Beneficiary(ies) In the event of death, or if there is more than one owner of this account, in the event of death of all the owners, the owners hereby designate as my/our beneficiary(ies) to receive all the sums in my/our account established on this form. |
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Under penalties of perjury, I certify that: (1) the number shown below on this form is my correct Taxpayer Identification Number, (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 (including a U.S. resident alien).
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