Exhibit 99.2
SUBSCRIPTION AGREEMENT
Alliance Farms Cooperative Association
c/o Farmland Industries, Inc.
0000 Xxxxx Xxx Xxxxxxxxxx
Xxxxxxxxxx 00
Xxxxxx Xxxx, Xxxxxxxx 00000
Attention: Xxxxx X. Xxxxxx
Gentlemen:
1. Subscription.
a. The undersigned understands that Alliance
Farms Cooperative Association, a Colorado cooperative
association (the "Company"), may offer up to (i) an
aggregate of 51 shares (the "Class A Shares") of its (Class
A) Common Stock, $.01 par value, on a "best efforts, all-or-
none" basis for not less than 17 Class A Shares (a "Minimum
Class A Block"), and thereafter may continue to offer Class
A Shares on such basis with respect to successive Minimum
Class A Blocks until 51 Class A Shares have been issued and
sold, (ii) an aggregate of 54 shares (the "Class B Shares")
of its Class B Common Stock, $.01 par value, on a "best
efforts, all-or-none" basis for not less than 18 Class B
Shares (a "Minimum Class B Block"), and thereafter may
continue to offer Class B Shares on such basis with respect
to successive Minimum Class B Blocks until 54 Class B Shares
have been issued and sold, and (iii) an aggregate of 72
shares (the "Class C Shares" and together with the Class A
Shares and the Class B Shares, the "Shares") of its Class C
Common Stock, $.01 par value, on a "best efforts, all-or-
none" basis for not less than 24 Class C Shares (a "Minimum
Class C Block"), and thereafter may continue to offer Class
C Shares on such basis with respect to successive Minimum
Class C Blocks until 72 Class C Shares have been issued and
sold. The undersigned acknowledges and agrees that prior to
the execution of this Subscription Agreement, the
undersigned has received the Company's Prospectus dated
______________, 1998 for the Shares, which Prospectus
contains the form of this Subscription Agreement.
b. The undersigned hereby subscribes for and
agrees to purchase (i) ______ Class A Shares at a price of
$80,000 per share, (ii) ______ Class B Shares at a price of
$60,000 per share, and (iii) ______ Class C Shares at a
price of $45,000 per share, pursuant to the terms and
conditions of this Subscription Agreement (the
"Subscription") The undersigned understands and agrees
that in order to subscribe for any Shares, the following
items must be delivered to the Company on or before 5:00
p.m. on January 7, 1999 (or by 5:00 p.m. on July 6,
1999 if the termination of the offering is extended by the
Company):
[FN]
One Class A Share, one Class B Share or one Class C Share is
the minimum number of Shares for which an investor may
subscribe, as described in the Prospectus.
(A) two completed and executed copies of
this Subscription Agreement;
(B) the undersigned's check, bank draft or
wire transfer (contact the Company for wire transfer
instructions), payable to the order of "Alliance Farms
Cooperative Association Escrow No. 465450" in an amount
representing the aggregate purchase price of the Shares
being subscribed for hereunder (which amount is equal
to the sum of (i) the product obtained by multiplying
the number of Class A Shares being subscribed for by
$80,000 per Share, plus (ii) the product obtained by
multiplying the number of Class B Shares being
subscribed for by $60,000 per Share, plus (iii) the
product obtained by multiplying the number of Class C
Shares being subscribed for by $45,000 per Share);
(C) two completed and executed copies of the
Pig Purchase Agreement in the form attached to the
Prospectus as Exhibit B;
[FN]
Please do not date the Feeder Pig Purchase Agreement; the
Company will date the Feeder Pig Purchase Agreement upon
acceptance of subscriptions.
(D) one executed stock power respecting the
Class A Shares, Class B Shares and Class C Shares,
respectively, subscribed for by the undersigned
hereunder in favor of the Company as contemplated by
Section 17 of the Pig Purchase Agreement.
[FN]
Please do not date the Weaned Pig Purchase Agreement; the
Company will date the Weaned Pig Purchase Agreement upon
acceptance of subscriptions.
