Local 11 Request for Information

Request for Taxpayer Identification Number and Certification

This form is required for ALL strikers and will NOT affect your income taxes. Your submission is encrypted and secured.
Se Puede ID
Full name—exactly as listed on your Social Security card or other official document issued by a U.S. federal or state government agency.*

First Name(s)Middle Name(s)Last Name(s)Suffix (Jr., III)
Workplace(s)
Federal Tax Classification

Individual
Home address*

Number, street, and apt. or suite no.

Street Address Line 2

CityState / Province

Postal / Zip Code
City, state, and ZIP code*

Street Address

Street Address Line 2

CityState

Zip Code
Have you lived at this address for less than 1 year?

Yes
Taxpayer Identification Number
Social Security number or ITIN*
Certification

Under penalties of perjury, I certify that:
1. The number shown on this form is my correct social security number (or I am waiting for a number to be issued to me).
2. I am not subject to backup withholding due to failure to report interest and dividend income.
3. I am a U.S. person (including a U.S. resident alien).
Signature*

Clear
Signature of U.S. person
Date

MonthDayYear
Check the box to verify that you are human*
Visit the IRS website for guidance related to the purpose of this form, instructions, or the latest information: www.irs.gov/FormW9.

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Request for Taxpayer Identification Number and Certification