HomeMy WebLinkAboutRESOLUTION - 35-25 - 5/27/2025 - 281 WILDWOOD ROAD GITABEN AND SHIRISHCHANDRA KHERADIA PERMANENT EASEMENTRESOLUTION NO.35-25
A RESOLUTION APPROVING THE ACQUISITION OF LAND AND PERMANENT
EASEMENT FOR THE PURPOSE OF ROADWAY IMPROVEMENTS ALONG TONNE
ROAD BETWEEN THE VILLAGE OF ELK GROVE VILLAGE AND THE
PROPERTY OWNERS OF 281 WILDWOOD ROAD, GITABEN AND
SHIRISHCHANDRA KHERADIA, AND PAYMENT TO THE PROPERTY OWNER IN
THE AMOUNT OF $21,500 FROM THE BUSINESS LEADERS FORUM
NOW, THEREFORE, BE IT RESOLVED by the Mayor and Board of Trustees of the
Village of Elk Grove Village, Counties of Cook and DuPage, State of Illinois, as follows:
Section 1: That the Mayor be and is hereby authorized to sign the attached documents
marked:
WARRANTY DEED
(Individual) (Non -Freeway)
a copy of which is attached hereto and made a part hereof as if fully set forth and the Village
Clerk is authorized to attest said document upon the signature of the Mayor.
Section 2: That this Resolution shall be in full force and effect from and after its passage
and approval according to law.
VOTE: AYES: 6 NAYS: 0 ABSENT: 0
PASSED this 27t' day of May 2025
APPROVED this 27" day of May 2025
APPROVED:
Mayor Craig B. Johnson
Village of Elk Grove Village
ATTEST:
Loretta M. Murphy, Village Clerk
Elk Grove Village
Owner:
Gitaben S. Kheradia and Shirishchandra M. Kheradia, wife and husband,
as Tenants by the Entirety
Address:
281 Wildwood Road
Elk Grove Village, IL 60007
Route:
2652 (Tonne Road)
Section:
20-00073-00-PV
County:
Cook
Job No.:
R-55-001-97
Parcel No.:
0012
P.I.N. No.:
08-28-224-008
State of Illinois
) ss
County of Cook
Gitaben S. Kheradia and
We, Shirishchandra M. Kheradia as Property Owners
being first duly sworn upon oath states as follows:
1. Affiant has personal knowledge of the facts averred herein.
Affidavit of Title
2. ® There are no parties other than Grantor in possession of any portion of the premises described in attached
Exhibit "A" through easement, lease, oral or written, or otherwise, whether or not of record.
❑ There are no parties other than Grantor and the parties listed below in possession of any portion of the
premises described in attached Exhibit "A" through easement, lease, oral or written, or otherwise, whether or
not of record:
SEE ATTACHED EXHIBIT "A"
3. This affidavit is made to provide factual representation as a basis for the Village of Elk Grove Village to accept a
document of conveyance for the premises described in said conveyance, the premises being a portion of or all of the
above described premises, from the record owners thereof.
4. The affiant has no knowledge of any driveway agreements, encroachments, overlaps, or boundary line disputes
involving the premises to be conveyed.
5. The said premises described in Exhibit "A" are: (Check One)
❑ Vacant and unimproved ❑ Agricultural and unimproved
® Improved and
(A) There have been no improvements made or contracted for on the premises within six (6) months
immediately preceding the date of the affidavit, out of which a claim for a mechanic's lien could accrue
or has accrued; and
(B) To the best of my knowledge all improvements now on the premises comply with all local building and
zoning ordinances.
Page 1 of 4 LA 4111A (Rev. 11/07/11)
6. There are no chattel mortgages, conditional sales contracts or financing statements existing on or in connection
with the premises to be conveyed which are not shown by the public records.
7. There are no taxes or special assessments which are not shown as existing liens by the public records involving the
premises described in Exhibit A.
8. Per 50 ILCS 105/3.1, the identities of all owners and beneficiaries having an interest in the premises to be
conveyed are as follows (check applicable box(es) and complete information requested):
® Individual. Individual owner of the property is: Gitaben S. Kheradia and Shirishchandra M. Kheradia,
Wife and husband, as Tenants by the Entirety
❑ Nonprofit Organization. There is no individual or other organization receiving distributable income from the
organization.
