Common use of Federal Taxpayer Identification Number; Nature of Entity Clause in Contracts

Federal Taxpayer Identification Number; Nature of Entity. Under penalties of perjury, Provider certifies that is Provider’s correct Federal Taxpayer Identification Number or Social Security Number (check one). Provider is doing business as a (please check one): Individual Sole Proprietorship Partnership Corporation (includes Not For Profit) Medical Corporation Governmental Unit Estate or Trust Pharmacy-Non Corporate Nonresident Alien Pharmacy/Funeral Home/Cemetery Corp. Tax Exempt Limited Liability Company (select applicable tax classification) □ D = disregarded entity □ C = corporation □ P = partnership

Federal Taxpayer Identification Number; Nature of Entity. Under penalties of perjury, Provider certifies that is Provider’s correct _ Federal Taxpayer Identification Number or _ Social Security Number (check one). Provider is doing business as a (please check one): Individual Sole Proprietorship Partnership Corporation (includes Not For Profit) Medical Corporation Governmental Unit Estate or Trust Pharmacy-Non Corporate Nonresident Alien Pharmacy/Funeral Home/Cemetery Corp. Tax Exempt Limited Liability Company (select applicable tax classification) □ D = disregarded entity □ C = corporation □ P = partnership

Federal Taxpayer Identification Number; Nature of Entity. Under penalties of perjury, Provider certifies that is Provider’s correct Federal Taxpayer Identification Number or Social Security Number (check one). Provider is doing business as a (please check one): Individual Sole Proprietorship Partnership Corporation (includes Not For Profit) Medical Corporation Governmental Unit Estate or Trust Pharmacy-Non Corporate Nonresident Alien Pharmacy/Funeral Home/Cemetery Corp. Tax Exempt Limited Liability Company (select applicable tax classification) □ D = disregarded entity □ C = corporation □ P = partnership

Federal Taxpayer Identification Number; Nature of Entity. Under penalties of perjury, Provider certifies that is Provider’s correct Federal Taxpayer Identification Number or Social Security Number (check one). Provider is doing business as a (please check one): Individual Sole Proprietorship Partnership Corporation (includes Not For Profit) Medical Corporation Governmental Unit Estate or Trust Pharmacy-Non Corporate Nonresident Alien Pharmacy/Funeral Home/Cemetery Corp. Tax Exempt Limited Liability Company (select applicable tax classification) □ D = disregarded entity □ C = corporation □ Pharmacy-Non Corporate P = partnership

Federal Taxpayer Identification Number; Nature of Entity. Under penalties of perjury, the Provider certifies that is the Provider’s correct Federal Taxpayer Identification Number or Social Security Number (check one). The Provider is doing business as a (please check one): Individual Sole Proprietorship Partnership Corporation (includes Not For Profit) Medical Corporation Governmental Unit Estate or Trust Pharmacy-Non Corporate Nonresident Alien Pharmacy/Funeral Home/Cemetery Corp. Tax Exempt Limited Liability Company (select applicable tax classification) □ D = disregarded entity □ C = corporation □ P = partnership

Federal Taxpayer Identification Number; Nature of Entity. Under penalties of perjury, Provider certifies that is Provider’s correct Federal Taxpayer Identification Number or Social Security Number (check one). Provider is doing business as a (please check one): Individual Sole Proprietorship Partnership Corporation (includes Not For Profit) Medical Corporation Governmental Unit Estate or Trust Pharmacy-Non Pharmacy‐Non Corporate Nonresident Alien Pharmacy/Funeral Home/Cemetery Corp. Tax Exempt Limited Liability Company (select applicable tax classification) □ D = disregarded entity □ C = corporation □ P = partnership

Federal Taxpayer Identification Number; Nature of Entity. Under penalties of perjury, Provider certifies that is Provider’s correct Federal Taxpayer Identification Number or Social Security Number (check one). Provider is doing business as a (please check one): Individual Nonresident Alien Sole Proprietorship Pharmacy/Funeral Home/Cemetery Corp. Partnership Tax Exempt Corporation (includes Not For Profit) imited Liability Company (select Medical Corporation applicable tax classification) Governmental Unit D = disregarded entity Estate or Trust C = corporation Pharmacy-Non Corporate Nonresident Alien Pharmacy/Funeral Home/Cemetery Corp. Tax Exempt Limited Liability Company (select applicable tax classification) □ D = disregarded entity □ C = corporation □ P = partnership