PROSPECTIVE MEMBERS FROM

Transcription

TO:
PROSPECTIVE MEMBERS
FROM:
THSRA STATE OFFICE
DATE:
August 2016
RE:
MEMBERSHIP REQUIREMENTS
Welcome prospective members to the National and Texas High School Rodeo Association. We
are pleased to know that you are thinking about becoming a member in this great association
where "The Elite Compete". Along with the requirements of the region you are thinking about
joining, there are a few the THSRA requires, and so there will be no misunderstanding as to what
these requirements are, they are listed below:
1. You must be in good standing, under 20 years of age, and be considered a full-time
student with passing grades in 70% of classes taken. Any student attending a private, homeschool, year-round school or correspondence school, must show proof of full-time status
(passing 70% of classes) and the grade report must be a professional, computer generated
document with the signatures of the teacher(s) for each subject. Any of these types of schools
must be a state accredited school/program. If there are any questions, you must get pre-approved
ONE (1) MONTH PRIOR TO DEADLINES through the THSRA State Office by calling 936-590-4447.
All students, even the ones in public school, will be required to turn in a report card or transcript
with their membership application, at mid-term and at the State Finals. Any questionable
documents of public, private, home, year-round or correspondence school received at deadline
times will result in ineligibility of points for a minimum of two (2) rodeos, until the problem is worked
out. Any documents that are falsified will result in immediate disqualification from the
association.
2. You will be required to sell fifteen (15) RAM Truck Raffle tickets by December
2016 and have these returned to your region secretary. For every five (5) tickets sold, you will
receive one (1) free ticket.
3. You will required to sell one (1) $50 Bloomer Trailer Raffle ticket by December
2016 and have this returned to your region secretary.
4. You will also be required to sell at least one (1) $50 State Ad for the THSRA State
Finals program. For any additional ads sold, the member will received 30% commission on the
additional ad amount and your region will receive 20% commission. The additional ads must total
more than $50 for commission to be paid. THSRA members selling the most total ads and
sponsorships will receive the following awards:
1st place - Trophy saddle
2nd place - hand crafted silver/rawhide breast collar and head stall, unless
the member sells over $5,000 in ads. If your ads total over $5,000, you will
also receive a gift certificate for a trophy saddle
3rd place - choice of hand crafted silver/rawhide breast collar or headstall
4th place - choice of hand crafted silver/rawhide breast collar or headstall
5th place - deluxe travel bag with hand-tooled leather logo "THSRA"
THANKS AND LET'S HAVE A FUN AND SAFE RODEO SEASON!!
TEXAS JUNIOR HIGH & HIGH SCHOOL RODEO ASSOCIATION
REGION VI
July 2016
Hello Region VI TJHRA & THSRA Members,
Hey! It is rodeo time again! Hard to believe, where did the summer go, we hope everyone had a
great summer and ready to start the 2016-17 rodeo season. We are looking forward to a great
season, with all the calls we have been receiving it looks like we are going to have a great region.
This year our High School adult directors will be: President – Bubba Bennight, Vice President –
Mike Islet, and Region Secretary – Nena Boettcher, State directors – Natalie Bennight,. This
year our Junior High adult directors will be: President-David Freemann, Vice President-Tommy
Ohrt, Secretary- Nena Boettcher, State Directors-Tommy Ohrt, Jason Underbrink, and David
Freemann. We all are so proud of Region VI and the main reason is because of you the
members and their parents. WE HAVE the greatest volunteers, and believe me we could not pull
these region rodeos off without each and every one of you. We usually have plenty of help and
are always looking for more, especially setting up barrels and poles. It takes no past experience
to getting involved in our region; we will train anyone that is willing to help us. Believe me, the
more help we have the quicker and smoother our rodeos are ran.
On the rodeo entry letter it outlines the rodeos and tells about the rodeos and tells about the first
rodeo. If any meeting is important, it will be the one on September 10, 2016. It will begin at 9
a.m. and we will give all the pole benders plenty of time to warm up after the meeting. We will
be going over all of the rules of TJHRA & THSRA that we feel need to be addressed and be
voting for student officers, student directors and adult event directors. THIS IS A
MANDATORY MEETING FOR EVERY CONTESTANT AND PARENT….PLEASE BE
THERE AT 9:00 A.M. We will give the girls plenty of time to warm up before poles.
Within this package, you will find many important papers:
1. Checklist check off – follow this and you will be doing good!!!
2. Membership application: must be filed out completely…both pages (membership and
liability), do not worry about the NHSRA membership number (I will fill that in), on the
signatures, this is very important, if it is wrong, National Office will kick it back. The only
case where one parent’s signature is acceptable is when the other parent is deceased, or
if the parent signing the form, has full custody. Those release forms should be marked
“deceased” or “have full custody” on the line where the second parent should
sign. Along with a completed membership application, you must include: a copy of
your last semester (May 2016) report card, a copy of your birth certificate, and a copy
of your coggins of the horse you are competing on (I need a copy, not just a look at it)
I have to send these all to the state office. It must also be notarized; these must be
completed before you may ride on September 10…NO EXCEPTIONS.
3. Photo Release – This needs to be signed and notarized.
4. Student Event Director Nomination – “new” – these must be turned in with first entry – see
form for instructions.
5. Rodeo Entry Information Letter attached to the top of your first entry blank. All entry blanks
for rodeos 3-12 can be found online thsra6.com.
6. Prospective Members Letter from state – very important TEXAS rules, regarding the
requirements that must be met, Dodge Raffle Ticket Sales, and the Ad Program Sales.
7. Donation Letter – it is never too early to start trying to get sponsors, it all goes back
into your awards and rewards.
