FMC Form No. TIN

Organization Number (if known): _______________ Date: ____________________

Name of Firm: _____________________________________________________________________

Street Address: ___________________________________________________________________

City: _______________________________ State: _____________ Zip: __________________

Phone: _________________________ Fax: _______________________

E-Mail: _______________________________________________________

Taxpayer Identifying Number: _________________________________________

(The TIN for an individual may be individual’s social security number)

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To be Completed by Person Preparing this Form

Name of Person Completing Form: ______________________________________

Phone Number: _____________________________

Privacy Act Notice: The Taxpayer Identifying Number ("TIN") is required by the Debt Colleciton Improvement Act of 1996, 31 U.S.C. §7701 (c) and (d). The TIN will be used for the purpose of collecting and reporting on any delinquent amounts owed the Commission.