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W-9 FORM <br /> REQUEST FOR TAYPAYER_IDENTIFICATION NUMBER AND CERTIFICATION <br /> In order to satisfy Internal Revenue Service(IRSj regulations,we are required to obtain your Taxpayer Identification Number(TIN) <br /> when maldng reportable payments to you or your company. If this information is not provided to us by you,we are required by law <br /> to withhold thirty-one percent(31%)of all payments due to you and remit those funds to the IRS as income tax withholding. Also,If <br /> you do not provide this information,you may be subject-to penalties imposed by the IRS. <br /> THIS COMPLETED FORM IS REQUIRED TO BE FILED WITH USA SWIMMING BEFORE ANY <br /> PAYMENTS CAN BE PROCESSED <br /> PART I -Name,Address and Tax Status <br /> Legal Name Indian River County Board of County Commissioners <br /> (As reported for Federal income tax purposes and matdhes the number listed below) <br /> Business or Trade Name Indian River County Recreation Department <br /> Address 18091 27th street <br /> City Vero Beach State Fi Zip 32960 <br /> Please indicate (X) ownership status and provide TIN <br /> ❑ Individual/Sole Proprietor Corporation (For Profit) <br /> ❑ Partnership LLC (Partner;- VE IMA <br /> ) <br /> Governmental (U.S./State/Local) ❑ Other THIS IS TO CERTIFY THAT THIS IS <br /> A TRUE AND CORRECT COPY OF <br /> THE ORIGINAL ON FILE IN THIS <br /> Non-Profit Organization (dredc type below) OFFICE <br /> 1 y � J Y R SMITH,CLERK <br /> 501(c) J BY / / D.0 <br /> ® DATE <br /> Designate 501(c) <br /> SOCIAL SEWRIfY NUMBER EMPLOYER TAX ID NUMBER <br /> 85-8012622034C-3 <br /> PART II-Exemption <br /> If you are exempt from Backup Withholding,you should still complete this form to avoid possible erroneous backup <br /> withholding. Enter your correct name and TIN in Part I and write pEXEMPT"on the line provided here ' ; <br /> sign,date and return to requester. (Individuals,Sole Proprietors are not exempt) <br /> PART III -Certlflcation <br /> Under penalties of perjury, I certify that: (1)the number shown on this form is my correct taxpayer identification <br /> number(or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because <br /> (a)I am exempt from backup withholding, or(b) I have not been notified by the IRS that I am subject to backup <br /> withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no <br /> longer subject to backup withholding, and (3) I am a U.S. person (including a U.S. resident alien) <br /> SIGNATURE TITLE DATE <br /> Updated 11/3/2015 <br />