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<br /> Form SS-4 Application for Employer Identification Number
<br /> (Rev. December 1995) (For use by employers,corporations,partnerships,trusts,estates,churches, EIN M . %
<br /> ' ' qt a l p
<br /> government agencies,certain individuals,and others.See instructions.)
<br /> epartment of the Treasury OMB No. 1545-0003
<br /> internal Revenue Service ► Keep a copy for your records.
<br /> 1 CNam1 Name of applicant(Legal name)(See instructions.) f J,� N
<br /> C. \ \v� t 4.0 r•0 iM.� L��v'2.A a '��,+ A u..4\De t
<br /> - 2 Trade name of business(if different from name on line 1) 3 Executor,trustee, "care of" name
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<br /> rn q Y\G E. I r e c..-4-or
<br /> c 4a Mailing address(street address)(room, apt.,or suite no.) 5a Business address(if different from address on lines 4a and 4b)
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<br /> \ L $ D '0J∎V C.•,ALAJ
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<br /> o 4b City, state, and ZIP code 5b City, state, and ZIP code
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<br /> E. f-\\.. :v- - c V\'f\ 5b3-So
<br /> w 6 County and state where principal business is located
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<br /> cu t.vVpL rY%e. Ccu.Vt.. lr \ ■NiNe SC:1h%.
<br /> a 7 Name of principal officer,general partner. ratitor,owner, or trustor—SSN required(See instructions.) •
<br /> 8a Type of entity(Check only one box.)(See instructions.) ❑ Estate(SSN of decedent) •
<br /> ❑ Sole proprietor(SSN) ❑ Plan administrator-SSN
<br /> ❑ Partnership ❑ Personal service corp. ❑ Other corporation(specify) ■
<br /> ❑ REMIC ❑ Limited liability co. ❑ Trust ❑ Farmers'cooperative
<br /> 14 State/local government ❑ National Guard ❑ Federal Govemment/military ❑ Church or church-controlled organization
<br /> ❑Other nonprofit organization (specify) ■ (enter GEN if applicable)
<br /> ❑ Other(specify) ►
<br /> 8b If a corporation, name the state or foreign country State Foreign country
<br /> Of applicable)where incorporated
<br /> 9 Reason for applying(Check only one box.) 14 Banking purpose(specify) ►—2tu1\cA. •=SS4-LS
<br /> ❑Started new business(specify) 110. • ❑ Changed type of organization(specify) •
<br /> III ❑ Hired employees ❑ Purchased going business
<br /> ❑ Created a trust(specify) ►
<br /> ❑Created a pension plan(specify type) ► ❑ Other(specify) ►
<br /> 10 Date business started or acquired(Mo.,day,year)(See instructions.) 11 Closing Closing month of accounting year(See instructions.)
<br /> ` ,P GR WOAD..
<br /> 12 First date wages or annuities were paid or will be paid(Mo.,day,year). Note:If applicant is a withholding agent, enter date income will first
<br /> be paid to nonresident alien. (Mo., day,year) ■
<br /> 13 Highest number of employees expected in the next 12 months. Note: If the applicant does Nonagricultural Agricultural Household
<br /> not expect to have any employees during the period, enter-0-. (See instructions.) . . . ■ o D , b
<br /> 14 Principal activity(See instructions.) ■ C–,c,v4,,,y�rwDan:E „ i.I., 9,M 1 c...--"3 a,v L.(0.1MtW.*
<br /> 15 Is the principal business activity manufacturing? ❑ Yes No
<br /> If"Yes." principal product and raw material used ►
<br /> 16 To whom are most of the products or services sold? Please check the appropriate box. ❑ Business(wholesale)
<br /> ❑ Public(retail) ❑ Other(specify) ► ❑ N/A
<br /> 17a Has the applicant ever applied for an identification number for this or any other business'? ❑ Yes R No
<br /> Note:If"Yes,"please complete lines 17b and 17c.
<br /> 17b If you checked "Yes"on line 17a,give applicant's legal name and trade name shown on prior application,if different from line 1 or 2 above.
<br /> Legal name ► Trade name ■
<br /> 17c Approximate date when and city and state where the application was filed. Enter previous employer identification number if known.
<br /> Approximate date when filed(Mo.,day,year) City and state where filed Previous EIN
<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. Business telephone number(include area code)
<br /> ` AQI4 \ 4-(LiI- 7ydd•
<br /> b r'). J d�(1 San v + 4' i n a. Ac--e. ' ■r.e. c�lrnr 'Fax teleph ne number(include rea code)
<br /> Name and title(Please type or print clearly.) • (0 I a,) 441- 15••
<br /> Signature •- LeA O+4 J 1� Date ► ,�42 (41 c u
<br /> Note:Do not write below this line. For official use only.
<br /> Please leave Geo. Ind. Class Size Reason for applying , .
<br /> blank •
<br /> For Paperwork Reduction Act Notice,see page 4. Cat.No.16055N Form SS-4 (Rev. 12-95)
<br /> 2/5/96
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