Post Mark Date for all Membership Packet is August 15, 2016. Save a stamp and mail
entry blanks for Rodeo #1 and Rodeo #2 with your membership packets and postdate your
check for August 29, 2016. If you have any questions, please do not hesitate to call me.
When you check in at the first rodeo and you have completed your application in full (remember
you WILL NOT ride until it is right) you will receive a rule book (if you are a new member),
back number, Dodge raffle tickets, Bloomer ticket, ad sales form, and various other important
papers from the state office and national office.
One more very important item is dress code. Remember new and old members, every contestant
must be in full western attire. This consists of cowboy hat, LONG sleeve shirt (tucked-in), blue
jeans, belt (may be taken off during your riding event), cowboy boots, and your number on your
back (keep up with your number, but if you loose it we will have more for $5). This is a must at
all times anytime you are under the covered arena area, even if you are not riding at the time.
This is a NHSRA rule, so let’s all follow it, we do not have time to keep telling everyone to get
in full dress, and you may be disqualified if it is a problem. You never know when we have
sponsors drop by, and we want them to know REGION VI IS THE BEST………………
PLEASE SIGN UP FOR REMIND 101:
HIGH SCHOOL: TEXT 81010 AND IN THE MESSAGE TYPE @3356012
JR HIGH SCHOOL: TEXT 80101 AND IN THE MESSAGE TYPE @region6j
THSRA / TJHRA
SHOOTING EVENT DIVISION.
Check out the
opportunities of
becoming a
member!
WHO WE ARE AND WHERE WE CAME FROM
In 2010, TJHRA held its first ever State Finals Light Rifle event in Gonzales and then the next year THSRA followed by
holding their first Trap and Light Rifle events in Abilene.
JR SHOOTING EVENT: MAY 20, 2017 - GONZALES SHOOTING RANGE, GONZALES, TX
1) Light Rifle Competition
*** REQUIREMENT: At shoot you must show proof of completing the Texas Parks and Wildlife’s Hunter Education
Course. Visit www.tpwd.state.tx.us for more information on how to enroll in the course.
Visit www.tjhra.org for more information on shooting division and official rules.
HS SHOOTING EVENT: JUNE 3, 2017 - CALLAHAN SHOOTING SPORTS CLUB, CLYDE, TX
1)Trap Competition
2)Light Rifle Competition
*** REQUIREMENT: At shoot you must show proof of completing the Texas Parks and Wildlife’s Hunter Education
Course. Visit www.tpwd.state.tx.us for more information on how to enroll in the course.
Visit www.thsra.org for more information on shooting division and official rules.
HOW TO GET STARTED
- Contact your Region Secretary for a membership packet. Visit www.tjhra.org or www.thsra.org and click on
About>Regional Divisions to locate your home region.
- Each member who joins to be a shooter only will need to join by March 1, 2017. Please note that all fundraising
requirements must also be turned in on this day (to view the membership requirements visit the website or request from
your region secretary).
BENEFITS TO SHOOTING MEMBERS
Shooting members receive all the benefits of being a member of the Texas High School Rodeo Association:
- Buckles to the Top 4 - High School Gives Award Money to first place in events - Chance to compete at National Finals in
July - Seniors can apply for thousands in scholarships given each year
Miss Texas High School Rodeo 2016, Bailey-Grace Snyder,
invites you to compete at the
2017 Miss THSRA Queen contest.
Bailey-Grace Snyder
Miss Texas High
School Rodeo 2016
Miss THSRA
Queen Contest
June 2-10, 2017
Abilene, Texas
Miss THSRA
Regional Qualifying Contest
December 10-11, 2016
Andrews, Texas
If you are interested in the queen’s contest, please send the following
information via email to DeeDee Dunda, the THSRA Queen Coordinator.
432-413-2358
prettywoman1965@hotmail.com
Name
Address
Grade
E-mail
Region
Phone
You can also email Bailey-Grace Snyder, Miss THSRA 2016, with any
questions about the contest and/or title at missthsra2016@gmail.com
GUIDELINES
TEXAS HIGH SCHOOL RODEO ASSOCIATION
2016/17 RAM TRUCK RAFFLE
*
Tickets will cost $5.00 per ticket
*
Tickets may only be sold by THSRA members or persons authorized by the THSRA
*
Each THSRA member is expected to sell a minimum of 15 tickets, and the
COMPETITION is to sell as many as possible.
*
For each five (5) tickets that a THSRA member sells they will receive one (1) ticket free
to place in the raffle.
*
The top selling THSRA member from each region will receive $250.00, providing the
member sells at least 50 tickets.
*
The top selling region will receive $1,000.00 and the second and third selling region will
receive $500.00 each. (This will be figured on a basis of number of members in each
region. In the event of a tie, the money will be split.)
*
The raffle may not be promoted through paid advertising
*
Raffle drawing will be held on June 10, 2017, at the THSRA State Finals in Abilene,
Texas.
*
The winner of the RAM Truck will be responsible for all Vehicle Tax, Title, License,
Transfer Costs, and all other taxes including income. Winner must receive truck as is
and leave advertising on truck for at least one (1) year from delivery date.
*
Call Susan at 936-590-4447 for more information about the raffle.
The 1st 15 tickets must be turned into your region secretary by December 1st
Thanks to HENSON FAMILY MOTORS for their support!
