Home Recovery Kit For our customers with considerable home damage If you have time to meet with a Wells Fargo Home Mortgage representative at today's event, you will be provided with contact information specific to your home mortgage. If you do not have time to meet with a Wells Fargo Home Mortgage representative today, when you are ready to discuss your property damage, please call our: Disaster Assistance Hotline at (888) 818-9147. Wells Fargo Home Mortgage is a division of Wells Fargo Bank, N.A. 2012 Wells Fargo Bank, N.A. All rights reserved. NMLSR ID 399801.
Table of contents: Introduction Letter... 3 Your guide to the home recovery process... 4 How your funds are distributed... 6 Your Home Recovery Checklist... 7 Frequently asked questions about the home recovery process... 8 Tips on choosing a contractor... 9 Forms Acceptance of Return Services... 10 General Information Form... 11 Third Party Authorization Form... 12 Conditional Waiver of Lien... 13 Substitute W-9, Request for Taxpayer Identification Number and Certification... 14 Certification Of Completion Of Repairs... 15 Appendix Includes additional copies of forms and a page for you to take notes. 2
Subject: Information you need to move forward with repairs to your home Count on us to help you through the home recovery process Dear Customer: We understand this is a difficult time for you, and we d like to do all we can to help you through the home recovery process, protecting you and the value of your home every step of the way. This Home Recovery Kit provides you with the guidance and forms you ll need to complete necessary repairs to your home. Please take some time to carefully review the information in Your Guide to the Home Recovery Process. It will walk you through all the documentation we ll need to process your claim, including the forms that are enclosed with this kit. It clearly explains how we ll watch over the repairs and release the insurance funds for repairs to your property after receiving appropriate inspection results. Please keep in mind that these guidelines have been put in place to protect you during the process, and to ensure your property is fully restored to its original or higher value. Also included in this kit is Your Home Recovery Checklist. Use it as a handy reference to check off what you ve completed as you move through the process. Take a few moments to review the Frequently Asked Questions About the Home Recovery Process plus the Tips on Choosing a Contractor for additional helpful information. Sincerely, Wells Fargo Home Mortgage 3
Your guide to the home recovery process As a Wells Fargo Home Mortgage customer, you can count on us to help you through this difficult time, protecting you and the value of your home every step of the way. The following information will walk you through the home recovery process. The parties involved in the process As the mortgage servicer on your property, Wells Fargo Home Mortgage is the named mortgagee on your insurance proceeds check. As such, we will protect your interests and the restoration of your home to its original or higher value by watching over the repairs and releasing the insurance funds to cover the cost of repairs to your property as they are completed. You can take comfort in knowing we ll also take care of ordering and paying for the required property inspections, making sure the reconstruction is appropriately completed. As the homeowner or mortgagor, you are our primary contact. That s why it s important for you to carefully review the instructions below to understand what we ll need from you along the way, including materials from your insurance carrier and contractor(s) working on the repairs to your property. What is needed to process your claim To help us move your claim through the process as quickly as possible, there are a number of requirements that need to be met. They ve been put in place to protect you throughout the process and ensure that the repairs to your home are completed as they should be. If your insurance check exceeds your current outstanding mortgage balance, you have the option to pay off your mortgage. If you d like to do that, contact Customer Service at the number listed below and request a payoff quote to verify the total amount needed to pay off the mortgage in full. After confirming the correct payoff amount, please send us: The fully endorsed claim check from your insurance carrier, together with A letter authorizing Wells Fargo Home Mortgage to use the funds to pay off your mortgage. If the claim amount of the check is less than the amount owed, you must send the certified funds for the difference. You will be required to contact Wells Fargo Home Mortgage payoff department at 800-423-5021 for further direction. Please include your mortgage loan number on the check and in the letter. Mail insurance company claim check(s) and letter by regular U.S. postal mail or overnight mail to: Wells Fargo Home Mortgage Attn: Payoffs, MAC X2302-045 1 Home Campus Des Moines, IA 50328 4