In addition, if the undersigned is a resident of Iowa, or
otherwise is subscribing for Shares in Iowa, the undersigned
may be required to deliver to the Company a completed and
executed Potential Investor Questionnaire with respect to
the representation and warranty made pursuant to Section 3.l
below. The undersigned understands that pending the
Company's acceptance of subscriptions for a Minimum Class A
Block, a Minimum Class B Block or a Minimum Class C Block in
this offering and the satisfaction of certain other
conditions, all funds received by the Company in payment of
the offering price for the Shares promptly will be deposited
in an interest-bearing escrow account established at The
Bank of New York (successor trustee to NationsBank, N. A.),
New York, New York. Payment of the applicable offering
price must be made payable to the order of "Alliance Farms
Cooperative Association Escrow No. 465450", the escrow
account established at such bank. Upon the Company's
acceptance of subscriptions for a Minimum Class A Block of
17 Class A Shares, for a Minimum Class B Block of 18 Class B
Shares or for a Minimum Class C Block of 24 Class C Shares,
and the satisfaction of certain other conditions, all funds
deposited in the escrow account with respect to such Shares,
together with any interest earned thereon, will be paid to
the Company. In the event that the Company does not issue
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Shares for which funds have been deposited in the escrow
account prior to the termination of the offering, such funds
will be refunded to the respective subscribers, together
with any interest earned thereon and without any deduction
being made for expenses.
c. The undersigned understands that this
Subscription shall be irrevocable, except as otherwise
provided by virtue of applicable federal and state
securities laws, and shall survive the death or disability
of the undersigned, in the case of an individual, or the
dissolution or bankruptcy of the undersigned, in the case of
an entity.
2. Acceptance of Subscription. The undersigned
understands that if and to the extent this Subscription is
not accepted by the Company, in whole or in part, prior to
5:00 p.m. on [JWA2]January 7, 1999 (or by 5:00 p.m. on July
6, 1999 if the termination date of the offering is extended
by the Company), any amount so received by the Company will
be returned to the undersigned. The undersigned
acknowledges that the management of the Company reserves the
right, in its sole and absolute discretion, to accept or
reject this Subscription, in whole or in part, and that this
Subscription shall not be binding unless and until accepted
by the Company. The undersigned agrees that subscriptions
need not be accepted in the order they are received.
3. Representations, Warranties and Agreement. The
undersigned represents and warrants to the Company and its
officers, directors, employees, agents and controlling
persons, and agrees with such persons, as follows:
a. The undersigned and his or her
representative, if any, have been furnished all
additional information relating to the Company,
its business and financial condition, the offering
of the Shares and any other matter set forth in
the Prospectus which they have requested.
b. The undersigned agrees that the
certificates evidencing the Shares being purchased
by the undersigned shall be stamped or otherwise
imprinted with a conspicuous legend in
substantially the following form:
Sale, transfer or hypothecation of the
shares represented by this certificate
is restricted by the provisions of the
Colorado cooperative association law and
the Articles of Incorporation and Bylaws
of Alliance Farms Cooperative
Association (the "Company"), a copy of
which provisions may be inspected at the
principal offices of the Company, and
all provisions of which are hereby
incorporated by reference in this
certificate.
The undersigned agrees that the Shares or any of
them shall be sold, pledged, assigned,
hypothecated, or otherwise transferred (with or
without consideration) (a "Transfer") only if such
Transfer is permissible under the Colorado
cooperative association law and the Company's
Articles of Incorporation and Bylaws. The
undersigned understands that the Company has not
agreed to register the Shares for distribution in
accordance with the provisions of certain
applicable state securities law (the "State
Acts"), that the Company is the only party who may
register the Shares under certain State Acts and
that the Company has not agreed to comply with any
exemption under the State Acts for the resale of
the Shares. The undersigned understands that
there is and likely will be no market for the
(Class A) Common Stock, Class B Common Stock or
Class C Common Stock of the Company and that the
undersigned therefore may be unable to sell or
dispose of the Shares.
c. The undersigned agrees that a stop
transfer order shall be placed on the transfer
books maintained with respect to the Shares which
gives effect to the restrictive legend set forth
in Section 3.b.
d. The undersigned understands that no
federal or state agency has passed upon the Shares
or upon the accuracy or adequacy of the
Prospectus, or made any finding or determination
as to the fairness of the investment or any
recommendation or endorsement of the Shares. The
undersigned understands that the Prospectus may
not have been filed with or reviewed by certain
state securities administrators.
e. The undersigned is a producer of
agricultural products, an association of such
producers, or a federation of such associations.
f. If a natural person, the undersigned is
a citizen of the United States of America, is at
least 21 years of age, and has the legal capacity
to execute, deliver and perform this Agreement,
and his or her principal residence is located
within the state designated under his or her name
below.