DodgeTruckRaffleGuidelines/word
2017 TEXAS
HIGH SCHOOL RODEO ASSOCIATION
STATE FINALS PROGRAM AD RATES
1/8 page or busines card
$
50.00
$
75.00
$
125.00
$
200.00
3.625" X 2.4375"
1/4 page
3.625" X 4.875"
1/2 page
7.25" X 4.875"
FULL PAGE
7.25" X 9.75"
BUCKLE SPONSOR
$
300.00
Includes a 1/2 page ad
4 Season Tickets & complimentary programs to rodeo performance
SADDLE SPONSOR
$
750.00
Includes a full page ad
6 Season Tickets & complimentary programs to rodeo performance
EVENT SPONSOR
$
1,200.00
Full page ad as an event sponsor
Company flag carried in grand entry & victory lap of event (Provided by Sponsor)
Banner displayed in arena (Provided by Sponsor)
10 Season Tickets & complimentary programs to rodeo
BUCKLE, SADDLE, & EVENT SPONSORS will receive recognition from the announcer
throughout the event at each performance if script is provided to announcer.
BUCKLE, SADDLE, & EVENT SPONSORS ONLY
PLEASE FILL IN THE INFORMATION BELOW
Please send my tickets and complimentary program to:
Name:
Address:
Town & Zip:
Phone:
THSRA Member:
** Ads may be sent in on a floppy disk or a CD. Any file types can be accepted, but EPS with type
as outlines or PDF files with embedded fonts are preferred. If you send in a disk or email the
ad, you also need to send in a hard copy print-out of the ad in case there are font problems.
Software files that are acceptable are:
Illustrator up to CS version
Quark 5.0
InDesign CS
LAST DAY FOR ARTWORK OR ADDITIONAL ADS TO BE
CorelDraw 10
RECEIVED IN THE STATE OFFICE IS: MARCH 1, 2017
Photoshop up to CS
Ad Rates.XLS
T H S R A STATE FINALS PROGRAM AD SALES
CONTESTANT _________________________________________
*1/4 PAGE AD - $75.00
REGION _____ AMOUNT OF AD $_________ AD SIZE _________
Lay out the ad as close as possible to the exact size and design
finished size in program will be 3.625" X 4.875"
you want. We will typeset ad at no charge. Please indicate any
original artwork or pictures you want used in the ad. Use the
back of this sheet for full page ads.
Turn all ads into your REGION SECRETARY
*1/8 PAGE OR BUSINESS CARD - $ 50.00
*1/2 PAGE AD - $125.00
*USE BACK FOR FULL PAGE AD - $200.00
ADSALES.XLS
REGION VI
CHECK – LIST
MEMBERSHIP PACKET: POST MARKED AUGUST 15, 2016
Filled out Membership Application in full, two pages. (Please
legible, and make sure I can read your email address if you want to
be put in the email address book.)
Have Membership Application Notarized, with proper signatures.
The only case where one parent signature is acceptable is when
the other parent is deceased, or if the parent signing the form,
has full custody. Those release forms should be marked
“deceased” or “have full custody” on the line where the second
parent should sign.
Photo Release signed and notarized.
Copy of your last semester Report Card (May 2016)
Copy of your Birth Certificate
Copy of coggins papers of the horse or horses you are competing
on. (Must be a copy, not just a visual look, I have to mail into the
State office.)
Student Event Nomination
Check for $290 made out to Region VI, THSRA
Contestant Approval Form (you can bring this form to 1st rodeo)
W9 form
Completed Adult Membership Form, with payment.
Entry Blank for 1st & 2nd Rodeo September 10,11, 2016 Postmark
date is August 29, 2016 to avoid late charges. Save a stamp and
mail Rodeo #1 & #2 with membership packet and postdate your
check 8/29/16.
BRING RODEO 3 & 4 ENTRY BLANKS WITH YOU TO
SAVE POSTAGE!
MAIL EVERYTHING TO: P.O. BOX 833, EAST BERNARD, TEXAS 77435
If you have any questions or concerns, please contact me (281)-468-8973 or email:
region6thsra@gmail.com
Nena Boettcher
Region VI Region Secretary
National High School Rodeo Association
Membership Application 2016-2017
STATE/PROVINCE
SECRETARY USE ONLY
NHSRA Membership #
(Please Print Clearly or Type and Fill In All Blanks)
Name:
Mailing Address:
Phone:(
City, State/Province:
)
Zip+4/Postal Code:
Country:
Gender:
Male
Female
Cell Phone:(
)
Email Address:
State/Province Attending School In:
Date of Birth: Month:
School Type:
Day:
Year:
Number of AQHA Registered Horses:
Public
Current Grade in School:
9
Private
10
11
0
Number of Years in JH Division:
Home
1
12
2
3
State/Province Association in which you are applying for membership:
If you live in a different state than the one you are applying for, have you submitted a signed transfer form?
Which Region/District (if applicable):
Check One:
Dues and Fees Competing Member
Number of Years in NHSRA (include current year):
Rookie (1st year) Member
and Insurance ................ $124.00 (U.S.) or $65.00 (Foreign)
OR Associate Member (non competing) $40.00 (U.S.) or $65.00 (Foreign)
Total...................................................................... $ 290.00
EVENTS
3
4
Competing
Associate
rodeos. Both categories are eligible for additional benefi ts as may be currently offered.
Important – Please Initial
I understand that I receive a one-year subscription to Western
Horseman magazine as a bene¿ t of my NHSRA membership.
Two dollars of my membership dues will be applied to this
one-year subscription. Initial Here:
If you are a new member, how did you learn about NHSRA?
As a competing member, you are eligible to enter any of the events offered for your gender. For statistical
purposes, please check any and all of the events you are planning to enter any time this rodeo season.