Documentation required to file claims For all other claims, you need to provide the following documents: Fully endorsed insurance claim check from your insurance carrier with your mortgage loan number information with your endorsement. Insurance adjuster s worksheet or contractor s estimate as accepted and paid by your insurance carrier. If the contractor s estimate is used in lieu of an adjuster s worksheet, you must include a letter from your insurance company verifying this. Contract(s) for repairs from each contractor working on your home, which must be signed by each contractor and the homeowner(s). General Information Form (enclosed) completed by the homeowner, including current home and work phone numbers. Third Party Authorization Form (enclosed) completed by homeowner if Wells Fargo Home Mortgage is to work with any other party during the claims process. Conditional Waiver of Lien (enclosed) fully completed by each contractor and signed by all homeowners. (Copies of the blank form to provide to your contractors are included in the Appendix.) Substitute W-9, Request for Taxpayer Identification Number (enclosed). IRS regulations require that the tax ID number or Social Security number be provided by all contractors or persons receiving payments for work being performed. Before any checks are issued, for your protection Wells Fargo Home Mortgage must receive one of these completed forms from each contractor. (Copies of the blank form to provide to your contractors are included in the Appendix.) Certification Of Completion Of Repairs (enclosed) signed by all homeowner(s) when work is complete. 5
How your funds are distributed How funds are released First we ll need to receive the required documents from you. Then Wells Fargo Home Mortgage will deposit the fully endorsed check into a restricted escrow account and release the funds to you in three increments to ensure that the property is fully restored to its original or higher value. To receive your first release of funds We must receive all of the documents listed on the previous page(s) (except the Certificate of Completion of Repairs) to begin the process. Then we will issue a check equal to one-half of the total claim check received by our office that will be made payable to you and your contractor(s). To receive your second release of funds When your repairs are 50 percent complete, contact our so we may order a property inspection. It s a good idea to contact us one week before the funds are needed. Once we receive inspection results showing 50 percent of the repairs have been completed, we will issue a second check for one-fourth of the total claim check to be made payable to you and your contractor(s). To receive your remaining funds When your repairs are complete, please contact our to request a final inspection. Complete, sign and return the Certification Of Completion Of Repairs (on page 15) to us at the address noted on the form. Important information If your mortgage is past due, these guidelines may change. If you have a dispute with the contractor(s) over work performed, these guidelines may change. For further information on disputes, contact the. (If you do not have the number available that they provided to you, call the Disaster Assistance Hotline at (888) 818-9147.) If you re working with a public adjuster, you are responsible for paying those fees. What you need to keep in mind All checks are mailed by regular U.S. postal mail. The Return Services option is available to homeowners who want overnight package delivery for the return of endorsed claim checks or disbursement checks. The service is available with the upfront payment of a service fee and completion of the Acceptance of Return Services Form (See page 10). Refer to form for service fee amounts. Keep copies of all documents for your records, as original documents will not be returned. Include your mortgage loan number on any information you send us about your claim. Contact our Disaster Assistance Hotline at (888) 818-9147 to obtain information on where to send your claim. We ll be in contact with you at least every 30 days until you indicate you are ready for a property inspection, or until the work is complete. If you have any questions along the way, contact our. (If you do not have the number available that they provided to you, call the Disaster Assistance Hotline at (888) 818-9147.) 6
Your Home Recovery Checklist To help you through the home recovery process, follow the steps noted below after you ve carefully reviewed the information in the guide that is included in your Home Recovery packet. Send us the following completed documents (All forms are included in this kit, starting on page 10): Fully endorsed insurance claim check Include your mortgage loan number Insurance adjuster s worksheet or contractor s estimate As approved and paid by your insurance carrier Contract(s) for repairs Signed by contractor(s) and homeowner(s) Acceptance of Return Services form Optional. If selected, must include fee payment in the form of a cashier s check, money order or company check. General Information form Optional. Include your current home and work phone numbers Third Party Authorization form Optional. If you want us to work with any other party Conditional Waiver of Lien for each contractor Substitute W-9, Request For Taxpayer Identification Number for each contractor Certification of Completion of Repairs signed by all homeowner(s) when work is complete. When we receive the above, we ll deposit the claim check and send you a check for the first release of funds (one-half of the total claim). When your repairs are 50 percent complete, contact our. (If you do not have the number available that they provided to you, call the Disaster Assistance Hotline at (888) 818-9147.) After we order a property inspection and receive results showing 50 percent of the repairs have been completed, we ll send you a check for the second release of funds (one-fourth of the total claim). When your repairs are complete, contact our to order a final inspection. Fill out, sign and return to us the Certification Of Completion Of Repairs (see page 15). After we order a property inspection, receive results showing 100 percent of the repairs have been completed, and have all required documents, the balance of funds will be released. Send all documents to the. If you have questions, please contact our Property Loss Department. (If you do not have the number available that they provided to you, call the Disaster Assistance Hotline at (888) 818-9147.) 7
