearing securities through their depositories. This number should be obtained from your Broker/Dealer.
- The number used to identify your account on the records of your Broker/Dealer. Please use it when inquiring about your account at your Broker/Dealer.
- Signature of current owner(s) exactly as it appears on the account registration. Please note that the signature(s) must be guaranteed by an Eligible Guarantor Institution such as a Commercial Bank, Trust Company, Securities Broker/Dealer, Credit Union, or Saving Association participating in a Medallion Program approved by the Securities Transfer Association, Inc. Unfortunately, no other form of signature verification can be accepted.
Transfer of ownership form
(This form is also known as a Stock Power.)
Use the following instructions to accurately complete the Transfer of Ownership form:
- Social security number or taxpayer identification number of the new owner.
- Complete, name and address of the new owner.
Please indicate if this is a:
- joint tenant account
- trust account -
- include name of trustee(s)
- date of trust
- name of the trust
- custodial account -
- name of the minor
- name of the custodian
- social security of the minor
- address of the minor
- state under which the uniform transfer/gift to minors act was created.
- Total certificate shares which are being transferred. If you do not have any certificates write "none."
- Book entry shares which are being transferred. If you are transferring all book entry shares write "all." If you do not have any book entry shares write "none."
- Name of the Corporation that appears on your certificate, Statement, or other correspondence.
- Current owner as the name(s) appears on the face of your certificate or Statement.
- Your account number as indicated on your dividend check or Statement.
- List the certificate number(s) printed on the left hand side of the certificate(s) that you choose to have transferred. This number will begin with two letters followed by a series of numbers. If all shares are held in book entry write "none."
Use the following instructions to accurately complete the IRS W8 form:
Use Form W-8 or a substitute form containing a substantially similar statement to tell the payer, mortgage interest recipient, middleman, broker, or barter exchange that you are a nonresident alien individual, foreign entity, or exempt foreign person not subject to certain U.S. information return reporting or backup withholding rules.
Caution: Form W-8 does not exempt the payee from the 30% (or lower treaty) nonresident withholding rates.
Nonresident Alien Individual
For income tax purposes, "nonresident alien individual" means an individual who is neither a U.S. citizen nor resident. Generally, an alien is considered to be a U.S. resident if:
- The individual was a lawful permanent resident of the United States at any time during the calendar year, that is, the alien held an immigrant visa (a "green card"), or
- The individual was physically present in the United States on:
- at least 31 days during the calendar year, and
- 183 days or more during the current year and the 2 preceding calendar years (counting all the days of physical presence in the current year, one -third the number of days of presence in the first preceding year, and only one -sixth of the number of days in the second preceding year).
See Pub. 519, U.S. Tax Guide for Aliens, for more information on resident and nonresident alien status.
Note: If you are a nonresident alien individual married to a U.S. citizen or resident and have made an election under section 6013(g) or (h), you are treated as a U.S. resident and may not use Form W-8.
Exempt Foreign Person For purpose of this form, you are an "exempt foreign person" for a calendar year in which:
- You are a nonresident alien individual or a foreign corporation, partnership, estate, or trust,
- You are an individual who has not been, and plans not to be, present in the United States for a total of 183 days or more during the calendar year, and
- You are neither engaged, nor plan to be engaged during the year, in a U.S. trade or business that has effectively connected gains from transactions with a broker or barter exchange.
If you do not meet the requirements of 2 or 3 above, you may instead certify on Form 1001, Ownership, Exemption, or Reduced Rate Certificate, that your country has a tax treaty with the United States that exempts your transactions from U.S. tax.
When To File — File Form W-8 or substitute form before a payment is made. Otherwise, the payer may have to withhold and send part of the payment to the Internal Revenue Service (see Backup Withholding below). This certificate generally remains in effect for three calendar years. However, the payer may require you to file a new certificate each time a payment is made to you.
Where To File - File this form with the payer of the qualifying income who is the withholding agent (see Withholding Agent below). Keep a copy for your own records.
