The registration process could take up to 5 minutes. You will have the option to save and return to the registration page later for completion. The following documents are required and will need to be uploaded for your registration to be complete.

Valid driver's license in the state of Missouri or Kansas (front and back)
Profile Photo
Malpractice Insurance
Proof of Education (Degree or Transcript)
Licenses of services (if applicable)
Other certifications (if applicable)
By submitting Mental Telehealth Provider application, you agree to allow Essential Families to perform a criminal background check.

Email*

User Password*

Confirm Password*

First Name: *

Last Name: *

Phone Number (Format: xxx-xxx-xxxx)*

Please enter valid mobile number!

Date Of Birth:*

Address:

City:

State:

Zip Code:

By Completing this section below, will help us to find a client that best matches your profile.

Schedule (Check all that apply)

8am - 5pm

3pm - 11pm

11pm - 7am

Language

Race Ethnicity

Gender:

Male

Female

Transgender

Not listed

Spiritually oriented

Yes

LGBTQ friendly

Yes

Are you trained in Trauma Informed Care?

Yes

What is your Theoretical Approach?

Humanistic

Cognitive

Behavioral

Psychoanalytic

Constructionist

Systemic

Licenses

Profile Photo
(photo name must be lower case letters only, no numbers Example terri.jpg)

Brief Profile Bio*

Malpractice Insurance

Upload Proof of Education

Certifications/Training Certificates

Driver's License Detail Front Back (JPEG/PNG)*

Thank you for completing the true Colors.This will help us match a client with your experience.

ACH Authorization Form

CREDIT/DEBIT AUTHORIZATION FORM

I (we) hereby authorize (THE COMPANY) to initiate entries to my (our) checking/savings accounts at the financial institution listed below (THE FINANCIAL INSTITUTION), and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until THE COMPANY is notified by me (us) in writing to cancel it in such time as to afford THE COMPANY and THE FINANCIAL INSTITUTION a reasonable opportunity to act on it.

(Name of Financial Institution)

(Address of Financial Institution - Branch, City, State, & Zip)

Sign Here

Sign above

Date:

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(Name - PLEASE PRINT)

(Address - PLEASE PRINT)

Set Amount: or Maximum Amount:

Financial Institution Routing Number:

Checking/Savings Account Number:

These numbers are located on the bottom of your check as follows:

PRIMARY TELEHEALTH PROVIDER CONTRACTOR AGREEMENT

This CONTRACTOR AGREEMENT (this "Agreement") between Essential Familiesdba Essential Families, a non-profitcharitable organization created by Terri English-Yancy, as Owner/CEO, established on January 30, 2020,and ("Contractor"), effective as of (the "Effective Date"), confirms the understanding of the parties of the terms and conditions under which Contractor will provide services to Essential Familiesas follows:This CONTRACTOR AGREEMENT (this "Agreement") between Essential Familiesdba Essential Families, a non-profitcharitable organization created by Terri English-Yancy, as Owner/CEO, established on January 30, 2020,and ("Contractor"), effective as of (the "Effective Date"), confirms the understanding of the parties of the terms and conditions under which Contractor will provide services to Essential Familiesas follows:

1. Nature, Term, and Scope of Agreement.Essential Families hereby engages Contractor and Contractor hereby accepts such engagement and agrees to serve Essential Families, Inc, INC as an independent contractor for the service(s) detailed in Attachment A (the "Statement of Work") beginning on (the “Effective Date”), through (one year from Effective Date, unless either party terminates this Agreement sooner as provided in Section 10. Any extension of the term of this Agreement will be subject to the mutual written agreement of the parties hereto.

2. Relationship of Parties.A contractor’s relationship toEssential Families will be that of an independent contractor and not an agent or employee. Nothing in this Agreement shall be construed to constitute any association, partnership, joint venture, employment, or agency relationship between the parties for any purpose and each party remains solely responsible and liable for its respective claims, debts, obligations, and liabilities, except as otherwise provided herein. Contractors shall have no right to receive or participate in any employee benefits offered byEssential Families including, but not limited to, health and accident insurance, life insurance, sick leave and/or vacation. Neither Contractor nor Contractor's employees, subcontractors, and/or agents (collectively, the "Contractor Staff') shall have the authority (and they shall not hold themselves out as having the authority) to bind, represent, or speak forEssential Familiesfor any purpose whatsoever without Essential Families express written authorization.

