Subs�tute Form Request for Taxpayer Give Form to the
W-9
requester. Do not
Iden�fica�on Number and Cer�fica�on send to the IRS.
● Go to [Link]/FormW9 for instructions and the latest information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Tony Bland
2 Business name/disregarded en�ty name, if different from above
Tony Bland
3 Check appropriate box for federal tax classifica�on of the person whose name is above. Check only one 4 Exemp�ons (codes apply only to
of the following seven boxes. certain en��es, not individuals; see
instruc�ons):
✔ Individual/sole proprietor C Corpora�on S Corpora�on Partnership Trust/estate
or single-member LLC
Exempt payee code (if any) _______
Limited liability company. Tax classifica�on (C=C Corpora�on, S=S corpora�on, P=Partnership): _______
Note: Check the appropriate box in the line above for the tax classifica�on of the single-member owner. Do not check LLC Exemp�on from FATCA repor�ng
if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another
LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is code (if any) ___________________
disregarded from the owner should check the appropriate box for the tax classifica�on of its owner.
(Applies to accounts maintained outside the US.)
Other (see instruc�ons):
5 Address (number, street, and apt. or suite no.) See instruc�ons.
1549 E 30th Street
6 City, state, and ZIP code
Jacksonville, FL 32206 United States
Part I Tax Iden�fica�on Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given above Social security number
in order to avoid backup withholding. For individuals, this is generally your social security
number (SSN). However, for a resident alien, sole proprietor, or disregarded en�ty, see the 5 9 1 – 0 7 – 5 2 8 7
instruc�ons. For other en��es, it is your employer iden�fica�on number (EIN). If you do not
or
have a number, see How to get a TIN, in the instruc�ons.
Employer iden�fica�on number
Note: If the account is in more than one name, see the instruc�ons. Also see What Name
and Number To Give the Requester for guidelines on whose number to enter. –
Part II Cer�fica�on
Under penal�es of perjury, I cer�fy that:
1. The number shown on this form is my correct taxpayer iden�fica�on number (or I am wai�ng 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 no�fied 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
no�fied me that I am no longer subject to backup withholding; and
3. I am a U.S. ci�zen or other U.S. person; and
4. The FATCA code(s) entered on this form (if any) indica�ng that I am exempt from FATCA repor�ng is correct.
Cer�fica�on instruc�ons: You must cross our item 2 above if you have been no�fied 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 transac�ons, item 2 does not apply. For mortgage
interest paid, acquisi�on or abandonment of secured property, cancella�on of debt, contribu�ons to an individual re�rement arrangement (IRA),
and generally, payments other than interest and dividends, you are not required to sign the cer�fica�on, but you must provide your correct TIN. See
the instruc�ons for Part II.
The Internal Revenue Service does not require your consent to any provision of this document other than the cer�fica�ons required to avoid backup
withholding.
Electronically Signed By:
Tony Bland
Sign Here On: 2025-12-05T[Link].644Z 12-05-2025
Signature of U.S. person Date (MM-DD-YYYY)
Please note, certain details (e.g., line numbers, instruc�on references) on this Subs�tute Form may differ from the IRS Form. Subs�tute Form W-9