A U.S. taxpayer identification number or Form W-8 or substitute form must be given to the payers of certain income. If a taxpayer identification number or Form W-8 or substitute form is not provided or the wrong taxpayer identification number is provided, these payers may have to withhold 20% of each payment or transaction. This is called backup withholding.
Note: On January 1, 1993, the backup withholding rate increases from 20% to 31%.
Reportable payments subject to backup withholding rules are:
- Interest payments under section 6049(a).
- Dividend payments under sections 6042(a) and 6044.
- Other payments (i.e., royalties and payments from brokers and barter exchanges) under sections 6041, 6041A(a), 6045, 6050A, and 6050N.
If backup withholding occurs, an exempt foreign person who is a nonresident alien individual may get a refund by filing Form 1040NR, U.S. Nonresident Alien Income Tax Return, with the Internal Revenue Service Philadelphia, PA 19255, even if filing the return is not otherwise requires.
U.S. Taxpayer Identification Number The Internal Revenue law requires that certain income be reported to the Internal Revenue Service using a U.S. taxpayer identification number (TIN). This number can be a social security number assigned to individuals by the Social Security Administration or an employee identification number assigned to businesses and other entities by the Internal Revenue Service.
Payments to account holders who are foreign persons (nonresident alien individuals, foreign corporations, partnerships, estates, or trusts) generally are not subject to U.S. reporting requirements. Also, foreign persons are not generally required to have a TIN, nor are they subject to any backup withholding because they do not furnish a TIN to a payer or broker.
However, foreign persons with income effectively connected with a trade or business in the United States (income subject to regular (graduated) income tax), must have a TIN. To apply for a TIN, use Form SS -4, Application for Employer Identification Number, available from local Internal Revenue Service offices, or Form SS -5, Application for a Social Security Card, available from local Social Security Administration offices.
Special Rules For purposes of the reporting rules, mortgage interest is interest paid on a mortgage to a person engaged in a trade or business originating mortgages in the course of that trade or business. A mortgage interest recipient is one who receives interest on a mortgage that was acquired in the course of a trade or business.
Mortgage interest is not subject to backup withholding rules, but is subject to reporting requirements under section 6050H. Generally, however, the reporting requirements do not apply if the payer of record is a nonresident alien individual who pays interest on a mortgage not secured by real property in the United States. Use Form W-8 or substitute form to notify the mortgage interest recipient that the payer is a nonresident alien individual.
Portfolio Interest — Generally, portfolio interest paid to a nonresident alien. individual or foreign partnership, estate, or trust is not subject to backup withholding rules. However, if interest is paid on portfolio investments to a beneficial owner that is neither a financial institution nor a member of a clearing organization, Form W-8 or substitute form is required.
Registered obligations not targeted to foreign markets qualify as portfolio interest not subject to 30% withholding, but require the filing of Form W-8 or substitute form. See Instructions to Withholding Agents on this page for reporting rules.
See Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Corporations, for registered obligations targeted to foreign markets and when Form W-8 or substitute form is not required on these payments.
Bearer obligations — The interest from bearer obligations targeted to foreign markets is treated as portfolio interest and is not subject to 30% withholding. Form If each owner of a joint account is a is not subject to 30% withholding. Form W-8 or substitute form is not required.
Dividends — Any distribution or payment of dividends by a U.S. corporation sent to a foreign address is subject to the 30% (or lower treaty) withholding rate, but is not subject to backup withholding. Also, there is no backup withholding on dividend payments made to a foreign person by a foreign corporation. However, the 30% withholding (or lower treaty) rate applies to dividend payments made to a foreign person by a foreign corporation if:
- 25% or more of the foreign corporation's gross income for the three preceding taxable years was effectively connected with a U.S. trade or business, and
- The corporation was not subject to the branch profits tax because of an income tax treaty (see section 884(e)).
If a foreign corporation makes payments to another foreign corporation, the recipient must be a qualified resident of its country of residence to benefit from that country's tax treaty.