3. Performance Standards and Professional Responsibility. Contractor will perform all services to or on behalf of Essential Families in a good and professional manner in accordance with the best professional judgment and consistent with applicable state licensing laws, ethics, and business practices. Will conduct himself/herself in a manner consistent with the purposes and goals of Essential Families, Inc. In performing the services hereunder, Contractor will act in compliance with all applicable industry data security and HIPPA standards. Unless otherwise specified in the Statement of Work, Contractor shall furnish, at its own expense, the materials, equipment, and other resources necessary to perform the services set forth in the Statement of Work.

4. Compensation. In exchange for the services to be performed hereunder, Essential Families shall pay Contractor those fees set forth in the Statement of Work (the "Consulting Fee") in accordance with and upon Essential Families acceptance of deliverables as satisfactory related to the scope of work set forth in the Statement of Work. Essential Families will not be responsible for any fees charged by Contractor's bank or any intermediary/correspondent banks, nor for any fees associated with cashing checks.

5. Insurance.The contractor is responsible for maintaining proper malpractice insurance and for compliance with all federal, state, and local laws and regulations to which Contractor is subject as an independent contractor. Essential Families will not be responsible for making any insurance contributions, including for unemployment or disability, or obtaining workers' compensation insurance on Contractor's behalf.

6. Tax Liability.Essential Families will report payment of professional fees and withhold taxes to the extent required by the U.S. Internal Revenue Code. Notwithstanding the foregoing, Essential Families will not be responsible for withholding or paying any income, payroll, Social Security, or other federal, state, or local taxes on Contractor's behalf. Contractor agrees to pay all such taxes, including self-employment taxes due in respect of the Consulting Fee and other taxes levied on fees received under this Agreement by U.S., foreign, state, and/or local governments. The contractor agrees to indemnify and hold Essential Families harmless from any claim or liability therefore, including penalties and interest.

7. Indemnification and Hold Harmless Provision. Contractor agrees to indemnify and holdEssential Families harmless from all claims, losses, or liability which Essential Families may incur, including attorneys' fees or other legal expenses, arising directly or indirectly from an act or omission of Contractor or the Contractor Staff in the course of performance of this Agreement. Without limiting the foregoing, Contractor shall be fully responsible for the Contractor Staff and Contractor shall indemnify Essential Families including the payment of attorneys' fees or other legal expenses, against any claims made by or on behalf of any Contractor Staff.

8. Intellectual Property.

(a) Essential Families and will be the sole and exclusive owner of all right, title, and interest to allthe results and deliverables of the services performed under this Agreement (collectively, the "Deliverables"), including, but not be limited to, all ideas, inventions, and original works of authorship including, but not limited to, photographs, copy, copyrights, technical data, trade secrets, know-how, research, services, technology, assessments, logos, artwork, trade dress, trademarks, service marks, business methods, and business information (collectively, the "Intellectual Property") therein. The contractor hereby assigns to Essential Families or its designee, for no additional consideration, all right, title, and interest in and to all Intellectual Property that Contractor may solely or jointly conceive or develop under this Agreement. Contractor will execute any appropriate instruments of assignment, including, but not be limited to, copyright registration applications, or other documents at the request of Essential Families, Inc. The rights include, but not be limited to: (i) all rights under the United States or foreign copyright laws; (ii) all reproduction, display, distribution, and other intellectual property rights; (iii) the rights to edit, modify, distort, or alter such Intellectual Property; (iv) the right to produce derivative works; and (v) all so-called moral rights. To the extent moral rights may not be assigned, Contractor hereby waivesthe benefit or protection of the same and waives all rights in the Intellectual Property under the Visual Arts Right Act.

