Expression, Supplemental Juror Information

• Court: United States Federal Court
• Legal Form Number: AO 229S
• Section: United States Federal Court

AO 229S

(Rev. 08/18)

SUPPLEMENTAL JUROR INFORMATION

Juror Name:

Juror Address: (number, street, and apt. or suite no.)

(city, state, and ZIP code)

Participant Number: Social Security 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.

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.

The Internal Revenue Service does not require your consent to any provision of this document other than the

certifications required to avoid backup withholding.

Signature:

* Privacy Act Information: The Federal Judiciary is required by section 6041 of the Internal Revenue Code to file an information return

(Form 1099) with the Internal Revenue Service containing the Social Security Number of a juror who receives $600 or more in jury attendance fees

during a calendar year. The district court must obtain your Social Security Number in the event it becomes necessary to file an information return for

your jury attendance fees. Your Social Security Number will be disclosed by the court only when required by law.

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