❑ Public Organization, including units of local government. There is no individual or other organization
receiving distributable income from the organization
❑ Publicly -Traded Corporation. There is no readily known shareholder entitled to receive more than 7-1/2%
interest in the total distribution income of the corporation.
❑ Corporation, Partnership, Limited Liability Company. Those entitled to receive more than 7-1/2% of the
total distributable income of said entity are as follows:
Name Address
*1.
2.
3.
4.
❑ Land Trust or Declaration of Trust. The identity of each beneficiary of Grantor Trust is as follows:
of
Name Address Interest
*1.
2.
3.
4.
* IF THE INITIAL DISCLOSURES SHOW INTERESTS HELD BY ANOTHER CORPORATION,
PARTNERSHIP, LIMITED LIABILITY COMPANY, OR TRUST, THEN FURTHER DISCLOSURES SHOULD
BE PROVIDED UNTIL THE NAMES OF INDIVIDUALS OWNING THE INTEREST IN THE ENTITY ARE
DISCLOSED.
Page 2 of 4 LA 4111 A (Rev. 11/07/11)
Dated this 1 5'f day of 12025.
Gitaben S. Kheradia and Shirishchandra M. Kheradia, wife and husband, as Tenants by the Entirety
t'-- ----------
Signature
_ Gitaben S. Kheradia
Print Name and Title if applicable
Signature
Shirishchandra M. Kheradia
Print Name and Title if applicable
State of F— )
_ )SS
County of )
This instrument was acknowledged before me on fflu ul I 2025, by
Gitaben S. Kheradia and Shirishchandra M. Kheradia.
(SEAL)
JAMIELGUTIERREZ i y Public
OFF CWL SEAL \,
Neuc Notary Public • State of ltllrole
- —�
STAMOf Commission No. 988211 -�r-
� M Comm'salon at0211 My Commission Expires: t'
NOTE: THIS AFFIDAVIT MAY BE EXECUTED AND ACKNOWLEDGED ON BEHALF OF THE RECORD
OWNER(S) BY ANY ONE OF THE RECORD OWNERS, OFFICERS, MANAGERS, PARTNERS,
OR TRUSTEES HAVING KNOWLEDGE OF THE FACTS IN THIS AFFIDAVIT.
Page 3 of 4 LA 4111A (Rev. 11/07/11)
LEGAL DESCRIPTION
LOT 406 IN ELK GROVE VILLAGE SECTION 1 SOUTH, BEING A
SUBDIVISION IN THE NORTH 112 OF SECTION 28, TOWNSHIP 41 NORTH,
RANGE 11, EAST OF THE THIRD PRINCIPAL MERIDIAN, ACCORDING TO
THE PLAT THEREOF RECORDED APRIL 24, 1957 AS DOCUMENT 16886255
AND FILED APRIL 24, 1957 AS DOCUMENT LR1734744, IN COOK COUNTY,
ILLINOIS.
PERMANENT TAX NUMBER(S): 08-28-224-008
Page 4 of 4 LA 4111 A (Rev. 11 /07/11)
Owner:
Gitaben S. Kheradia and Shirishchandra M
as Tenants by the Entirety
Address:
281 Wildwood Road
Elk Grove Village, IL 60007
Route:
2652 (Tonne Road)
Section:
20-00073-00- P V
County:
Cook
Job No.:
R-55-001-97
Parcel No.:
0012
P.I.N. No.:
08-28-224-008
Kheradia, wife and husband,
WARRANTY DEED
(Individual) (Non -Freeway)
Gitaben S. Kheradia and Shirishchandra M. Kheradia, wife and husband, as Tenants
by the Entirety, (Grantor), of the County of Cook and State of Illinois, for and in consideration of
Nineteen Thousand Five Hundred Dollars ($19,500), receipt of which is hereby acknowledged,
grants, conveys, and warrants to the Village of Elk Grove Village, (Grantee), the following
described real estate:
See attached legal description.
situated in the County of Cook, State of Illinois, and hereby releases and waives all right under
and by virtue of the Homestead Exemption Laws of the State of Illinois. The above -described
real estate and improvements located thereon are herein referred to as the "premises."