Frequently asked questions about the home recovery process Why is Wells Fargo Home Mortgage listed on my check? Wells Fargo Home Mortgage is listed as the loss payee on the insurance policy, and is included on the check because we have a secured interest in the property. Our responsibility is to help you by ensuring the property is repaired in the event of damage and restored to its original or higher value. What happens if I don t sign the insurance claim check? If Wells Fargo Home Mortgage receives a claim check that has not been endorsed by the homeowner(s), our will return it to the homeowner(s) to be signed. Be sure to write your mortgage loan number on the check. We cannot begin the home recovery process until we receive the endorsed check and all required paperwork. Why does Wells Fargo Home Mortgage release the funds in three increments? Wells Fargo Home Mortgage follows these guidelines to make certain the property is fully restored to its original or higher value. These increments protect the homeowner from contractors who would complete part of the work and still get full payment without completing the entire job they were hired to do. Why does Wells Fargo Home Mortgage have to inspect the property for the funds to be released? In order to protect the interests of the homeowner and the restoration of the home to its original or higher value, Wells Fargo Home Mortgage orders and pays for inspections of the property. By doing this, we watch over the repairs and release the insurance funds to cover the cost of repairs to the property as they re completed. Can I use part of the claim funds to bring my delinquent mortgage payments current? No. The funds must be used for property repair and restoration only. Can I use the claim funds to pay off my mortgage? Yes, if the amount of the claim exceeds the amount required to pay the mortgage in full. The amount to pay off the mortgage in full can be obtained by calling Customer Service and requesting a payoff quote for the amount needed. The homeowner must send the endorsed claim check with a letter authorizing Wells Fargo Home Mortgage to use the funds to pay off the mortgage. If the amount of the check is less than the amount owed, the homeowner must send certified funds for the difference along with the endorsed claim check and a letter authorizing Wells Fargo Home Mortgage to pay off the mortgage. Payoff overages will be released 15 calendar days after the date the mortgage is paid off. What happens if my mortgage balance is less than the claim amount? The insurance claim funds could be used to pay the mortgage in full (see above). However, if the funds are going to be used for repairs to the property, the claim funds will be retained by Wells Fargo Home Mortgage and released in three increments until the repairs are completed. What should I do if my contractor needs more than one-half of the funds to start or continue repairs? The contractor must submit a written request that is signed by both the contractor and you the homeowner, to Wells Fargo Home Mortgage,. Our will review the request and determine whether additional funds may be released. What if I don t use all the insurance money for the repairs? When the repairs are 100 percent complete, inspection(s) have occurred, and all contractors and repairmen have been paid, any remaining money is refunded to you, the homeowner. All mortgage payments must be current in order for you to receive a refund. 8
Tips on choosing a contractor Before you choose a contractor(s) for the repairs to your property, here are some tips to help you. Keep in mind that a good contractor may provide additional value, through the economical purchase of materials, coordination or subcontracting work, and time saved. First, doing your homework can help you find the right contractor for your needs. Begin by asking for referrals. Check with family and friends, colleagues, material suppliers, or your local chapter of the National Association of the Remodeling Industry. Make sure the contractors being recommended meet these criteria: Choose a contractor who has an established business in your area. Ensure the contractor meets your state s requirements to be licensed or bonded. Check with your Better Business Bureau for any complaints. Ask contractors to show you a copy of their insurance certification. Select at least three contractors to submit written bids for your job, each using the same plans and specs. Be careful of a bid that s significantly lower than the others, as there may be omissions or mistakes. Go with the professional you feel most comfortable with. Here are some questions to ask when you re interviewing potential contractors: How long have you been in business? What percentage of your business is repeat or referral? How many projects of similar scope have you completed in the past year? May I have a list of referrals and suppliers from these projects? Who will be working on the project? Do you have regular employees or subcontractors that you work with? Will you be on-site to supervise the job? What steps will you take with this project? How long will the project take? Once you ve selected a contractor and decided on the scope of your repairs, you should secure a contract for the work being done. A good contract can help prevent mistakes, avoid misunderstandings, and keep your project on time and within a budget. You also might want to consider having an attorney review the contract. 9
