1. Name (as shown on your income tax return).
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 (Check only one of the following seven boxes).
Individual/sole proprietor or single-member LLC
Limited liability company
4. Exempt payee code (if any)
5. Address (number, street, and apt. or suite no.)
6. City, state, and ZIP code
7. List account number(s) here (optional)
Taxpayer Identification Number
Social Security Number or
Employer Identification Number