Grantor does possess rights of Homestead in the premises.
Grantor, without limiting the interest above granted and conveyed, acknowledges that
upon payment of the agreed consideration, all claims arising out of the above acquisition have
been settled, including without limitation, any diminution in value to any remaining property of the
Grantor caused by the opening, improving and using the premises for highway purposes. This
acknowledgment does not waive any claim for trespass or negligence against the Grantee or
Grantee's agents which may cause damage to the Grantor's remaining property.
Page 1 of 3 (Rev. 11/11)
Dated this day of ' VI 6�Ly 2025.
Gitaben S. Kheradia and Shirishchandra M. Kheradia, wife and husband, as Tenants by the
Entirety
G s - KIA -t
Signature
Gitaben S. Kheradia
Print Name
State of�-- )
ss
County of )
AlIc r tt
Signature
Shirishchandra M. Kheradia
Print Name
This instrument was acknowledged before me on 2025
by Gitaben S. Kheradia and Shirishchandra M. Kheradia.
(SEAL)
JAMIE L GUTIERREZ
E
OFFICIALSEAL
Notary Pubtlo -State of Illlnols
Commisslon No.996211
Comdue n �et9U,20--I
Exempt under 35 ILCS 200/31-45(b), Real E
'�V1.a-q- 2-7.20 25
"r
Notary Public
My Commission Exs: C 1
Page 2 of 3 (Rev. 11/11)
LEGAL DESCRIPTION
That part of Lot 406 in Elk Grove Village Section 1 South, per Document 16886255, as recorded on April
24, 1957, being a subdivision in the North Half of Section 28, Township 41 North, Range 11 East of the
Third Principal Meridian, in Cook County, Illinois, bearings and distances are based on the Illinois State
Plane Coordinate System, East Zone, NAD83 (2011 Adjustment), described as follows:
Beginning at the southeast corner of said Lot 406; thence along the southerly line of said Lot 406, North
75 degrees 16 minutes 46 seconds West, 66.50 feet; thence North 14 degrees 43 minutes 14 seconds
East, 4.00 feet to a line that is 4.00 feet northerly of and parallel with said southerly line; thence along
said parallel line, South 75 degrees 16 minutes 46 seconds East, 66.50 feet to the east line of said Lot
406; thence along said east line, South 14 degrees 43 minutes 14 seconds West, 4.00 feet to the point of
beginning.
Said parcel containing 0.006 acres (266 square feet), more or less.
Page 3 of 3 (Rev. 11/11)
Owner:
Gitaben S. Kheradia and Shirishchandra M
as Tenants by the Entirety
Address:
281 Wildwood Road
Elk Grove Village, IL 60007
Route:
2652 (Tonne Road)
Section:
20-00073-00-PV
County:
Cook
Job No.:
R-55-001-97
Parcel No.:
0012
P.I.N. No.:
08-28-224-008
Kheradia, wife and husband,
TEMPORARY CONSTRUCTION EASEMENT
(Individual)
Gitaben S. Kheradia and Shirishchandra M. Kheradia, wife and husband, as Tenants
by the Entirety (Grantor), of the County of Cook and State of Illinois, for and in consideration of
Two Thousand Dollars ($2,000), receipt of which is hereby acknowledged, hereby represents that
Grantor owns the fee simple title to and grants and conveys to the Village of Elk Grove Village
(Grantee), a temporary construction easement for the purpose of roadway improvements and
other highway purposes, on, over, and through the following described real estate:
See attached legal description.
situated in the County of Cook, State of Illinois. The above -described real estate and
improvements located thereon are herein referred to as the "premises."
The right, easement and privilege granted herein shall terminate 5 years from the execution
of this document, or on the completion of the proposed project, whichever is the sooner.
Grantor shall have and retain all rights to use and occupy the premises and access to
Grantor's remaining property, except as herein expressly granted; provided, however, that
Grantor's use and occupation of the premise may not interfere with Grantee's use of the premises
for the purposes herein described.