Wells Fargo Home Mortgage Homeowner Instructions: If you would like the optional service of having your claims funds expedited via overnight shipping, please choose one of the two options offered, fill out this form, and submit applicable payment as instructed below. Delivery address must be a street address; not a P.O. Box. Ensure information provided is clearly printed to avoid delays. Make a copy for your records and return the completed original signed and dated form to the Property Loss Department. Acceptance of Return Services Form We offer the option of overnight shipping for expedited delivery of your claim funds at an additional fee. If you would like to use this service, please select from one of the following options*: $10.00 for one-time overnight shipment of check or $30.00 for multiple overnight shipments for life of claim *Should you choose not to select this service, your funds will be shipped via USPS standard mail. Overnight Delivery Information Delivery Address: Street Address City, State, Zip Telephone Number: ( ) I have enclosed a cashier s check, money order, or company check for the amount of the service fee selected above made payable to: Return Services Please sign below: Borrower Date Co-borrower (if applicable) Date 10
Wells Fargo Home Mortgagege Homeowner owner Instructions: Provide us with details about your claim by completing this form. Make a copy for your records and return rn the completed original signed and dated d form to the Property Loss Department. General Information Form Loss Information 1. Date of loss: 2. Type of loss (i.e., fire, hail, water, etc.): 3. Area(s) damaged (i.e., roof, ceilings, walls, total loss, etc.): Contact Information 1. Homeowner (For phone contact, please indicate day or evening): Home phone number: ( ) Work phone number: ( ) Cell phone number: ( ) Other: ( ) Mailing address while repairs are being made (if applicable): 2. Contractor(s) (if applicable) name, address and phone number: 3. Insurance adjuster name and phone number: 4. Individual to contact to arrange property inspections name and phone number: 11
Wells Fargo Home Mortgage Homeowner Instructions: Complete this form if you want to authorize a third party (someone other than the owner(s) of this property) to handle certain particulars of your claim (see list below). Copies of this form are located in the Appendix. Please fill in each homeowner(s) name. Please write the third party s full name, list their relationship to you and provide a phone number for the third party. Please initial each type of authorization you would like to give to the third party (you may initial multiple authorizations). Please ensure each homeowner signs and dates the completed form for authorization to be valid. Wells Fargo reserves the right to terminate working with any authorized third party at its discretion. Third Party Authorization Form I/We Borrower(s) Name authorize the following third party Third party name Relationship to homeowner Third party phone number Please initial the type(s) of authorization you would like the above-mentioned third party to have regarding your claim. Request inspections Request claim status information Send draws directly to third party address Be the main contact for the property repair process Other Please sign below: Borrower Date Co-borrower (if applicable) Date 12
Wells Fargo Home Mortgagege Homeowner owner Instructions: Copies of this form are located in the Appendix. pendix. Have each contractor complete and sign the top portion of this form. The dollar amount on this form must match the dollar amount on the contractor s contract. As the homeowner, complete and sign the bottom portion of each form. Make a copy of each form for your records and return all completed original forms to the. Any correspondence/contact t about this claim will be directed ed to you or authorized third party. Conditional Waiver of Lien For contractor(s) to complete: Conditional upon the payment of ($ _), the undersigned agrees to release and/or waive any and all claim(s) of lien for labor/materials described as: used in construction, restoration, and/or alteration of the building situated on the premises known as the property address noted above, and same being owned by the homeowner noted above. Signed this day of AD 20. Contractor/Company name (please print): Contractor/Company officer signature: Contractor/Company phone number: ( ) For homeowner to complete: Please sign below, indicating to Wells Fargo Home Mortgage that you agree with the above information. Borrower Co-borrower (if applicable) Homeowner phone number: ( ) Homeowner phone number: ( ) 13
