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By signing below, I (we) hereby authorize United Midwest Savings Bank ("UMWSB") to initiate debit and credit entries to the depository account specified above. The authority is to remain in full force and effect until UMWSB has received written notification from merchant of its termination in such time and in such manner as to afford UMWSB and DEPOSITORY a reasonable opportunity to act upon it.
The Dealer and the authorized person signing below on behalf of the business entity "Dealer" submit the above information as being true and accurate as of the date shown. The Dealer further agrees that UMWSB may at its discretion make whatever inquiries it deems necessary, in connection with the information contained herein or in the course of the review or collection of any credit extended in reliance on this information. The Dealer authorizes any person or Consumer Reporting Agency to compile and furnish UMWSB any information it may have in response to such credit inquiries.
The Dealer agrees to immediately notify UMWSB of any change in ownership. UMWSB promises not to divulge any information contained herein to any individual, company or entity for any reason. This information is for internal use only to establish financial soundness and creditworthiness of the Dealer. The dealer gives express permission to UMWSB to use Constant Contact to send promotional emails at UMWSB’s discretion. The dealer may opt out of these emails at any time by using the "safe unsubscribe" feature provided by Constant Contact.
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.
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.
Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.
An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.
Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.
