318-22 Exhibit A-Coronis Health for Emergency Transport Third Party Billing - 2022.pdf

rom W=9 Request for Taxpayer oo. Give Form to the (Rev. October 2018) Identification Number and Certification requester. Do not Department of the Treasury 7 . send to the IRS. Intemal Revenue Service > Go to www.irs.gov/FormW/9 for structions and the latest information. 1 Name (as shown on your Income tax return). Names required on this line; do not leave this line blank, Coconis [Health LLC 2 Business name/disregarded entity name, if different from above Coronts Wealthy BCax, LLC ‘8 Check appropriate box for federal tax classification of the person whose name Is entered on line 1. Check only one of the | 4 Exemptions (codes apply only to following seven boxes. certain entities, not individuals; Instructions on page 3): tncividuavsole proprietor or ©] c Corporation CO trustiestate ‘single-member LLC. O scorporation [1 Partnership Exempt payee coda (it any) [Limited iaitty company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)>_° Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check | Exemption from FATCA reporting LLC Ifthe LLCs classified as a single-member LLC that is disregarded from the owner unless the owner of the LLGIS | cous Gf any) another LLC that Is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLG that| {s disregarded from the owner should check the appropriate box for the tax classification of Its owner. 1 Other (see Instructions) > 5 Address (number, street, and apt. or suite no) See Instructions, 5963 Exchanne Drive, Ste 4 6 City, state, and ZIP code Sukesvile , MO APY 7 List eeéount number(s) here (optional) ‘Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avold backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole propriotor, or disregarded entity, see the instructions for Part I, later. For other - - entitles, it Ts your employer identification number EIN), I you do not have a number, see How to get a y, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Part Il Certification Under penalties of

ccount is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Part Il Certification Under penalties of perjury, | certify that: 1. The number shown on this form is my correct taxpayer identification number (or | am waiting for a number to be issued to me}; and 2. 1am not subject to backup withholding because: (a) | am exempt from backup withholding, or (b) | have not been notified by the Internal Revenue Service (IRS) that | am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the [RS has notified me that | am no longer subjact to backup withholding; and 3.1am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (f any) indicating that | am exempt from FATCA reporting is correct. Certification instructions. You must cross aut 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 for Part Il, later. Sign | signature of Ss of 2am (pps to cecounts malntnd cueldo th US) Requester’s name and address (optional) Print or type. See Specific Instructions on page 3. [Social security number or ‘Employer identification number Bf QI -|LBISIOWN|G Ft Here | us. person General Instructions” oO Bestion references are to the Internal Revenue Code unless otherwise noted. Date > o/s 8/a0aa ‘* Form 1099-DIV (dividends, including those from stocks or mutual funds) Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form ‘An individual or entity (Form W-9 requester) who is required to fle an Information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security

‘An individual or entity (Form W-9 requester) who is required to fle an Information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (TIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an Information return. Examples of information retums include, but are not limited to, the following. * Form 1099-INT (Interest earned or paid) * Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) * Form 1099-8 (stock or mutual fund sales and certain other transactions by brokers) ‘* Form 1099-S (proceeds from real estate transactions) ‘* Form 1099-K (merchant card and third party network transactions) * Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) * Form 1099-C (canceled debt) ‘* Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. Ifyou do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No, 10281 Form W-9 (Rev. 10-2018)