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Form $$-4 Applicatiot, for Employer Identification Number OMB No. 1545-0003
<br /> (Rev.January 2010) (For use by employers, corporations,partnerships,trusts,estates, churches, EIN
<br /> government agencies, Indian tribal entities,certain individuals, and others.)
<br /> Department of the Treasury �� ��
<br /> Internal Revenue Service ► See separate instructions for each line. ► Keep a copy for your records.
<br /> 1 Legal name of entity(or individual)for whom the EIN is being requested
<br /> L'
<br /> L2 Trade name of business if different from nae a bn line 1) 3 Executor, administrator, trustee, "care of name
<br /> d � ri 0c
<br /> V 4a Mailing address(room, apt., suite no. and street,or P.O. box) 5a Street address (if different) (Do not enter a P.O.box.)
<br /> C. 4b City, state, and ZIP code(if foreign, see instructions) 5b City,state, and ZIP code(if foreign,see instructions)
<br /> L-
<br /> 0 Lo i 952 O
<br /> 4 6 County and state where principal business is located
<br /> P SGS 3oAot>t uJ C
<br /> L77a Name of responsible party 7b
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<br />
<br /> a foreign equivalent)? . . • , . , , . . ❑ Yes P�r'No LLC members ►
<br /> 8c If 8a is"Yes,"was the LLC organized in the United States?
<br /> Type of entity y ) ❑ Yes El No
<br /> 9a T
<br /> YP ty(check only one box).Caution. If 8a is "Yes,"see the instructions for the correct box to check.
<br /> ❑ Sole proprietor(SSN) ❑ Estate(SSN of decedent)
<br /> ❑ Partnership ❑ Plan administrator(TIN)
<br /> Corporation(enter form number to be filed) ► ❑ Trust (TIN of grantor)
<br /> ❑ Personal service corporation ❑ National Guard ❑ State/local government
<br /> ❑ Church or church-controlled organization ❑ Farmers'cooperative ❑ Federal govemment/military
<br /> ❑ Other nonprofit organization (specify) ► ❑ REMIC ❑ Indian tribal governments/enterprises
<br /> ❑ Other(s eci ► Group Exemption Number(GEN)if any 10-
<br /> 9b If a corporation, name the state or foreign country StateI Foreign country
<br /> (if applicable)where incorporated C!�6Ir r Q
<br /> 10 Reason for applying(check only one box)
<br /> ❑ Banking purpose(specify purpose) 0-
<br /> El Started new business(specify type) ► ❑ Changed type of organization(specify new type) ►
<br /> ❑ Purchased going business
<br /> ❑ Hired employees(Check the box and see line 13.) ❑ Created a trust (specify type) ►
<br /> ❑ Compliance with IRS withholding re ulations Elreated a pension plan (specify?e)e) No[Other(s eci ► N(�,ry) � �
<br /> 11 Date business started or acquired(month, day, ye See
<br /> ZU� instructions. 2 Closing month of accounting year
<br /> I Z
<br /> enter 0 if none). 14 If you expect your employment tax liability to be$1,000
<br /> 13 Highest number of employees expected in the next 12 months
<br /> ( ) or less in a full calendar year and want to file Form 944
<br /> If no employees expected, skip line 14. annually instead of Forms 941 quarterly,check here.
<br /> (Your employment tax liability generally will be$1,000
<br /> Agricultural Household or less If you expect to pay$4,000 or less In total
<br /> Other wages.)If you do not check this box,you must file
<br /> 2-- Form 941 for every quarter. ❑
<br /> 15 First date wages or annuities were paid(month, day, year).Note. If applicant is a withholding agent, enter date income will first be paid to
<br /> nonresident alien(month,day, year) . . . • . • • . 111- ' �g��—
<br /> 16 Check one box that best describes the principal activity of your business. ❑ Health care&social assistance
<br /> El Wholesale-agent/broker
<br /> ❑ Construction 1:1Rental&leasing ElTransportation&warehousing ❑ Accommodation&food service ❑ Wholesale-other W Retail
<br /> ❑ Real estate ❑ Manufacturing ❑ Finance&insurance ❑ Other(specify)
<br /> 17 Indicate principal line of merchandise sold, specific construction work done, products produced,or services provided.
<br /> r"X'0-a-}i Mr a 1 V V VX C4 e c a- b i-S
<br /> 18 Has the applicant entity shown on line 1 ever applied for and received an EIN? J?J Yes ❑ No
<br /> If"Yes," write previous EIN here ► -.
<br />
<br /> the entity's EIN and answer questions about the completion of this form.
<br /> Third Designee's name
<br /> Designee's telephone number include area code)
<br /> Party ( )
<br /> Designee Address and ZIP code Designee's fax number include area code)
<br /> Under penalties of perjury,I declare that I have examined this application,and to the best of my knowledge and belief,it is true,correct,and complete. Applicant's telephone number include area code)
<br /> Name and title(type or prin cl arly) ► r V f t e5 ( a ) , r r
<br /> Applicant's fax number(include area code)
<br /> Signature ► Date ►
<br /> For Privacy Act and Pa o Reduction Act Notice, see separate instructions. Cat.No.16055N Form .S$-4 (Rev.1-2010)
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