Boys Events
Tie-Down Roping
Steer Wrestling
Bareback Riding
Saddle Bronc Riding
Bull Riding
Team Roping
Cutting
Reined Cow Horse
2
Competing members are eligible to enter events at qualifying rodeos, compete for awards
and scholarships and qualify for the NHSFR. Associate members are not eligible to enter
State/Province Dues.............................................. $ 71.00
Region/District Dues............................................. $ 95.00
1
No
Renewing Member
Type of Membership:
NHSRA Dues, NHSRA Times, Western Horseman
Yes
Girls Events
Barrel Racing
Pole Bending
Queen Contest
Goat Tying
Breakaway Roping
Team Roping
Cutting
Reined Cow Horse
Website
Print Advertisement
Friend or Relative
(Which Publication)
Trade Show Booth
Membership Poster
Other (Please List)
Television Advertising
FFA/School Poster
Facebook or Social Media
Read and Sign Below
We certify that the information supplied in this application is true and correct to the best of our knowledge and belief, and that the student applying for membership meets the quali¿cations and criteria for membership in the District/Region High School Rodeo Association, the State/Province High School Rodeo Association and that National High School Rodeo
Association. By applying for and receiving membership in the District/Region, State/Province and the National High School Rodeo Association, we hereby agree to follow all rules
and guidelines set forth by the Region/District, State/Province and the National High School Rodeo Association and to abide by all decision and rulings of the governing committees
and boards of these associations.
Member’s Signature:
Date:
Mother’s Signature:
Date:
Father’s Signature:
Date:
BOTH PARENTS AND/OR GUARDIANS MUST SIGN APPLICATION
COMPLETE THE RELEASE FORM ON THE REVERSE SIDE OF THIS APPLICATION
NHSRA Membership # ____________________
NATIONAL HIGH SCHOOL RODEO ASSOCIATION
(Please Print Clearly or Type and fill in all blanks)
Member’s Name:_________________________________________________________________________________________
Address:_________________________________________ City:___________________________ State:_______ Zip:________
Telephone #:____________________________________________ DOB: Month_________ Day_________ Year___________
MINOR’S RELEASE, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT
We, the undersigned, hereby request that the below named minor (minor) be granted permission (1) to enter the restricted area, (2) to participate as a contestant,
assistant, official or otherwise in rodeo events, (3) to compete for money, prizes, recognition or reward, (4) to be covered by participants’ hospitalization insurance, if
applicable, as limited by the master policy (all collectively hereinafter called “permissive entry”).
In consideration of “permissive entry” to minor into the restricted area, which is the area from which admission to the general public is restricted, which includes, but is
not limited to the rodeo arena, competition area, chutes, pens, adjacent walkways, concessions, and other appurtenances, we, the undersigned, on behalf of the minor
and for ourselves, our personal representatives, heirs, next of kin, spouses and assigns, do hereby:
1. RELEASE, DISCHARGE AND COVENANT NOT TO SUE the rodeo committee, stock contractor, rodeo association, sponsors, arena operators or owners, and
each of them, their officers, agents and employees (all hereinafter collectively referred to as “releasees”) from any and all claims and liabiltiy arising out of strict liability
or ordinary negligence of releasees or any other participant which causes the undersigned injury, death, damages or property damage. We, the undersigned, jointly,
severally, and in common, covenant to hold releasees harmless and to indemnify releasees from any claim, judgement or expenses releasees may incur arising out of
any of the minor’s activities or presence in the restricted area.
2. UNDERSTAND that minor’s entry into the restricted area and/or participation in rodeo events contains DANGER AND RISK OF INJURY OR DEATH TO MINOR,
that conditions of the rodeo arena change from time to time and may become more hazardous, that rodeo animals are dangerous and unpredictable, and that there is
INHERENT DANGER in rodeo which we each appreciate and voluntarily assume because the minor and we choose to do so. Each of the undersigned has observed
events of the type that the minor seeks to participate in. We further understand that the arena surface, access ways or lack thereof, lighting or lack thereof, and weather conditions all change and pose a danger to the minor. We further understand that other contestants and participants pose a danger to the minor, but nevertheless,
WE EACH VOLUNTARILY ELECT TO ACCEPT ALL RISKS connected with the minor’s entry into the restricted area and/or participation in any rodeo events.
3. AGREE that this agreement shall apply to any incident, injury, accident or death occurring on the above date and FOR A PERIOD OF TIME covering any statutory
period in which a cause of action may accrue for minors or adults. All subsequent agreements and release documents signed by any of the undersigned shall amplify,
but shall in no way limit the provisions of this document. The provisions of this document may be cancelled by any one of the undersigned by delivering to the above
rodeo association written cancellation of this agreement which shall be effective 24 hours after the date said cancellation is actually received by the rodeo association.
4. Releasor or parents or guardians of the undersigned minor AGREE TO INDEMNIFY the Releasees and each of them from any loss, liability, damage or costs they
may incur due to the presence or participation of the minor in the described activities whether caused by the negligence of the Releasees or otherwise.
WE HAVE READ THIS DOCUMENT, WE UNDERSTAND IT IS A RELEASE OF ALL CLAIMS. WE APPRECIATE AND ASSUME ALL RISKS INHERENT IN RODEO.
___________________________________________ __________________________________________
Signature of Natural Father
Print Clearly or Type Name of Natural Father
___________________________________________ __________________________________________
Signature of Natural Mother
Print Clearly or Type Name of Natural Mother
___________________________________________ __________________________________________
Signature of Legal Guardian
Print Clearly or Type Name of Legal Guardian
___________________________________________ __________________________________________
Signature of Member
Print Clearly or Type Name of Member
On this _________ day of ___________________ 20_____, before me, personally appeared ____________________________________________________
Notary: List all Names Notorized
_______________________________________________________________________________________________________________________________,
to me known to be the persons who executed the foregoing Release and acknowledged that they signed same as their free act and deed.