g. If the undersigned is a corporation,
trust, partnership, or any other entity, such
entity is authorized and otherwise duly qualified
and empowered to execute and deliver this
Subscription Agreement and thereupon shall become
legally bound thereby, all necessary actions have
been taken to authorize and approve the investment
in the Shares, such entity was not formed for the
purpose of making the investment in the Shares and
such entity's principal place of business is
located at the address set forth on the signature
page hereof.
h. The undersigned acknowledges and agrees
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that certain commissions as described in the
Prospectus may be due and payable to certain
selling agents or other representatives of the
Company in connection with this Subscription.
i. The undersigned acknowledges that the
Company may assign the Company's rights in and to
the Pig Purchase Agreement executed by the
undersigned and any and all other assets of the
Company to any lender that may provide financing
to the Company in connection with the construction
of feeder or weaned pig production facilities or
the operation thereof, or both, and the
undersigned consents to any such assignment.
j. If the undersigned is a resident of
Iowa, or otherwise is subscribing for Shares in
Iowa, the undersigned certifies that the
undersigned either (i) has a net worth, or joint
net worth with the undersigned's spouse, in either
case, exclusive of home, furnishings and
automobiles ("Adjusted Net Worth") of at least
$65,000 as of the date hereof, and an annual gross
income of at least $65,000 for each of the
undersigned's two most recent tax years; or
(ii) has Adjusted Net Worth of at least $250,000
as of the date hereof.
4. Taxpayer Identification Number. The undersigned
agrees to complete, execute and return to the Company a Form
W-9, "Payer's Request for Taxpayer Identification Number and
Certification", concurrently with the delivery of the
executed copy of this Subscription Agreement.
[FN]
A Form W-9 is attached hereto as Annex 2 for your
convenience.
5. Indemnification. The undersigned agrees to
indemnify and hold harmless the Company, its officers,
directors, employees, shareholders and affiliates, and any
person acting on behalf of the Company, from and against any
and all damage, loss, liability, cost and expense (including
attorneys' fees) which any of them may incur by reason of
the failure by the undersigned to fulfill any of the terms
or conditions of this Subscription Agreement. All
representations, warranties and covenants contained in this
Subscription Agreement, and the indemnification contained in
this Section 5 shall survive the acceptance of this
Subscription.
6. No Waiver. Notwithstanding any of the
representations, warranties, acknowledgments or agreements
made herein by the undersigned, the undersigned does not
thereby or in any other manner waive any of the rights
granted to the undersigned under federal or state securities
law.
7. Entire Agreement; Modification. This Subscription
Agreement constitutes the entire agreement between the
parties hereto with respect to the subject matter hereof,
and neither this Subscription Agreement nor any provisions
hereof shall be waived, changed, discharged or terminated
except by an instrument in writing signed by the party
against whom any waiver, change, discharge or termination is
sought.
8. Notices. Any notice, demand or other
communication which any party hereto may be required, or may
elect, to give to anyone interested hereunder shall be
effective only if it is in writing and personally delivered
or sent by certified or registered mail, return receipt
requested, postage prepaid, or by a nationally recognized
overnight delivery service, with delivery confirmed,
addressed to: in the case of the Company: Alliance Farms
Cooperative Association, c/o Farmland Industries, Inc., 0000
Xxxxx Xxx Xxxxxxxxxx, Xxxxxxxxxx 00, Xxxxxx Xxxx, Xxxxxxxx
00000, Attention: Xxxxx X. Xxxxxx, or at such other address
as the Company shall so notify the undersigned pursuant
hereto, and in the case of the undersigned at the address
set forth on the signature page thereof or at such other
address as the undersigned shall so notify the Company
pursuant hereto. Any such notice, demand or other
communication shall be deemed to have been given as of the
date when so delivered.
9. Binding Effect. Except as otherwise provided
herein, this Subscription Agreement shall be binding upon
and inure to the benefit of the parties hereto and their
respective heirs, executors, administrators, successors,
legal representatives and assigns. If the undersigned is
more than one person, the obligations of the undersigned
shall be joint and several and the agreements,
representations, warranties and acknowledgments herein
contained shall be deemed to be made by and be binding upon
each such person and the undersigned's respective heirs,
executors, administrators, successors, legal representatives
and assigns.