(b) As between Contractor and Essential Families, Essential Families, will remain, the sole and exclusive owner of all right, title, and interest in and to any documents, specifications, data, know-how, methodologies, and other materials provided to Contractor by Essential Families (“Essential Families, NoW Video”) including all intellectual property rights therein. Contractor has no right or license to reproduce or use any Essential Families NoW videoexcept solely to the extent necessary to perform its obligations under this Agreement

(c) Contractor warrants that all Deliverables are and shall be Contractor's original work (except for NoW Video) and (i) do not contain matter that is libelous or otherwise in contravention of law, and (ii) do not and will not violate or infringe upon the intellectual property right or any other right whatsoever of any person, firm, corporation, or other entity.

(d) Contractor agrees to indemnify, defend, and hold Essential Families harmless from any and all claims or liability which Essential Families may incur, including attorneys' fees or other legal expenses, arising directly or indirectly from the Deliverables.

9. Confidentiality.

(a) Contractor agrees to safeguard all confidential information("Confidential Information") that it receives or learns of or creates in connection with this Agreement. Such information shall include, but not be limited to, handwritten therapy notes, all financial information, information obtained in response to any assessments, client provider feedback forms, other personal information, correspondence between Essential Families and Contractor, Intellectual Property owned by Essential Families, Inc, and program development or other internal program information. Confidential Information shall not include information that is or becomes generally available to the public other than through Contractor's or Contractor Staff's breach of this Agreement or is communicated to Contractor by a third party that had no confidentiality obligations with respect to such information. Contractor maintains confidentiality as required by HIPPAA(Health Insurance Portability and Accountability Act) and/ or other state or federal law requires.

(b) Upon termination of this Agreement for any reason, Contractor will immediately be denied access to the NoW Video, assessments, client provider feedback forms, financial information, other personal information, andcorrespondence.

(c) Contractor agrees to use such Confidential Information during the term of this Agreement only in the performance of its obligations under this Agreement, and to take reasonable measures to preserve the confidentiality of the Confidential Information; provided, however, that nothing herein shall be construed to prevent disclosure of Confidential Information as may be required by applicable law or regulation, or pursuant to the valid order of a court of competent jurisdiction or an authorized government agency, provided that the disclosure does not exceed the extent of disclosure required by such law, regulation, or order. Contractor agrees to provide written notice of any such order to Essential Families, INC within forty-eight (48) hours of receiving such order, but in any event sufficiently in advance of making any disclosure to permit the Trust to contest the order or seek confidentiality protections, as determined in the Trust's sole discretion.

10. Termination, The Trust may terminate this Agreement (a) with one month's prior written notice to Contractor if terminated without Cause, or (b) immediately with written notice to Contractor if terminated for Cause. "Cause" shall include untimely or unsatisfactory performance, dishonesty, insolvency, unauthorized actions, or violation of any material provision of this Agreement. Upon termination, the Trust shall not have any further liabilities or obligations to Contractor except to promptly pay any fees earned, and expenses incurred and documented, through the effective date of termination, and Contractor shall hand over to the Trust all work done on behalf of the Trust through date of termination regardless of the state of completion and shall promptly return all property and materials of the Trust. Except for the Contractor’sobligations as stated in Sections 7, 8, 9, 11, 12 and 13, which shall survive termination, all rights and obligations of Contractor hereunder shall cease as of termination.

11. Notices. All invoices, notices, requests, consents, claims, demands, waivers and othercommunications hereunder shall be in writing and shall be deemed to have been given: (a) when delivered by hand (with written confirmation of receipt), (b) when received by the addressee if sent by a nationally recognized overnight courier (receipt requested), (c) on the date sent by facsimile or e-mail of a PDF document (with confirmation of transmission) if sent during normal business hours of the recipient, and on the next business day if sent after normal business hours of the recipient, or (d) on the third day after the date mailed, by certified or registered mail, return receipt requested, postage prepaid. Such communications must be sent to the respective parties at the following addresses (or at such other address for a party as shall be specified in a notice given in accordance with this Section):

