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1. Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2. Business name/disregarded entity name, if different from above

3. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check
only one of the following seven boxes.

Federal Tax Classification

Individual/sole proprietor or single-member LLC

C Corporation

S Corporation

Partnership

Trust/estate

Limited liability company

Note: Check the appropriate box in the line above for the tax classification of the single-member owner.
Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner
unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax
purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the
appropriate box for the tax classification of its owner.

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any):
Exemption from FATCA reporting code (if any):
(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

7 List account number(s) here (optional)

8 Requester's name and address (optional)

1040TaxBiz, LLC
11723 Pendleton Pike
Indianapolis, IN 46236

Part I Taxpayer Identification Number (TIN)

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 generally your social security number (SSN). However, for a resident alien,
sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your
employer identification number (EIN). If you do not have a number, see How to get a TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.

Social Security Number or EIN

Social Security Number

Employer Identification Number

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 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 no longer subject to backup
withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is
correct.
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 interest paid, 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 for Part II, later.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Signed by 1040TaxBiz Admin
Signed On: September 26, 2023

Timestamp

Audit

April 19, 2023 2:44 pm GMT

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