Grantor, without limiting the interest above granted and conveyed, acknowledges that
upon payment of the agreed consideration, all claims arising out of the above acquisition have
been settled, including without limitation, any diminution in value to any remaining property of the
Grantor caused by the opening, improving and using the premises for highway purposes. This
Page 1 of 2 (Rev. 1/12)
acknowledgment does not waive any claim for trespass or negligence against the Grantee or
Grantee's agents which may cause damage to the Grantor's remaining property.
This grant shall constitute a covenant, which runs with the land, and shall be binding upon
the legal representatives, successors and assigns of Grantor.
Dated this 5't day of C(st 2025.
Gitaben S. Kheradia and Shirishchandra M. Kheradia, wife and husband, as Tenants by the
Entirety
By:
Signature
Gitaben S. Kheradia
Print Name
State of
) ss
County of )
This instrument was acknowledged before me on
by Gitaben S. Kheradia and Shirishchandra M. Kheradia
(SEAL)
Signature
Shirishchandra M. Kheradia
Print Name
2025
JAMIELOtmERREt `i Notary Public
wear MI.E L"L SEAL 'J
Notary Publk - Sfate of Allnois �)
ob MMI'MI.,N..88B211 My Commission Expires: + ,
M Commbelon us180,M8 j
Page 2 of 2 (Rev. 1/12)
LEGAL DESCRIPTION
That part of Lot 406 in Elk Grove Village Section 1 South, per Document 16886255, as recorded on April
24, 1957, being a subdivision in the North Half of Section 28, Township 41 North, Range 11 East of the
Third Principal Meridian, in Cook County, Illinois, bearings and distances are based on the Illinois State
Plane Coordinate System, East Zone, NAD83 (2011 Adjustment), described as follows:
Commencing at the southeast corner of said Lot 406; thence along the southerly line of said Lot 406,
North 75 degrees 16 minutes 46 seconds West, 66.50 feet to the point of beginning; thence continuing
along said southerly line, North 75 degrees 16 minutes 46 seconds West, 33.53 feet; thence North 14
degrees43 minutes 14 seconds East, 7.00 feet to a line that is 7.00 feet northerly of and parallel with
said southerly line; thence along said parallel line, South 75 degrees 16 minutes 46 seconds East, 100.03
feet to the east line of said Lot 406; thence along said east line, South 14 degrees 43 minutes 14 seconds
West, 3.00 feet to the point of beginning.
Said parcel containing 0.010 acres (434 square feet), more or less.
Page 3 of 2 (Rev. 1/12)
11 U,
Elk Grove Village
Receipt of Conveyance Documents and
Disbursement Statement
Owner: Gitaben S. Kheradia and Shirishchandra M. Kheradia, wife and husband, as Tenants by the Entirety
Job No: R-55-001-97
Parcel No.: 0012
The Village of Elk Grove Village (Grantee) acknowledges Receipt of the following:
(Check all that apply)
® Warranty Deed covering 0.006 acres
® Temporary Construction Easement covering 0.010 acres
all located in Cook County, Illinois as right of way for Route 2652 (Tonne Road), Section: 20-00073-00-PV
dated Y,�� 115' 3� executed by the undersigned Grantors.
Grantor and Grantee agree as follows:
The payment of the sum of Twenty -One Thousand Five Hundred Dollars ($21,500) to Grantor as total
consideration for the Deed and TE by Grantee is subject to Grantee's approval of title and
documentation and, if applicable, Grantee's final approval in accordance with Section 9.02 of the Illinois
State Finance Act.
2. All improvements located, wholly or partially, on the parcel shall become the property of the Village of
Elk Grove Village, unless provided as follows:
None
3. Possession and transfer of title to the Village of Elk Grove Village occur when Grantee delivers a state
warrant to Grantor, in person or to the address stated herein, in the amount of the above stated
consideration, unless provided herein. Grantor shall have the sole responsibility and obligation to
protect, preserve and maintain the parcel and improvements thereon until delivery of possession to
Grantee.
4. Grantor directs Grantee to disburse the above stated consideration by warrant or by separate warrants
as follows:
Name* TIN/FEIN/SSN** Address Amount
Gitaben S. Kheradia 3 r 13 rK A � 1 281 Wildwood Road $21,500
Shirishchandra M.