If to Essential Families:
ATTN: Terri English-Yancy
2409 Prospect
Suite 413
Kansas City, MO. 64127
T:816.248.5316
E:terri@efamilies.org

12. Conflict Resolution and Binding Arbitration. Contractor and the Trust agree that all disputes concerning, arising from, or relating to this Agreement (including all attachments) or Contractor's engagement shall be settled by final binding arbitration under the Rules of the American Arbitration Association ("AAA") in effect as of the Effective Date. Claims shall be heard by a single arbitrator appointed in accordance with said Rules. If the parties are unable to agree to an arbitrator, AAA shall appoint one from its panel of neutrals or equivalent roster. Any arbitration proceedings shall take place in the State of Missouri. The parties agree that any arbitration award may be entered in any court having jurisdiction over the subject matter or parties. The parties understand that these methods shall be the sole remedy for any controversy or claim arising out of this Agreement and expressly waive their right to file a lawsuit or claim in a court of law against one another for such disputes, except to enforce an arbitration decision.

13. Remedies. In the event Contractor breaches or threatens to breach this Agreement, Contractor hereby acknowledges and agrees that the Trust shall be entitled to seek, in addition to other available remedies, a temporary or permanent injunction or other equitable relief restraining such breach or threatened breach from any court of competent jurisdiction, and that money damages would not afford an adequate remedy, without the necessity of showing any actual damages, and without the necessity of posting any bond or other security. This equitable relief shall be in addition to, not in lieu of; legal remedies, monetary damages, or other available forms of relief.

14. Due Authorization. This Agreement has been executed by Contractor or a duly authorized representative of Contractor, who has carefully read and considered all provisions of this Agreement and accepts all terms and conditions contained herein.

15. Counterparts. This Agreement may be executed in multiple counterparts and by electronic or facsimile signature, each of which shall be deemed an original and all of which together shall constitute one instrument.

IN WITNESS WHEREOF, the undersigned parties have executed this Agreement as of the Effective Date.
ESSENTIAL FAMILIES, INC:
Essential Families, a registered 501c3 nonprofit organization, established January 30, 2020, by Terri English-Yancy.
By:
Name: Terri English-Yancy
Title: Chief Executive Officer

Contractor Name:

Signature

Sign above

Date:

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Statement of Work

Description of Service(s):

Essential Families:

Provide family, child and/or individual leads to Contractor via client intake form, Digital Navigator, Virtual Parental Education, and referrals from other agencies.
Provide Contractor with NoW Video set up between client and Essential Families.
Provider Contractor with W-9.
Provide payment for completed session.
Provide quarterly opportunity to connect with other Contractors through Essential Families on NoW Video.

Contractor:

1. Carries out Essential Families Vision: To reach, inform and inspire the lives of children and families. Mission Statement: Strengthen Families are Essential to our Community, City, and State. And we believe Everything Starts at Home…
2. Provide Essential Families with credentials.
3. Complete W-9.
4. Complete ACH form.
5. Obtain required 30 hours for Missouri and 40 hours for Kansas Continuing Education Units (CEU) as required for licensing renewal every 2 years. (Ethics and Suicidal training are required, in addition to other hours of contractor’s choice).
6. CEU’s can be obtained through Show-Me ECHO https://showmeecho.org/ (Extension for Community Healthcare Outcomes) uses videoconferencing to connect interdisciplinary teams of experts with primary care clinicians and other professionals. They collaborate in interactive case-based learning to develop advanced skills and best practices, which improves patient care access, quality, and efficiency. Show-Me ECHO learning sessions also offer free continuing education and are provided at no cost to participating sites and individuals. CEU’s can also be obtained through other organizations of the contractor’s choice.
7. Complete True Colors Personality Assessment.
8. Identifies theoretical practice and approach for serving clients.
9. Attends Virtual Meetings and or trainings offered by Essential Families.
10. Agrees to train Digital Navigator, And VPE's on Trauma Informed Care.
11. Maintain confidentiality as required by HIPPA (Health Insurance Portability and Accountability Act) and/or as other state or federal law requires.
12. Complete Virtual Mental Health Care Provider Session Assessment at the end of each session to ensure services are complete for payment submission.
13. Provide Essential Families with a 24-hour notice via email if services between client and provider are terminated.

