The Internal Revenue Service requires that the information requested below be provided in order to receive full payment.
If the information you provide below is not accurate, your payment will be subject to backup withholding.
Enter your name and social security number ("SSN") as it appears on your social security card.
If you anticipate a change in your name on your social security card, please enter the name that will appear on the card.
Enter your current mailing address, i.e. where you are expected to receive payment or tax information.
If your residence or mailing address is not in the U.S., please contact your local Genesis Market Representative who will work with HMA Finance for an appropriate Form W-8.
If you fail to furnish your correct name and SSN combination, you are subject to backup withholding.
Willfully falsifying this information may subject you to criminal penalties including fines and/or imprisonment.
The IRS uses the information provided for identification purposes and to verify information on your tax return.
You must provide your correct name and SSN whether or not you are required to file a tax return.
