MOC Mid-Atlantic Spiff Enrollment & W-9

Thank you for participating in the MOC Mid-Atlantic spiff program.

Please complete the Digital W-9 form as well as your information below to assist us with our new digital spiff / payment system:

First Name *

Last Name *

What is your role in the dealership? *

choose Technician, Advisor, or other

Dealership Name *

Select your dealership

Date of Birth *

Date of Birth

Your Cell #: *

enter your cell to stay updated on the spiff program - we will not share!

Your Email: *

example@example.com

Entity for this 1099 income? *

Individual Sole proprietor or single-member LLC

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

Business name/disregarded entity name, if different from above

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

HOME Street Address (NO PO BOX ALLOWED) *

HOME Street Address 2 (APARTMENT or UNIT #)

City (for your HOME ADDRESS - required) *

Please type your HOME ADDRESS CITY

STATE (for your HOME ADRESS 2-Letter Abbreviation) *

Choose your State

Zip Code (for your HOME ADDRESS - required) *

Please type your HOME ZIP CODE

Social security number *

Optional - Employer identification number

only if you use a single member llc or filing with a business tax #

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.

Signature of U.S. person

Clear

Date *

Date

OLD Name (first / last)

First Name Last Name

OLD Address

OLD Street Address (NO PO BOXES ALLOWED)

OLD Street Address Line 2

OLD City OLD State

OLD Zip Code

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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