10. Type of Ownership. The Subscriber wishes to own
the Shares as follows (xxxx one):
[ ] Separate or individual property;
[ ] Joint tenants with right of survivorship (both
parties must sign all required documents);
[ ] Community property (both parties must sign all
required documents);
[ ] Trust (include name of trust, name of trustee, and
include a copy of the trust instrument);
[ ] Corporation (include articles of incorporation,
bylaws and certified corporate resolution
authorizing the investment and signature);
[ ] Partnership (include a copy of the partnership
agreement and a written consent of partners
authorizing the investment and signature);
[ ] Other (specify):
.
(Note: Subscribers should seek the advice of their attorney
in deciding in which of the above forms they should take
ownership of the Shares, since different forms of ownership
may have varying gift tax, estate tax, income tax and other
consequences, depending on the state of the Subscriber's
domicile and the Subscriber's particular personal
circumstances.)
The name(s) in which the Shares are to be held is:
11. Assignability. The undersigned agrees not to
transfer or assign this Subscription Agreement, or any of
the undersigned's interest herein, and further agrees that
the transfer or assignment of the Shares shall be made only
in accordance with the terms and conditions of this
Subscription Agreement, the Company's Articles of
Incorporation and Bylaws, and all applicable laws.
12. Applicable Law. This Subscription Agreement shall
be governed by and construed in accordance with the laws of
the State of Colorado.
[The remainder of this page intentionally has been left
blank]
The undersigned hereby represents that the undersigned
has read this Subscription Agreement in its entirety.
IN WITNESS WHEREOF, the undersigned has executed this
Subscription Agreement this ___ day of _____________,
199__,at _________________, ____________.
(city) (state)
INDIVIDUALS SIGN HERE
Note: If the Subscriber wishes to own the Shares with
another person as joint tenants, or as community property,
both individuals must sign this Subscription Agreement.
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Signature
Name (please print)
Social Security Number
Principal Residence Address of Subscriber
Street Address
City and State Zip Code
Additional Individual (if any)
Signature
Name (please print)
Social Security Number
Principal Residence Address of Subscriber
Street Address
City and State Zip Code
The undersigned hereby represents that the undersigned
has read this Subscription Agreement in its entirety.
IN WITNESS WHEREOF, the undersigned has executed this
Subscription Agreement this ___ day of _____________, 199__,
at _________________, .
(city)
(state)
ORGANIZATIONS SIGN HERE
Note: If signed on behalf
of a corporation, please
submit the corporation's Printed Name of
articles of incorporation, Organization
bylaws, and certified
corporate resolution
authorizing the investment By:
and signature. If signed Signature
on behalf of a partnership,
please submit a copy of the
partnership agreement and a Printed Name and Title
written consent of partners
authorizing the investment
and signature. If signed By:
on behalf of a trust, (Additional signature
please submit the name of if required by
the trust, name of the governing instrument)
trustee, and a copy of the
trust instrument.
Printed Name and Title
Federal Taxpayer
Identification Number
Address of Principal Place
of Business:
Street Address
City and State Zip
Code
Country (if other than
U.S.A.)
ALLIANCE FARMS COOPERATIVE ASSOCIATION hereby
[accepts][rejects] the above Subscription on this _____ day
of _____________, 199__, at Yuma, Colorado.
ALLIANCE FARMS COOPERATIVE
ASSOCIATION
By:
Name:
Title:
ANNEX 1
STOCK POWER
FOR VALUE RECEIVED, hereby sell,
assign and transfer unto
(__________) Shares of the Class __ Common Capital Stock of
the Alliance Farms Cooperative Association standing in its
name on the books of said association represented by
Certificate No. herewith and do hereby irrevocably
constitute and appoint
attorney to transfer the said stock on the books of the
within named Company with full power of substitution in the
premises.
Dated 19
In the Presence of
ANNEX 2
Form W-9
(Rev. March 1994)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give form to the requester. Do NOT send to the IRS.
Please print or type:
Name (if joint names, list first and circle the name of the
person or entity whose number you enter in Part 1 below.
See instructions on page 2 if your name has changed.)
Business name (Sole proprietors see instructions on page 2.
Please check appropriate box: [ ] Individual/Sole
proprietor [ ] Corporation
[ ] Partnership[ ] Other
Address (number, street, and apt. or suite no.)
Requester's name and address
(optional)
City, state and ZIP code
Part I Taxpayer Identification Number (TIN)
List account numbers(s) here
(optional)
Enter your TIN in the appropriate box. For Social security
number individuals, this is your social security number
(SSN). For sole proprietors, see the instructions
on page 2. For other entities, it is your employer
identification number (EIN). IF you do not have a number,
How To Get a TIN below.