My Commission Expires: ____________________________________________ _____________________________________________________________
Notary Public
*Both parents and member or legal guardian must sign this form in the appropriate places above. If only one parent is signing, please note reason on signature
line. For example, DECEASED, DIVORCED AND FULL CUSTODY, ETC. All signatures must be witnessed by a notary and listed as personally appearing in the
appropriate place on the form. Be sure that notary signs, dates and places his/her seal on the form. Please return original Minor’s Release form to the state/province secretary with membership application and fees.
704 ½ Southview Circle
Center, Texas 75935
Permission to Use Photograph or Video Images, Release and Indemnity Agreement
Member’s Name: ____________________________________
Address:
____________________________________
Telephone:
____________________________________
To Whom It May Concern:
We/I, the undersigned, do hereby grant and release the right to the Texas High School Rodeo
Association, it agents, employees, officers, members or licensees (hereinafter refereed to as Texas High School
Rodeo Association), to make copies and assume ownership of the photographic or video images of our minor child
that are obtained in connection with our child’s participation in any and all Texas High School Rodeo Association
activities. We/I authorize the Texas High School Rodeo Association to copyright, use and publish the same in print
and/or electronically.
We/I agree that the Texas High School Rodeo Association may use such photograph(s) or video images
that are taken of the above-identified member for any lawful purpose, including but not limited to publicity,
illustration, advertising, and Web content. The use of said photographic or video images either in print ,
electronically or as Web content by any third party for any manner of unlawful or unauthorized purposes shall
not be the responsibility of the Texas High School Rodeo Association.
We/I hereby RELEASE, DISCHARGE AND COVENANT NOT TO SUE the Texas High School Rodeo
Association, its agents, employees, officers, members or licensees (hereinafter called the “releasees”) from any and
all claims and liability arising out of strict liability or ordinary negligence of releasees or any other party which
causes the above referenced member injury, damages or property damage. We/I the undersigned, jointly and
severally, covenant to hold releasees harmless and to indemnify releasees from any claim, judgment or expense
releasees may incur arising out of the use of the minor child’s photographic or electronic image of minor child’s
participation in the activities of the Texas High School Rodeo Association. WE HAVE READ THIS DOCUMENT,
WE UNDERSTAND IT IS A RELEASE OF ALL CLAIMS:
Signature _____________________________
Date: ___________________________
Printed Name: _________________________
Title: FATHER/LEGAL GUARDIAN
Signature _____________________________
Date: ___________________________
Printed Name: _________________________
Title: MOTHER/LEGAL GUARDIAN
STATE OF TEXAS
§
COUNTY OF ____________ §
This instrument was acknowledged before me on the _______ day of ______, 20____ by
______________________________________&______________________________________
(Seal)
____________________________________
Notary Public Signature
NOTARY PUBLIC, State of Texas
My Commission Expires: ______________
W-9
Form
(Rev. December 2014)
Department of the Treasury
Internal Revenue Service
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 page 2.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
Individual/sole proprietor or
C Corporation
S Corporation
Partnership
single-member LLC
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
Trust/estate
▶
Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for
the tax classification of the single-member owner.
Other (see instructions) ▶
5 Address (number, street, and apt. or suite no.)
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
Requester’s name and address (optional)
6 City, state, and ZIP code
7 List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally 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
TIN on page 3.
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for
guidelines on whose number to enter.
Part II
Social security number
–
–
or
Employer identification number
–
Certification
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); and
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.
Sign
Here
Signature of
U.S. person ▶
Date ▶
General Instructions
• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T
(tuition)
Section references are to the Internal Revenue Code unless otherwise noted.
• Form 1099-C (canceled debt)
Future developments. Information about developments affecting Form W-9 (such
as legislation enacted after we release it) is at www.irs.gov/fw9.
• 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.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file 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 (ITIN), 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
returns include, but are not limited to, the following:
If you do not return Form W-9 to the requester with a TIN, you might be subject
to backup withholding. See What is backup withholding? on page 2.
• Form 1099-INT (interest earned or paid)
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
• Form 1099-DIV (dividends, including those from stocks or mutual funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
• Form 1099-B (stock or mutual fund sales and certain other transactions by
brokers)
• Form 1099-S (proceeds from real estate transactions)
By signing the filled-out form, you:
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
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
page 2 for further information.
• Form 1099-K (merchant card and third party network transactions)
Cat. No. 10231X
Form W-9 (Rev. 12-2014)
Page 2
Form W-9 (Rev. 12-2014)
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.
In the cases below, the following person must give Form W-9 to the partnership
for purposes of establishing its U.S. status and avoiding withholding on its
allocable share of net income from the partnership conducting a trade or business
in the United States:
• In the case of a disregarded entity with a U.S. owner, the U.S. owner of the
disregarded entity and not the entity;
• In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally,
the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and
• In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a
grantor trust) and not the beneficiaries of the trust.
Foreign person. If you are a foreign person or the U.S. branch of a foreign bank
that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use
the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax
on Nonresident Aliens and Foreign Entities).
Nonresident alien who becomes a resident alien. Generally, only a nonresident
alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on
certain types of income. However, most tax treaties contain a provision known as
a “saving clause.” Exceptions specified in the saving clause may permit an
exemption from tax to continue for certain types of income even after the payee
has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception contained in the
saving clause of a tax treaty to claim an exemption from U.S. tax on certain types
of income, you must attach a statement to Form W-9 that specifies the following
five items:
1. The treaty country. Generally, this must be the same treaty under which you
claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the saving
clause and its exceptions.
4. The type and amount of income that qualifies for the exemption from tax.
5. Sufficient facts to justify the exemption from tax under the terms of the treaty
article.