Broker or Barter Exchanges — Income from transactions with a broker or barter exchanges is subject to reporting rules and backup withholding unless Form W-8 or substitute form is filed to notify the broker or barter exchange that you are an exempt foreign person as defined on page 1.
Name of Owner — If Form W-8 is being filed for portfolio interest, enter the name of the beneficial owner.
U.S. Taxpayer Identification Number — If you have a U.S. taxpayer identification number, enter your number in this space (see the discussion earlier).
Permanent Address — Enter your complete address in the country where you reside permanently for income tax purposes.
If you are:
- An individual — Show the address of: Your permanent residence
- A partnership or corporation — Show the address of: Principal office
- An estate or trust —Show the address of: Permanent residence or principal office of any fiduciary
Also show your current mailing address if it differs from your permanent address. Account Information (optional) - If you have more than one account (savings, certificate of deposit, pension, IRA, etc.) with the same payer, list all account numbers and types on one Form W-8 or substitute form unless your payer requires you to file a separate certificate for each account. If you have more than one payer, file a separate Form W-8 with each payer. Signature - If only one foreign person owns the account(s) listed on this form, that foreign person should sign the Form W-8. If each owner of a joint account is foreign, each person should sign a separate Form W-8.
Notice of Change in Status — If you become a U.S. citizen or resident after you have filed Form W-8 or substitute form, or you cease to be an exempt foreign person, you must notify the payer in writing within 30 days of your change in status.
To notify the payer, you may check the box in the space provided on this form or use the method prescribed by the payer.
Reporting will then begin on the account(s) listed and backup withholding may also begin unless you certify to the payer that:
- The U.S. taxpayer identification number you have given is correct, and
- The Internal Revenue Service has not notified you that you are subject to backup withholding because you failed to report certain income. You may use form W-9. Request for Taxpayer Identification Number and Certification to make these certifications.
If an account is no longer active, you do not have to notify a payer of your change in status unless you also have another account with the same payer that is still active.
False Certificate — If you file a false certificate when you are not entitled to the exemption from withholding or reporting,you may be subject to fines and/or imprisonment under U.S. perjury laws.
Instructions to Withholding Agents Withholding Agent — Generally, the person responsible for payment of the items discussed above to a nonresident alien individual or foreign entity is the withholding agent (see Pub. 515).
Retention of Statement — Keep Form W-8 or substitute form in your records for at least four years following the end of the last calendar year during which the payment is paid or collected.
Portfolio Interest — Although registered obligations not targeted to foreign markets are not subject to 30% withholding, you must file Form 1042S, Foreign Person's U.S. Source Income Subject to Withholding, to report the interest payment. Both Form 1042S and a copy of Form W-8 or substitute form must be attached to Form 1042, Annual Withholding Tax Return for U.S. Source Income of Foreign Persons.
Use the following instructions to accurately complete the IRS W9 form:
Purpose of Form — A person who is required to file an information return with the IRS 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.
Use Form W-9 to give your correct TIN to the person requesting it (the requester) and, when applicable, to:
- Certify the TIN you are giving is correct (or you are waiting for a number to be issued),
- Certify you are not subject to backup withholding, or
- Claim exemption from backup withholding if you are an exempt payee.
Note: If a requester gives you a form other than a W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9.
What Is Backup Withholding? — Persons making certain payments to you must withhold and pay to the IRS 31% of such payments under certain conditions. This is called "backup withholding." Payments that may be subject to backup withholding include interest, dividends, broker and barter exchange transactions, rent, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. If you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return, payments you receive will not be subject to backup withholding. Payments you receive will be subject to backup withholding if:
- You do not furnish your TIN to the requester, or
- The IRS tells the requester that you furnished an incorrect TIN, or
- The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or
- You do not certify your TIN when required. See the Part III instructions below for details.
Certain payees and payments are exempt from backup withholding. See the Part II instructions below and the separate Instructions for the Requester of Form W-9.
