W-9 Form - Southwest Energy

Section 1: Taxpayer Identification Information

Name (as shown on your income tax return)

Business name/disregarded entity name (if different from above)

Check appropriate box:

Individual/Sole Proprietor LLC Partnership C Corporation

Section 2: Address

Street address (including apt. or suite no.)

City, State, ZIP Code

Section 3: Taxpayer Identification Number (TIN)

Social Security Number

Employer ID Number (EIN) - if applicable

Section 4: 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 have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (b) 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.

Signature (required)

Sign in the box below

Date

FORM W-9