Kheradia Y:�O Elk Grove Village IL 60007 $
*If multiple names on the same warrant, list first and circle the name of the person or entity whose
TIN/FEIN/SSN is entered above. If lien holder is to be paid by warrant, use Grantor's TIN or SSN with
their name listed first and lien holder second. The first payee must match the TIN used.
**Attach a current W-9 form for each TIN/FEIN/SSN.
Page 1 of 2 LA 4112A Template (Rev. 02/9/16)
5. NON -FOREIGN CERTIFICATION — FIRPTA. Section 1445 of the Internal Revenue Code provides
that a transferee (buyer) of a U.S. real property interest must withhold tax if the transferor is a foreign
person. For purposes of this paragraph, "Transferee" shall mean "Grantee" and "Transferor" shall
mean "Grantor". To inform the Grantee that withholding of tax is not required upon the disposition of a
U.S. real property interest by Grantor, the Grantor hereby certifies the following:
a. Transferor is the owner of the real property being conveyed.
b. Transferor is not a foreign person, entity, or disregarded entity (as such terms are defined in the
Internal Revenue Code and Income Tax Regulations); and
c. Transferor's U.S. Taxpayer Identification Number and address set forth above are true and correct.
Transferor understands that this certification may be disclosed to the Internal Revenue Service by
Transferee and that any false statement contained herein could be punished by fine, imprisonment or
both. 0, Yk- S.`W
Initial Initial
6. Illinois law (15 ILCS 405/10.05 to 405/10.05b) requires the State of Illinois Comptroller to deduct from
any warrants or payments the amount of any outstanding account or claim in favor of the State of
Illinois and any amount necessary to satisfy past due child support or delinquent student loan and
financial aid obligations on any loan guaranteed by the Illinois Student Assistance Commission.
7. This Receipt of Conveyance Documents and Disbursement Statement is the entire and exclusive
agreement between the parties and supersede any written or oral understanding, promise or
agreement, directly or indirectly related to the conveyance of parcel and improvements. The parties
agree that any changes to this Receipt may only be made in writing and signed by the parties.
Date:
Grantor: Gitaben S. Kheradia and Shirishchandra M. Kheradia, wife and husband, as Tenants by the
Entirety
C - > ' �C1�cL�t
Signature
Gitaben S. Kheradia
Print Name (and Title, if applicable)
Elk Grove Village
for the Village of Elk Grove
Page 2 of 2
4e e-,-tic AQ
Signature
Shirishchandra M. Kheradia
Print Name (and Title, if applicable)
LA 4112A Template (Rev. 0219/16)
Form W-9 Request for Taxpayer Give form to the
(Rev. March2024) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service Go to www.irs.gov/FormW9 for instructions and the latest information.
Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.
1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner's name on line 1, and enter the business/disregarded
entity's name on line 2.)
Oat�'U .
2 Business name/disregarded entity name, if different from above.
c')
3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check
4 Exemptions (codes apply only to
only one of the following seven boxes.
certain entities, not individuals;
n
Individual/sole proprietor ❑ C corporation El❑ ❑ S corporation Partnership Trust/estate
see instructions on page 3):
o
N
❑ LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) . . . .
Exempt payee code (if any)
�a �o
Note: Check the "LLC" box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax
u
classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate
Exemption from Foreign Account Tax
o
box for the tax classification of its owner.
Compliance Act (FATCA) reporting
.L �
❑ Other (see instructions)
code (if any)
a w
(Applies to accounts maintained
3b If on line 3a you checked "Partnership" or "Trust/estate," or checked "LLC" and entered "P" as its tax classification,
y
and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check
❑
outside the United States.)
CL
this box if you have any foreign partners, owners, or beneficiaries. See instructions . . . . . . .
a)
5 Address (number, street, and apt. or suite no.). See instructions.
-( r. 11
Requester's name
and address (optional)
6 City, state, and ZIP code
V _ v"�1(t{ 20
7 List accoun umber(s) here (optional)
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, fora
I Socrai security number
?
_
MO5
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
.�
J
7
entities, it is your employer identification number (EIN). If you do not have a number, see Now to get a
or
TIN, later.