Note: If the account is in more than one name, see the
chart on page 2 for guidelines on whose number
to enter.
Part II For Payees Exempt
From Backup Withholding (See, see Part II Instructions on
page 2)
OR
Employer identification
____ - _____________ >
Part III 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 that I am
subject to backup withholding as a result of a failure to
report all interest or dividends, or (d) the IRS has
notified me that I am no longer subject to backup
withholding.
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 of underreporting
interest or dividends on your tax return. For real estate
transactions, item 2 does not apply. For mortgage interest
paid, the acquisition or abandonment of secured property,
cancellation of debt, contributions to an individual
retirement arrangement (XXX), and generally payments other
than interest and dividends, you are not required to sign
the Certification, but you must provide your correct TIN.
(Also see Part III Instructions on page 2.)
Sign
Here Signature > Date >
Section references are to the Internal Revenue Code.
Purpose of Form.--A person who is required to file an
information return with the IRS must get your correct TIN to
report income paid to you, real estate transactions,
mortgage interest you paid, the acquisition or abandonment
of secured property, cancellation of debt, or contributions
you made to an XXX. Use Form W-9 to give your correct TIN
to the requester (the person requesting your TIN) and, when
applicable, (1) to certify the TIN you are giving is correct
(or you are waiting for a number to be issued), (2) to
certify you are not subject to backup withholding, or (3) to
claim exemption from backup withholding if you are an exempt
payee. Giving your correct TIN and making the appropriate
certifications will prevent certain payments from being
subject to backup withholding.
Note: If a requester gives you a form other than a W-9 to
request your TIN, you must use the requester's form if it is
substantially similar to this Form W-9.
What Is Backup Withholding?--Persons making certain payments
to you must withhold and pay to the IRS 31% of such payments
under certain conditions. This is called "backup
withholding." Payments that could be subject to backup
withholding include interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay,
and certain payments from fishing boat operators. Real
estate transactions are not subject to backup withholding.
If you give the requester your correct TIN, make the proper
certifications, and report all your taxable interest and
dividends on your tax return, your payments will not be
subject to backup withholding. Payments you receive will be
subject to backup withholding if:
1. You do not furnish your TIN to the requestor, or
2. The IRS tells the requester that you furnished an
incorrect TIN, or
3. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or
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4. You do not certify to the requester that you are
not subject to backup withholding under 3 above (for
reportable interest and dividend accounts opened after 1983
only), or
5. You do not certify your TIN. See the Part III
instructions for exceptions.
Certain payees and payments are exempt from backup
withholding and information reporting. See the Part II
instructions and the separate Instructions for the Requester
of Form W-9.
How to Get a TIN.--If you do not have a TIN, apply for
one immediately. To apply, get Form SS-5, Application for a
Social Security Number Card (for individuals), from your
local office of the Social Security Administration, or Form
SS-4, Application for Employer Identification Number (for
businesses and all other entities), from your local IRS
office.
If you do not have a TIN, write "Applied For" in the
space for the TIN in Part I, sign and date the form, and
give it to the requester. Generally, you will then have 60
days to get a TIN and give it to the requester. If the
requester does not receive your TIN within 60 days, backup
withholding, if applicable, will begin and continue until
you furnish your TIN.
Note: Writing "Applied For" on the form means that you have
already applied for a TIN OR that you intend to apply for
one soon.
As soon as you receive your TIN, complete another Form
W-9, include your TIN, sign and date the form, and give it
to the requester.
Penalties
Failure to Furnish TIN.--If you fail to furnish your correct
TIN to a requester, you are subject to a penalty of $50 for
each such failure unless your failure is due to reasonable
cause and not to willful neglect.
Civil Penalty for False Information With Respect to
Withholding.--If you make a false statement with no
reasonable basis that results in no backup withholding, you
are subject to a $500 penalty.
Criminal Penalty for Falsifying Information.--Willfully
falsifying certifications or affirmations may subject you to
criminal penalties including fines and/or imprisonment.
Misuse of TINs.--If the requester discloses or uses TINs in
violation of Federal law, the requester may be subject to
civil and criminal penalties.
Specific Instructions
Name.--If you are an individual, you must generally enter
the name shown on your social security card. However, if
you have changed your last name, for instance, due to
marriage, without informing the Social Security
Administration of the name change, please enter your first
name, the last name shown on your social security card, and
your new last name.