Example. Article 20 of the U.S.-China income tax treaty allows an exemption
from tax for scholarship income received by a Chinese student temporarily present
in the United States. Under U.S. law, this student will become a resident alien for
tax purposes if his or her stay in the United States exceeds 5 calendar years.
However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30,
1984) allows the provisions of Article 20 to continue to apply even after the
Chinese student becomes a resident alien of the United States. A Chinese student
who qualifies for this exception (under paragraph 2 of the first protocol) and is
relying on this exception to claim an exemption from tax on his or her scholarship
or fellowship income would attach to Form W-9 a statement that includes the
information described above to support that exemption.
If you are a nonresident alien or a foreign entity, give the requester the
appropriate completed Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons making certain payments to you must
under certain conditions withhold and pay to the IRS 28% of such payments. This
is called “backup withholding.” Payments that may be subject to backup
withholding include interest, tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay, payments made in
settlement of payment card and third party network transactions, and certain
payments from fishing boat operators. Real estate transactions are not subject to
backup withholding.
You will not be subject to backup withholding on payments you receive if you
give the requester your correct TIN, make the proper certifications, and report all
your taxable interest and dividends on your tax return.
Payments you receive will be subject to backup withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part II instructions on page
3 for details),
3. The IRS tells the requester that you furnished an incorrect TIN,
4. The IRS tells you that you are subject to backup withholding because you did
not report all your interest and dividends on your tax return (for reportable interest
and dividends only), or
5. You do not certify to the requester that you are not subject to backup
withholding under 4 above (for reportable interest and dividend accounts opened
after 1983 only).
Certain payees and payments are exempt from backup withholding. See Exempt
payee code on page 3 and the separate Instructions for the Requester of Form
W-9 for more information.
Also see Special rules for partnerships above.
What is FATCA reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign
financial institution to report all United States account holders that are specified
United States persons. Certain payees are exempt from FATCA reporting. See
Exemption from FATCA reporting code on page 3 and the Instructions for the
Requester of Form W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you claimed to be
an exempt payee if you are no longer an exempt payee and anticipate receiving
reportable payments in the future from this person. For example, you may need to
provide updated information if you are a C corporation that elects to be an S
corporation, or if you no longer are tax exempt. In addition, you must furnish a new
Form W-9 if the name or TIN changes for the account; for example, if the grantor
of a grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are
subject to a penalty of $50 for each such failure unless your failure is due to
reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you make a
false statement with no reasonable basis that results in no backup withholding,
you are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully falsifying certifications or
affirmations may subject you to criminal penalties including fines and/or
imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of federal law,
the requester may be subject to civil and criminal penalties.
Specific Instructions
Line 1
You must enter one of the following on this line; do not leave this line blank. The
name should match the name on your tax return.
If this Form W-9 is for a joint account, list first, and then circle, the name of the
person or entity whose number you entered in Part I of Form W-9.
a. Individual. Generally, enter the name shown on your tax return. If you have
changed your last name without informing the Social Security Administration (SSA)
of the name change, enter your first name, the last name as shown on your social
security card, and your new last name.
Note. ITIN applicant: Enter your individual name as it was entered on your Form
W-7 application, line 1a. This should also be the same as the name you entered on
the Form 1040/1040A/1040EZ you filed with your application.
b. Sole proprietor or single-member LLC. Enter your individual name as
shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade,
or “doing business as” (DBA) name on line 2.
c. Partnership, LLC that is not a single-member LLC, C Corporation, or S
Corporation. Enter the entity's name as shown on the entity's tax return on line 1
and any business, trade, or DBA name on line 2.
d. Other entities. Enter your name as shown on required U.S. federal tax
documents on line 1. This name should match the name shown on the charter or
other legal document creating the entity. You may enter any business, trade, or
DBA name on line 2.
e. Disregarded entity. For U.S. federal tax purposes, an entity that is
disregarded as an entity separate from its owner is treated as a “disregarded
entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on
line 1. The name of the entity entered on line 1 should never be a disregarded
entity. The name on line 1 should be the name shown on the income tax return on
which the income should be reported. For example, if a foreign LLC that is treated
as a disregarded entity for U.S. federal tax purposes has a single owner that is a
U.S. person, the U.S. owner's name is required to be provided on line 1. If the
direct owner of the entity is also a disregarded entity, enter the first owner that is
not disregarded for federal tax purposes. Enter the disregarded entity's name on
line 2, “Business name/disregarded entity name.” If the owner of the disregarded
entity is a foreign person, the owner must complete an appropriate Form W-8
instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.
Page 3
Form W-9 (Rev. 12-2014)
Line 2
2
If you have a business name, trade name, DBA name, or disregarded entity name,
you may enter it on line 2.
Line 3
Check the appropriate box in line 3 for the U.S. federal tax classification of the
person whose name is entered on line 1. Check only one box in line 3.
Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a
partnership for U.S. federal tax purposes, check the “Limited Liability Company”
box and enter “P” in the space provided. If the LLC has filed Form 8832 or 2553 to
be taxed as a corporation, check the “Limited Liability Company” box and in the
space provided enter “C” for C corporation or “S” for S corporation. If it is a
single-member LLC that is a disregarded entity, do not check the “Limited Liability
Company” box; instead check the first box in line 3 “Individual/sole proprietor or
single-member LLC.”
However, the following payments made to a corporation and reportable on Form
1099-MISC are not exempt from backup withholding: medical and health care
payments, attorneys' fees, gross proceeds paid to an attorney reportable under
section 6045(f), and payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify payees
that are exempt from reporting under FATCA. These codes apply to persons
submitting this form for accounts maintained outside of the United States by
certain foreign financial institutions. Therefore, if you are only submitting this form
for an account you hold in the United States, you may leave this field blank.