Failure To Furnish TIN — If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.
Civil Penalty for False Information With Respect to Withholding — If you make a false statement with no reasonable basis that results in no backup withholding , you are subject to a $500 penalty.
Criminal Penalty for Falsifying Information — Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.
Misuse of TINs — If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties.
Name — If you are an individual, you must generally enter the name shown on your social security card. However, if you have changed your last name, for instance, due to marriage, without informing the Social Security Administration 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 Part I of the form.
Sole Proprietor — You must enter your individual name as shown on your social security card. You may enter your business, trade, or "doing business as" name on the business name line.
Other Entities — Enter the business name as shown on required Federal tax documents. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or "doing business as" name on the business name line.
Part I - Taxpayer Identification Number (TIN)
You must enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How To Get a TIN below.
If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, using your EIN may result in unnecessary notices to the requester.
Note: See the list below for further clarification of name and TIN combinations.
How To Get a TIN — If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5 from your local Social Security Administration office. Get Form W-7 to apply for an ITIN or Form SS-4 to apply for an EIN. You can get Forms W-7 and SS-4 from the IRS by calling 1-800-TAX-FORM (1-800-829-3676).
If you do not have a TIN, write "Applied For" in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, you will generally have 60 days to get a TIN and give it to the requester. Other payments are subject to backup withholding.
Note: Writing "Applied For" means that you have already applied for a TIN OR that you intend to apply for one soon.
Part II — For Payees Exempt From Backup Withholding
Individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. For more information on exempt payees, see the separate Instructions for the Requester of Form W-9.
If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. Enter your correct TIN in Part I, write "Exempt" in Part II, and sign and date the form.
If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester a completed Form W-8, Certificate of Foreign Status.
Part III — Certification
For a joint account, only the person whose TIN is shown in Part I should sign (when required).
- Interest, Dividend, and Barter Exchange Accounts Opened Before 1984 and Broker Accounts Considered Active During 1983. You must give your correct TIN, but you do not have to sign the certification.
- Interest, Dividend, Broker, and Barter Exchange Accounts Opened After 1983 and Broker Accounts Considered Inactive During 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.
- Real Estate Transactions. You must sign the certification. You may cross out item 2 of the certification.
- Other Payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. "Other payments" include payments made in the course of the requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services (including attorney and accounting fees), and payments to certain fishing boat crew members.
- Mortgage Interest Paid by You, Acquisition or Abandonment of Secured Property, Cancellation of Debt, or IRA Contributions. You must give your correct TIN, but you do not have to sign the certification.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to give your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation and to cities, states, and the District of Columbia to carry out their tax laws.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 31% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
What Name and Number To Give the Requester
For this type of account; Give Name and SSN of:
- Name: The Individual
- Number: 1
Two or more individuals (joint account)
- Name: The actual owner of the account or, if combined funds, the first individual on the account.
- Number: 1
Custodian account of a minor (uniform gifts to minors act)
- Name: The minor
- Number: 2
The usual revocable savings trust (grantor is also a trustee)
- Name: The grantor trust
- Number: 1
So-called trust account that is not a legal or valid trust under state law
- Name: The actual owner
- Number: 1
- Name: The owner
- Number: 3
For this type of account; Give name and EIN of:
- Name: The owner
- Number: 3
A valid trust, estate or pension trust
- Name: Legal entity
- Number: 4
- Name: The corporation
- Number: N/A
Association, club religious, charitable, educational or other tax exempt organization
- Name: The organization
- Number: N/A
- Name: The partnership
- Number: N/A
A broker or registered nominee
- Name: The broker or nominee
- Number: N/A
Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district or prison) that receives agricultural program payments
- Name: The public entity
- Number: N/A
1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person's number must be furnished.
2 Circle the minor's name and furnish the minor's SSN.
3 You must show your individual name, but you may also enter your business or "doing business as" name. You may use either your SSN or EIN (if you have one).
4 List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.)
Note: 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.