Employer identification number
Note: If the account is in more than one name, see the instructions for line 1. See also What Name and
Number To Give the Requester for guidelines on whose number to enter.
-
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. 1 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. 1 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 Signature of 1 (`
Here U.S. person /" S- I` L c- _ _t�— Date M 41 1 S 9
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/F`ormW9.
What's New
Line 3a has been modified to clarify how a disregarded entity completes
this line. An LLC that is a disregarded entity should check the
appropriate box for the tax classification of its owner. Otherwise, it
should check the "LLC" box and enter its appropriate tax classification.
New line 3b has been added to this form. A flow -through entity is
required to complete this line to indicate that it has direct or indirect
foreign partners, owners, or beneficiaries when it provides the Form W-9
to another flow -through entity in which it has an ownership interest. This
change is intended to provide a flow -through entity with information
regarding the status of its indirect foreign partners, owners, or
beneficiaries, so that it can satisfy any applicable reporting
requirements. For example, a partnership that has any indirect foreign
partners may be required to complete Schedules K-2 and K-3. See the
Partnership Instructions for Schedules K-2 and K-3 (Form 1065).
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS is giving you this form because they
Cat. No. 10231X Form W-9 (Rev. 3-2024)
Form W-9 Request for Taxpayer
(Rev. March2024) Identification Number and Certification
Department of the Treasury Internal Revenue Service Go to www.irs.gov/FormW9 for instructions and the latest information.
Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.
Give form to the
requester. Do not
send to the IRS.
1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner's name on line 1, and enter the business/disregarded
entity's name on line 2.)
_ -/ / /-n �YGt C�A C,l
2 Business name/disregarded entity name, if different from above.
3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check
4 Exemptions (codes apply only to
0
only one of the following seven boxes.
certain entities, not individuals;
CL
Individual/sole proprietor El corporation ❑ S corporation El Partnership ❑ Trust/estate
SK
see instructions on page 3):
o
yr
❑ LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) . . . .
Exempt payee code (if any)
a o
u
Note: Check the "LLC' box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax
classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate
Exemption from Foreign Account Tax
`o
box for the tax classification of its owner.
Compliance Act (FATCA) reporting
❑ Other (see instructions)
code (if any)
t3. u
?_
(Applies to accounts maintained
3b If on line 3a you checked "Partnership" or "Trust/estate," or checked 'LLC" and entered "P" as its tax classification,
y
and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check Eloutside
instructions
the United States.)
�4
this box if you have any foreign partners, owners, or beneficiaries. See . . . . . . .
a)
5 Address (number, street, and apt. or suite no.). See instructions.
Requester's name and address (optional)
6 City, state, and ZIP code
;iitu
7 List accou number(s) here (optional)
111111*7.11111
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid I Social secunty number
backup withholding. For individuals, this is generally your social security number (SSN). However, for a _mc(b
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other Ei�] G 5
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a or
TIN, later.
Employer identification number
Note: If the account is in more than one name, see the instructions for line 1. See also What Name and
Number To Give the Requester for guidelines on whose number to enter. 7-1 1 1 1 1 1 1
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. 1 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. 1 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 11, later.
Sign Signature of
Here I U.S. person
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.
What's New
Line 3a has been modified to clarify how a disregarded entity completes
this line. An LLC that is a disregarded entity should check the
appropriate box for the tax classification of its owner. Otherwise, it
should check the "LLC" box and enter its appropriate tax classification.
Date %y%l� L l S /• 2c Z 5,
I-
New line 3b has been added to this form. A flow -through entity is
required to complete this line to indicate that it has direct or indirect
foreign partners, owners, or beneficiaries when it provides the Form W-9
to another flow -through entity in which it has an ownership interest. This
change is intended to provide a flow -through entity with information
regarding the status of its indirect foreign partners, owners, or
beneficiaries, so that it can satisfy any applicable reporting
requirements. For example, a partnership that has any indirect foreign
partners may be required to complete Schedules K-2 and K-3. See the
Partnership Instructions for Schedules K-2 and K-3 (Form 1065).
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS is giving you this form because they
Cat. No. 10231 X Form W-9 (Rev. 3-2024)