Wells Fargo Home Mortgagege Homeowner owner Instructions: Copies of this form are located in the Appendix. pendix. Ensure informatio ation provided is clearly printed to avoi oid delays. Have each contractor receiving ing payment for work on your home compl mplete, sign and date this form. We must receive completed form(s (s) before any checks will be issued. Make a copy of each form for your records and return all completed original forms to the Property Loss Department. This is an importa rtant t tax document for contractor(s ctor(s) to complete. Substitute W-9 Request for Taxpayer Identification ion Number and Certification Part I Taxpayer Identification Number (TIN) Check only one choice and provide your complete name and Taxpayer Identification Number. U. S. Resident Individual/Sole Proprietor/Single Member LLC Business name: Name of owner of the business: Social Security Number or Employer Identification Number U. S. Partnership, Limited Liability Company (LLC), or Trust Name (as shown on your tax return) Employer Identification Number: U. S. Corporation Name (as shown on your tax return) Employer Identification Number: Please check here if you are exempt from backup withholding. Note to Contractor: A corresponding 1099 form will be generated for tax reporting purposes. Part II Certification Cross out item 2 below 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. Under penalty 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 Service (IRS) that I am subject to backup withholding as a result of 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 a U.S. resident (including U.S. resident alien). Signature of U.S. resident: Phone number: ( ) Print Name: Title: Date: Business address: City: State: Zip Code: 14
Wells Fargo Home Mortgage Homeowner Instructions: When your property repairs are finished, complete and sign this form. Provide both a day and evening phone number so we may schedule your property inspection. Be sure you include your loan number on any information you send us about your claim. We must receive this completed form from you before the final draw can be made. Make a copy for your records and return the completed, signed original form to the Property Loss Department. Certification Of Completion Of Repairs By signing this form, I/we certify that all necessary repairs from damage sustained to the property address noted above have been completed in a workmanlike manner and that no material, labor, or like liens have been or will be incurred as a result of labor performed or materials used. Subject property has now been restored to its original or higher value. Homeowner(s) signature(s): Borrower Date: Day phone number: ( ) Evening phone number: ( ) Homeowner(s) signature(s): Co-borrower (if applicable) Date: Day phone number: ( ) Evening phone number: ( ) 15
Appendix Includes a page to take notes and two additional copies of the following forms in case you need them: Third Party Authorization Conditional Waiver of Lien Substitute W-9, Request for Taxpayer Identification Number and Certification 16
Notes 17
Wells Fargo Home Mortgage Homeowner Instructions: Complete this form if you want to authorize a third party (someone other than the owner(s) of this property) to handle certain particulars of your claim (see list below). Please fill in each homeowner(s) name. Please write the third party s full name, list their relationship to you and provide a phone number for the third party. Please initial each type of authorization you would like to give to the third party (you may initial multiple authorizations). Please ensure each homeowner signs and dates the completed form for authorization to be valid. Wells Fargo reserves the right to terminate working with any authorized third party at its discretion. Third Party Authorization Form I/We Borrower(s) Name authorize the following third party Third party name Relationship to homeowner Third party phone number Please initial the type(s) of authorization you would like the above-mentioned third party to have regarding your claim. Request inspections Request claim status information Send draws directly to third party address Be the main contact for the property repair process Other Please sign below: Borrower Co-borrower (if applicable) Date Date 18
Wells Fargo Home Mortgage Homeowner Instructions: Complete this form if you want to authorize a third party (someone other than the owner(s) of this property) to handle certain particulars of your claim (see list below). Please fill in each homeowner(s) name. Please write the third party s full name, list their relationship to you and provide a phone number for the third party. Please initial each type of authorization you would like to give to the third party (you may initial multiple authorizations). Please ensure each homeowner signs and dates the completed form for authorization to be valid. Wells Fargo reserves the right to terminate working with any authorized third party at its discretion. Third Party Authorization Form I/We Borrower(s) Name authorize the following third party Third party name Relationship to homeowner Third party phone number Please initial the type(s) of authorization you would like the above-mentioned third party to have regarding your claim. Request inspections Request claim status information Send draws directly to third party address Be the main contact for the property repair process Other Please sign below: Borrower Co-borrower (if applicable) Date Date 19