Sole Proprietor.--You must enter your individual name.
(Enter either your SSN or EIN in Part I.) You may also
enter your business name or "doing business as" name on the
business name line. Enter your name as shown on your social
security card and business name as it was used to apply for
your EIN on Form SS-4.
Part I--Taxpayer Identification Number (TIN)
You must enter your TIN in the appropriate box. If you are
a sole proprietor, you may enter your SSN or EIN. Also see
the chart on this page for further clarification of name and
TIN combinations. If you do not have a TIN, follow the
instructions under How To Get a TIN on page 1.
Part II--For Payees Exempt From Backup Withholding
Individuals (including sole proprietors) are not exempt from
backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and
dividends. For a complete list of exempt payees, see the
separate Instructions for the Requestor of Form W-9.
If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
withholding. Enter your correct TIN in Part I, write
"Exempt" in Part II, and sign and date the form. If you are
a nonresident alien or a foreign entity not subject to
backup withholding, give the requester a completed Form W-8,
Certificate of Foreign Status.
Part III--Certification
For a joint account, only the person whose TIN is shown in
Part I should sign.
1. Interest, Dividend, and Barter Exchange Accounts
Opened Before 1984 and Broker Accounts Considered Active
During 1983. You must give your correct TIN, but you do not
have to sign the certification.
2. Interest, Dividend, Broker, and Barter Exchange
Accounts Opened After 1983 and Broker Accounts Considered
Inactive During 1983. You must sign the certification or
backup withholding will apply. If you are subject to backup
withholding and you are merely providing your correct TIN to
the requester, you must cross out item 2 in the
certification before signing the form.
3. Real Estate Transactions. You must sign the
certification. You may cross out item 2 of the
certification.
4. Other Payments. You must give your correct TIN,
but you do not have to sign the certification unless you
have been notified of an incorrect TIN. Other payments
include payments made in the course of the requester's trade
or business for rents, royalties, goods (other than bills
for merchandise), medical and health care services, payments
to a nonemployee for services (including attorney and
accounting fees), and payments to certain fishing boat crew
members.
5. Mortgage Interest Paid by You, Acquisition or
Abandonment of Secured Property, Cancellation of Debt, or
XXX Contributions. You must give your correct TIN, but you
do not have to sign the certification.
Privacy Act Notice
Section 6109 requires you to give your correct TIN to
persons who must file information returns with the IRS to
report interest, dividends, and certain other income paid to
you, mortgage interest you paid, the acquisition or
abandonment of secured property, cancellation of debt, or
contributions you made to an XXX. The IRS uses the numbers
for identification purposes and to help verify the accuracy
of your tax return. You must provide your TIN whether or
not you are required to file a tax return. Payers must
generally withhold 31% of taxable interest, dividend, and
certain other payments to a payee who does not give a TIN to
a payer. Certain penalties may also apply.
What Name and Number To Give the Requester
For this type of account
Give name and SSN of:
1. Individual The individual
2. Two or more individuals
(joint account) The actual
owner of the account
or,
if combined funds, the
first individual on the
account(1)
3. Custodian account of a minor (Uniform The minor(2)
Gift to Minors Act)
4. a.The usual revocable savings (grantor The grantor-tustee(1)
is also trustee)
b.So-called trust account that is not a The actual owner(1)
legal or valid trust under state law
5. Sole proprietorship The owner(3)
For this type of account: Give name and EIN of:
6. Sole proprietorship The owner(3)
7. A valid trust, estate, or pension trust Legal entity(4)
8. Corporate The corporation
9. Association, club, religious, charitable,
educational, or other tax-exempt
organization The organization
10. Partnership The partnership
11. A broker or registered nominee The broker or
nominee
12. Account with the Department of The public
Agriculture entity in the name of a public
entity (such as a state or local government,
school district, or prison) that receives
agricultural program payments
(1) List first and circle the name of the person whose
number you furnish.
(2) Circle the minor's name and furnish the minor's SSN.
(3) You must show your individual name, but you may also
enter your business or "doing business as" name. You may
use either your SSN or EIN.
(4) List first and circle the name of the legal trust,
estate, or pension trust. (Do not furnish the TIN of the
personal representative or trustee unless the legal entity
itself is not designated in the account title.)
Note: If no name is circled when more than one name is
listed, the number will be considered to be that of the
first name listed.