Consulting Fee: For all payments, Contractor must complete the Virtual Mental Health Care Provider session assessment at the end of each session. Group Session Payment rate of $156. Youth under 12 years Payment rate of $75

Form W-9
(Rev. October 2018) Department of the Treasury Internal Revenue Service

Request for Taxpayer
Identification Number and Certification

GO to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the requester. Do not send to the IRS.

Print or type.
See Specific Instructions on page 3

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor or single-member LLC

C Corporation

S Corporation

Partnership

Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ▶

Note : Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions) ▶

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
Exempt payee code (if any)

Exemption from FATCA reporting code (if any

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

part I Taxpayer Identification Number (TIN)

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.

Social security number

- -

Employer identification number

part IICertification

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

Sign Here

Signature of U.S. person

Sign above

Date:

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General Instructions

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.

Purpose of Form

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.

Form 1099-INT (interest earned or paid)

By signing the filled-out form, you:

Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
Certify that you are not subject to backup withholding, or
Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and
Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting, later, for further information.

Note: If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

An individual who is a U.S. citizen or U.S. resident alien;
A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States;
An estate (other than a foreign estate); or
A domestic trust (as defined in Regulations section 301.7701-7)

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States.

In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;
In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and
In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items.

The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.
The treaty article addressing the income.
The article number (or location) in the tax treaty that contains the saving clause and its exceptions.
The type and amount of income that qualifies for the exemption from tax.
Sufficient facts to justify the exemption from tax under the terms of the treaty article.

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

Line 1

You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.

If this Form W-9 is for a joint account (other than an account maintained by a foreign financial institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9.

a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

Note: ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.

b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2.

c. Partnership, LLC that is not a single-member LLC, C corporation, or S corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.

d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.

e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.

Line 2

If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.

Line 3

Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3.

The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.

IF the payment is for . . .	THEN the payment is exempt for . . .
Interest and dividend payments	All exempt payees except for 7
Broker transactions	Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012.
Barter exchange transactions and patronage dividends	Exempt payees 1 through 4
Payments over $600 required to be reported and direct sales over $5,0001	Generally, exempt payees 1 through 52
Payments made in settlement of payment card or third party network transactions	Exempt payees 1 through 4

¹ See Form 1099-MISC, Miscellaneous Income, and its instructions.

² However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys’ fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.

Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code.

A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)

B—The United States or any of its agencies or instrumentalities

C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)

E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i)

F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state

G—A real estate investment trust

H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940

I—A common trust fund as defined in section 584(a)

J—A bank as defined in section 581

K—A broker

L—A trust exempt from tax under section 664 or described in section 4947(a)(1)

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 that you have previously given 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 (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), ABLE accounts (under section 529A), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the Requester

For this type of account:	Give name and SSN of:
1. Individual	The individua
2. Two or more individuals (joint account) other than an account maintained by an FFI	The actual owner of the account or, if combined funds, the first individual on the account¹
3. Two or more U.S. persons (joint account maintained by an FFI)	Each holder of the account
4. Custodial account of a minor (Uniform Gift to Minors Act)	The minor²
5. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law	The grantor-trustee ¹ The actual owner ¹
6. Sole proprietorship or disregarded entity owned by an individual	The owner³
7. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i)(A))	The grantor^*

For this type of account:	Give name and EIN of:
8. Disregarded entity not owned by an individua	The owner
9. A valid trust, estate, or pension trust	Legal entity⁴
10. Corporation or LLC electing corporate status on Form 8832 or Form 2553	The corporation
11. Association, club, religious, charitable, educational, or other taxexempt organization	The organization
12. Partnership or multi-member LLC	The partnership
13. A broker or registered nominee	The broker or nominee

The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts

If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at spam@uce.gov or report them at www.ftc.gov/complaint. You can contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338). If you have been the victim of identity theft, see www.IdentityTheft.gov and Pub. 5027.

