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Form ss-4 Application 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
<br /> of entity(or individual)for whom the EIN is being requested
<br /> ;Z01
<br /> 2 Trade name of business(if different from na pe on line 1) 3 Executor,administrator, trustee, "care of"name
<br /> d r,wk SRe r
<br /> V 4a Mailing address(room,apt.,suite no.and street,or P.O.box) :..a Street address(if different)(Do not enter a P.O. box.)
<br /> 2D S &
<br /> ci 4b City, state, and ZIP code(if foreign, see instructions) City,state, and ZIP code(if foreign,see instructions)
<br /> L-
<br /> ► 95 O
<br /> a 6 County and state where principal business is located
<br /> (` N X0,0 c
<br /> 7a Name of responsible party 7b SSN, ITIN,or EIN
<br /> Q r%eao rq 2+1
<br />
<br /> a foreign equivalent)? . . • . • • _ . . [:1L�yes No LLC members ►
<br /> 8c It 8a is"Yes,"was the LLCor anized in the United States?
<br /> 9a Type of entity ) El Yes ❑ No
<br /> YP ty(check only one box). 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
<br /> lo. ElIndian tribal governments/enterprises
<br /> ❑ Other(speci
<br /> Group Exemption Number(GEN)if any ►
<br /> 9b If a corporation, name the state or foreign country State r��
<br /> n country
<br /> (if applicable)where incorporated CaAi'rc�o_
<br /> 10 Reason for applying(check only one box)
<br /> ❑ Banking purpose(specify purpose) IN-
<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) 0-
<br /> El
<br /> ❑ Compliance with IRS withholding re ulations ❑ Ore a pension plan(specify type) ►
<br /> (Other(specify) ► N ye A-1) —C, 7: • eX-
<br /> 11 Date business started or acquired (month, day, ye4ry See instructions. 2 Closing month of accounting year
<br /> 13 Highest number of employees expected in the next 12 months(enter-0-if none). 14 for less n a full calendar year and wyou exct your employment tax antt t file Form ability to be 440
<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 Other or less if you expect to pay$4,000 or less in total
<br /> 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) . . . • • • . • ► ` ,
<br /> 2004L-
<br /> 16 Check one box that best describes the principal activity of your business. ❑ Health care&social assistance
<br /> ❑ Wholesale-agent/broker
<br /> ❑ Construction ❑ Rental&leasing ❑ Transportation&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 /> rec lrea ' VCW 01e s a- bock-is
<br /> 18 Has the applicant entity shown on line 1 ever applied for and
<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) ► 0 r, V ka.r I eS t+ rt' 1
<br /> Applicant's fax number(include area code)
<br /> Signature ► Date ►For Privacy Act and Pa 0 Reduction Act Notice,see separate instructions. Cat.No.16055N Form SS-4 (Rev. 1-2010)
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