* Require field

Ultra Mobile Authorized Retailer(AR)

Acknowledgement Form

June 2014

Ultra Mobile Authorized Retailer Acknowledgment

Open Enrolment

Date of Authorization:*
Authorization Retailer Agreed and Accepted:
Business Name:*
Principal First Name:*
Principal Last Name:*
Business Address:*
State, Zip:*,
Current UltraAgents.com Retailer Code(s): (Please list ALL previously used)
epay Terminal ID or Emida Site ID: (if applicable)
Selected Exclusive Master Agent:
Retailer Agreed and Accepted:
Business Name:*

Principal Signature:

Exclusive Master Agent Agreed and Accepted:
Business Name:*

Is this a 'Brick and Mortar'/Permanent Retailer Address? Yes

If No, please explain type of location:

Do you want this retail location displayed on the Ultra Mobile Store locator? Yes

If No, please explain type of location:

Attached hereto is a copy of the W9 submitted to the Master Agent by Retailer.

Ultra Mobile("Ultra") has authorized * [insert legal name of Retailer]

("Retail") located at * [insert business name of Retailer location]("Location")

to participate in the Ultra Mobile Authorized Retailer Program ("Program") with * [insert

name of Exclusive Authorized Master Agent] as the sole distributor to of record for the Location ("Master Agent").

page 1 of 2

Form W-9
(Rev. August 2013)
Department of the Treasury
Internal Revenue Services
Request for Taxpayer
Identification Number and Certification
Give form to the requester. Do not send to the IRS.
Print or type
See Specific Instructions on page2.
*Name (as shown on your income tax return)
Business name/disregard entity name, if different from above
*Check appropriate box for federal tax classification:
Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate
Limited liability company. Enter the tax classification (C=C Corporation, S=S Corporation, P=partnership) ▶
Other (see instructions)▶ {%OtherTaxClass%}

Exemptions(see instructions):

Exempt payee code(if any) _____

Exemption from FATCA reporting

code(if andy) ________

Address (number, street, and apt. or suite no.)
City, state, and ZIP code
Requester's name and address (optional)

List account number(s) here (optional)
Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
on page 3.

Note. If the account is in more than one name, see the chart on page 4 for guidleines on whose
number to enter.

Social security number
- -
Employee identification number

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting 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 notified 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 notified me that I am
no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person (defined below).
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified 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 transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.


Signature of
U.S. person ▶

Date ▶

General Instructions

Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. The IRS has created a page on IRS.gov for information about Form W-9, at www.irs.gov/w9. Information about any future developments
affecting Form W-9 (such as legislation enacted after we release it) will be posted
on that page.

Purpose of Form

A person who is required to file an information return with the IRS must obtain your
correct taxpayer identification number (TIN) to report, for example, income paid to
you, payments made to you in settlement of payment card and third party network
transactions, real estate transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or contributions you made
to an IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), to
provide your correct TIN to the person requesting it (the requester) and, when
applicable, to:

1. Certify that the TIN you are giving is correct (or you are waiting for a number
to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership income from a U.S. trade or business is not subject to the

withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
exempt from the FATCA reporting, is correct.

Note. If you are a U.S. person and a requester gives you a form other than Form
W-9 to request your TIN, you must use the requester¡¯s form if it is substantially
similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

● An individual who is a U.S. citizen or U.S. resident alien,

● A partnership, corporation, company, or association created or organized in
the United States or under the laws of the United States,
● An estate (other than a foreign estate), or

● A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section
1446 on any foreign partners¡¯ share of effectively connected taxable income from
such business. Further, in certain cases where a Form W-9 has not been received,
the rules under section 1446 require a partnership to presume that a partner is a
foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
U.S. person that is a partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to establish your U.S. status
and avoid section 1446 withholding on your share of partnership income.

Cat.No. 10231XForm W-9(Rev. 8-2013)
Register Information Confirm
Acknowledgement Form
Register Information
Dealer Name:

Referral Agent: *
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