Wells Fargo Home Mortgage Homeowner Instructions: Have each contractor complete and sign the top portion of this form. The dollar amount on this form must match the dollar amount on the contractor s contract. As the homeowner, complete and sign the bottom portion of each form. Make a copy of each form for your records and return all completed original forms to the. Any correspondence/contact about this claim will be directed to you or authorized third party. Conditional Waiver of Lien For contractor(s) to complete: Conditional upon the payment of ($ _), the undersigned agrees to release and/or waive any and all claim(s) of lien for labor/materials described as: used in construction, restoration, and/or alteration of the building situated on the premises known as the property address noted above, and same being owned by the homeowner noted above. Signed this day of AD 20. Contractor/Company name (please print): Contractor/Company officer signature: Contractor/Company phone number: ( ) For homeowner to complete: Please sign below, indicating to Wells Fargo Home Mortgage that you agree with the above information. Borrower Co-borrower (if applicable) Homeowner phone number: ( ) Homeowner phone number: ( ) 20
Wells Fargo Home Mortgagege Homeowner owner Instructions: Have each contractor complete and sign the top portion of this form. The dollar amount on this form must match the dollar amount on the contractor s contract. As the homeowner, complete and sign the bottom portion of each form. Make a copy of each form for your records and return all completed original forms to the. Any correspondence/contact t about this claim will be directed ed to you or authorized third party. Conditional Waiver of Lien For contractor(s) to complete: Conditional upon the payment of ($ _), the undersigned agrees to release and/or waive any and all claim(s) of lien for labor/materials described as: used in construction, restoration, and/or alteration of the building situated on the premises known as the property address noted above, and same being owned by the homeowner noted above. Signed this day of AD 20. Contractor/Company name (please print): Contractor/Company officer signature: Contractor/Company phone number: ( ) For homeowner to complete: Please sign below, indicating to Wells Fargo Home Mortgage that you agree with the above information. Borrower Co-borrower (if applicable) Homeowner phone number: ( ) Homeowner phone number: ( ) 21
Wells Fargo Home Mortgagege Homeowner owner Instructions: Ensure informatio ation provided is clearly printed to avoi oid delays. Have each contractor receiving ing payment for work on your home compl mplete, sign and date this form. We must receive completed form(s (s) before any checks will be issued. Make a copy of each form for your records and return all completed original forms to the Property Loss Department. This is an important tax document for contractor(s) to complete. Substitute W-9 Request for Taxpayer Identification ion Number and Certification Part I Taxpayer Identification Number (TIN) Check only one choice and provide your complete name and Taxpayer Identification Number. U. S. Resident Individual/Sole Proprietor/Single Member LLC Business name: Name of owner of the business: Social Security Number or Employer Identification Number U. S. Partnership, Limited Liability Company (LLC), or Trust Name (as shown on your tax return) Employer Identification Number: U. S. Corporation Name (as shown on your tax return) Employer Identification Number: Please check here if you are exempt from backup withholding. Note to Contractor: A corresponding 1099 form will be generated for tax reporting purposes. Part II Certification Cross out item 2 below 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. Under penalty 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 Service (IRS) that I am subject to backup withholding as a result of 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 a U.S. resident (including U.S. resident alien). Signature of U.S. resident: Phone number: ( ) Print Name: Title: Date: Business address: City: State: Zip Code: 22
Wells Fargo Home Mortgagege Homeowner owner Instructions: Ensure informatio ation provided is clearly printed to avoi oid delays. Have each contractor receiving ing payment for work on your home compl mplete, sign and date this form. We must receive completed form(s (s) before any checks will be issued. Make a copy of each form for your records and return all completed original forms to the Property Loss Department. This is an importa rtant t tax document for contractor(s ctor(s) to complete. Substitute W-9 Request for Taxpayer Identification ion Number and Certification Part I Taxpayer Identification Number (TIN) Check only one choice and provide your complete name and Taxpayer Identification Number. U. S. Resident Individual/Sole Proprietor/Single Member LLC Business name: Name of owner of the business: Social Security Number or Employer Identification Number U. S. Partnership, Limited Liability Company (LLC), or Trust Name (as shown on your tax return) Employer Identification Number: U. S. Corporation Name (as shown on your tax return) Employer Identification Number: Please check here if you are exempt from backup withholding. Note to Contractor: A corresponding 1099 form will be generated for tax reporting purposes. Part II Certification Cross out item 2 below 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. Under penalty of perjury, I certify that: 1. 111 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 Service (IRS) that I am subject to backup withholding as a result of 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 a U.S. resident (including U.S. resident alien). Signature of U.S. resident: Phone number: ( ) Print Name: Title: Date: Business address: City: State: Zip Code: 23