9903c Taxpayer Reporting Requirements

OMB No. 3316-0062

Exp. Date: 05/31/2007

Taxpayer Reporting Requirements

Please TAB to gray areas

1. The Offeror is required to submit the information requested in paragraphs B through D below in order to comply with reporting requirements of the Internal Revenue Code and implementing regulations issued by the Internal Revenue Service (IRS).

2. Taxpayer Identification Number (TIN) (the number required by the IRS to be used by the Offeror in reporting income tax and other returns).

TIN

     

If Offeror does not have a TIN, the reason is:

TIN has been applied for.

TIN is not required because:

Offeror is a nonresident alien foreign corporation or foreign partnership that does not have income effectively connected with the conduct of a trade or business in the United States and does not have an office or place of business or fiscal paying agent in the United States;

Offeror is an agency or instrumentality of a foreign government;

Offeror is an agency or instrumentality of a state or local government;

Other. State basis:

     

.

3. Corporate Status:

Corporation providing medical and health care services, or engaged in the billing and collecting of payments for such services;

Other corporate entity;

Not a corporate entity;

Sole proprietorship;

Hospital or extended care facility described in 26 C.F.R. § 501(c)(3) that is exempt from taxation under 26 C.F.R. § 501(a).

4. Common Parent:

Offeror is a member of an affiliated group of corporations that files its Federal income tax returns on a consolidated basis.

Name and TIN of common parent:

Name:

     

TIN:

     

TVA 9903C [5-2004]