Visit www.irs.gov/IdentityTheft to learn more about identity theft and how to reduce your risk.

Form 1099-DIV (dividends, including those from stocks or mutual funds)
Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)
Form 1099-S (proceeds from real estate transactions)
Form 1099-K (merchant card and third party network transactions)
Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)
Form 1099-C (canceled debt)
Form 1099-A (acquisition or abandonment of secured property)

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

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.

Backup Withholding

What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 24% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return

Payments you receive will be subject to backup withholding if:

You do not furnish your TIN to the requester,
You do not certify your TIN when required (see the instructions for Part II for details),
The IRS tells the requester that you furnished an incorrect TIN,
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
You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information

Also see Special rules for partnerships, earlier

What is FATCA Reporting?

The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information.

Updating Your Information

You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

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.

IF the entity/person on line 1 is a(n) . . .	THEN check the box for . . .
• Corporation	Corporation
• Individual • Sole proprietorship, or • Single-member limited liability company (LLC) owned by an individual and disregarded for U.S. federal tax purposes.	Individual/sole proprietor or singlemember LLC
• LLC treated as a partnership for U.S. federal tax purposes, • LLC that has filed Form 8832 or 2553 to be taxed as a corporation, or • LLC that is disregarded as an entity separate from its owner but the owner is another LLC that is not disregarded for U.S. federal tax purposes.	Limited liability company and enter the appropriate tax classification. (P= Partnership; C= C corporation; or S= S corporation)
• Partnership	Partnership
• Trust/estate	Trust/estate

Line 4, Exemptions

If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you.

Exempt payee code

• Generally, individuals (including sole proprietors) are not exempt from backup withholding.

• Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.

• Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions

• Corporations are not exempt from backup withholding with respect to attorneys’ fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC.

The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4.

1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)

2—The United States or any of its agencies or instrumentalities

3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

4—A foreign government or any of its political subdivisions, agencies, or instrumentalities

5—A corporation

6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession

7—A futures commission merchant registered with the Commodity Futures Trading Commission

8—A real estate investment trust

9—An entity registered at all times during the tax year under the Investment Company Act of 1940

10—A common trust fund operated by a bank under section 584(a)

11—A financial institution

12—A middleman known in the investment community as a nominee or custodian

13—A trust exempt from tax under section 664 or described in section 4947

M—A tax exempt trust under a section 403(b) plan or section 457(g) plan

Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.

Line 5

Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns. If this address differs from the one the requester already has on file, write NEW at the top. If a new address is provided, there is still a chance the old address will be used until the payor changes your address in their records.

Line 6

Enter your city, state, and ZIP code.

Part I. Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN.

If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Note: See What Name and Number To Give the Requester, later, for further clarification of name and TIN combinations

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.SSA.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/Businesses and clicking on Employer Identification Number (EIN) under Starting a Business. Go to www.irs.gov/Forms to view, download, or print Form W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or SS-4 mailed to you within 10 business days.

If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note: Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.

Part II. Certification

To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, 4, or 5 below indicates otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code, earlier.

Signature requirements. Complete the certification as indicated in items 1 through 5 below.

For this type of account:	Give name and EIN of:
14. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments	The public entity
15. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i)(B))	The trust

¹ List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

² Circle the minor’s name and furnish the minor’s SSN

³ You must show your individual name and you may also enter your business or DBA name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.

⁴ List first and circle the name of the 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.) Also see Special rules for partnerships, earlier.

*Note: The grantor also must provide a Form W-9 to trustee of trust

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.

Secure Your Tax Records From Identity Theft

Identity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk

Protect your SSN,
Ensure your employer is protecting your SSN, and
Be careful when choosing a tax preparer

If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Pub. 5027, Identity Theft Information for Taxpayers.

Victims of identity theft who are experiencing economic harm or a systemic problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.

Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.

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