Consult with the person requesting this form if you are uncertain if the financial
institution is subject to these requirements. A requester may indicate that a code is
not required by providing you with a Form W-9 with “Not Applicable” (or any
similar indication) written or printed on the line for a FATCA exemption code.
A—An organization exempt from tax under section 501(a) or any individual
retirement plan as defined in section 7701(a)(37)
B—The United States or any of its agencies or instrumentalities
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting, enter in the
appropriate space in line 4 any code(s) that may apply to you.
Exempt payee code.
• Generally, individuals (including sole proprietors) are not exempt from backup
withholding.
• Except as provided below, corporations are exempt from backup withholding
for certain payments, including interest and dividends.
• Corporations are not exempt from backup withholding for payments made in
settlement of payment card or third party network transactions.
• Corporations are not exempt from backup withholding with respect to attorneys'
fees or gross proceeds paid to attorneys, and corporations that provide medical or
health care services are not exempt with respect to payments reportable on Form
1099-MISC.
C—A state, the District of Columbia, a U.S. commonwealth or possession, or
any of their political subdivisions or instrumentalities
D—A corporation the stock of which is regularly traded on one or more
established securities markets, as described in Regulations section
1.1472-1(c)(1)(i)
E—A corporation that is a member of the same expanded affiliated group as a
corporation described in Regulations section 1.1472-1(c)(1)(i)
F—A dealer in securities, commodities, or derivative financial instruments
(including notional principal contracts, futures, forwards, and options) that is
registered as such under the laws of the United States or any state
G—A real estate investment trust
H—A regulated investment company as defined in section 851 or an entity
registered at all times during the tax year under the Investment Company Act of
1940
The following codes identify payees that are exempt from backup withholding.
Enter the appropriate code in the space in line 4.
I—A common trust fund as defined in section 584(a) J—
1—An organization exempt from tax under section 501(a), any IRA, or a
custodial account under section 403(b)(7) if the account satisfies the requirements
of section 401(f)(2)
K—A broker
2—The United States or any of its agencies or instrumentalities
3—A state, the District of Columbia, a U.S. commonwealth or possession, or
any of their political subdivisions or instrumentalities
4—A foreign government or any of its political subdivisions, agencies, or
instrumentalities
5—A corporation
6—A dealer in securities or commodities required to register in the United
States, the District of Columbia, or a U.S. commonwealth or possession
7—A futures commission merchant registered with the Commodity Futures
Trading Commission
8—A real estate investment trust
9—An entity registered at all times during the tax year under the Investment
Company Act of 1940
10—A common trust fund operated by a bank under section 584(a)
11—A financial institution
12—A middleman known in the investment community as a nominee or
custodian
13—A trust exempt from tax under section 664 or described in section 4947
The following chart shows types of payments that may be exempt from backup
withholding. The chart applies to the exempt payees listed above, 1 through 13.
A bank as defined in section 581
L—A trust exempt from tax under section 664 or described in section 4947(a)(1)
M—A tax exempt trust under a section 403(b) plan or section 457(g) plan
Note. You may wish to consult with the financial institution requesting this form to
determine whether the FATCA code and/or exempt payee code should be
completed.
Line 5
Enter your address (number, street, and apartment or suite number). This is where
the requester of this Form W-9 will mail your information returns.
Line 6
Enter your city, state, and ZIP code.
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. If you are a resident alien and you do not
have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer
identification number (ITIN). Enter it in the social security number box. If you do not
have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may enter either your SSN
or EIN. However, the IRS prefers that you use your SSN.
If you are a single-member LLC that is disregarded as an entity separate from its
owner (see Limited Liability Company (LLC) on this page), enter the owner’s SSN
(or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC
is classified as a corporation or partnership, enter the entity’s EIN.
IF the payment is for . . .
THEN the payment is exempt for . . .
Note. See the chart on page 4 for further clarification of name and TIN
combinations.
Interest and dividend payments
All exempt payees except
for 7
Broker transactions
Exempt payees 1 through 4 and 6
through 11 and all C corporations. S
corporations must not enter an exempt
payee code because they are exempt
only for sales of noncovered securities
acquired prior to 2012.
How to get a TIN. If you do not have a TIN, apply for one immediately. To apply
for an SSN, get Form SS-5, Application for a Social Security Card, from your local
SSA office or get this form online at www.ssa.gov. You may also get this form by
calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer
Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer
Identification Number, to apply for an EIN. You can apply for an EIN online by
accessing the IRS website at www.irs.gov/businesses and clicking on Employer
Identification Number (EIN) under Starting a Business. You can get Forms W-7 and
SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM
(1-800-829-3676).
Barter exchange transactions and
patronage dividends
Exempt payees 1 through 4
Payments over $600 required to be
1
reported and direct sales over $5,000
Generally, exempt payees
2
1 through 5
Payments made in settlement of
payment card or third party network
transactions
Exempt payees 1 through 4
1
See Form 1099-MISC, Miscellaneous Income, and its instructions.
If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN
and write “Applied For” in the space for the TIN, sign and date the form, and give it
to the requester. For interest and dividend payments, and certain payments made
with respect to readily tradable instruments, generally you will have 60 days to get
a TIN and give it to the requester before you are subject to backup withholding on
payments. The 60-day rule does not apply to other types of payments. You will be
subject to backup withholding on all such payments until you provide your TIN to
the requester.
Note. Entering “Applied For” means that you have already applied for a TIN or that
you intend to apply for one soon.
Caution: A disregarded U.S. entity that has a foreign owner must use the
appropriate Form W-8.
Page 4
Form W-9 (Rev. 12-2014)
3
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or resident alien,
sign Form W-9. You may be requested to sign by the withholding agent even if
items 1, 4, or 5 below indicate otherwise.
For a joint account, only the person whose TIN is shown in Part I should sign
(when required). In the case of a disregarded entity, the person identified on line 1
must sign. Exempt payees, see Exempt payee code earlier.
Signature requirements. Complete the certification as indicated in items 1
through 5 below.
1. Interest, dividend, and barter exchange accounts opened before 1984
and broker accounts considered active during 1983. You must give your
correct TIN, but you do not have to sign the certification.
2. Interest, dividend, broker, and barter exchange accounts opened after
1983 and broker accounts considered inactive during 1983. You must sign the
certification or backup withholding will apply. If you are subject to backup
withholding and you are merely providing your correct TIN to the requester, you
must cross out item 2 in the certification before signing the form.
3. Real estate transactions. You must sign the certification. You may cross out
item 2 of the certification.
4. Other payments. You must give your correct TIN, but you do not have to sign
the certification unless you have been notified that you have previously given an
incorrect TIN. “Other payments” include payments made in the course of the
requester’s trade or business for rents, royalties, goods (other than bills for
merchandise), medical and health care services (including payments to
corporations), payments to a nonemployee for services, payments made in
settlement of payment card and third party network transactions, payments to
certain fishing boat crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of secured
property, cancellation of debt, qualified tuition program payments (under
section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct TIN, but you
do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account:
Give name and SSN of:
1. Individual
2. Two or more individuals (joint
account)
The individual
The actual owner of the account or,
if combined funds, the first1
individual on the account
3. Custodian account of a minor
(Uniform Gift to Minors Act)
The minor
4. a. The usual revocable savings
trust (grantor is also trustee)
b. So-called trust account that is
not a legal or valid trust under
state law
The grantor-trustee
5. Sole proprietorship or disregarded
entity owned by an individual
6. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Regulations section 1.671-4(b)(2)(i)
(A))
The owner
2
1
The actual owner
3
9. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
10. Association, club, religious,
charitable, educational, or other taxexempt organization
Give name and EIN of:
The owner
4
Legal entity
The corporation
The organization
11. Partnership or multi-member LLC
12. A broker or registered nominee
The partnership
The broker or nominee
13. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
The public entity
14. Grantor trust filing under the Form
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulations section 1.671-4(b)(2)(i)
(B))
The trust
1
List first and circle the name of the person whose number you furnish. If only one person on a
joint account has an SSN, that person’s number must be furnished.
2
Circle the minor’s name and furnish the minor’s SSN.
4
List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the
personal representative or trustee unless the legal entity itself is not designated in the account
title.) Also see Special rules for partnerships on page 2.
*Note. Grantor also must provide a Form W-9 to trustee of trust.
Note. If no name is circled when more than one name is listed, the number will be
considered to be that of the first name listed.
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal information such as your
name, SSN, or other identifying information, without your permission, to commit
fraud or other crimes. An identity thief may use your SSN to get a job or may file a
tax return using your SSN to receive a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a notice from
the IRS, respond right away to the name and phone number printed on the IRS
notice or letter.
If your tax records are not currently affected by identity theft but you think you
are at risk due to a lost or stolen purse or wallet, questionable credit card activity
or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit
Form 14039.
For more information, see Publication 4535, Identity Theft Prevention and Victim
Assistance.
Victims of identity theft who are experiencing economic harm or a system
problem, or are seeking help in resolving tax problems that have not been resolved
through normal channels, may be eligible for Taxpayer Advocate Service (TAS)
assistance. You can reach TAS by calling the TAS toll-free case intake line at
1-877-777-4778 or TTY/TDD 1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes. Phishing is the
creation and use of email and websites designed to mimic legitimate business
emails and websites. The most common act is sending an email to a user falsely
claiming to be an established legitimate enterprise in an attempt to scam the user
into surrendering private information that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does
not request personal detailed information through email or ask taxpayers for the
PIN numbers, passwords, or similar secret access information for their credit card,
bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS, forward this
message to phishing@irs.gov. You may also report misuse of the IRS name, logo,
or other IRS property to the Treasury Inspector General for Tax Administration
(TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal
Trade Commission at: spam@uce.gov or contact them at www.ftc.gov/idtheft or 1877-IDTHEFT (1-877-438-4338).
Visit IRS.gov to learn more about identity theft and how to reduce your risk.
The grantor*
For this type of account:
7. Disregarded entity not owned by an
individual
8. A valid trust, estate, or pension trust
1
You must show your individual name and you may also enter your business or DBA name on
the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you
have one), but the IRS encourages you to use your SSN.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct
TIN to persons (including federal agencies) who are required to file information
returns with the IRS to report interest, dividends, or certain other income paid to
you; mortgage interest you paid; the acquisition or abandonment of secured
property; the cancellation of debt; or contributions you made to an IRA, Archer
MSA, or HSA. The person collecting this form uses the information on the form to
file information returns with the IRS, reporting the above information. Routine uses
of this information include giving it to the Department of Justice for civil and
criminal litigation and to cities, states, the District of Columbia, and U.S.
commonwealths and possessions for use in administering their laws. The
information also may be disclosed to other countries under a treaty, to federal and
state agencies to enforce civil and criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism. You must provide your TIN whether or
not you are required to file a tax return. Under section 3406, payers must generally
withhold a percentage of taxable interest, dividend, and certain other payments to
a payee who does not give a TIN to the payer. Certain penalties may also apply for
providing false or fraudulent information.
THSRA PHONE LINE – 936-590-4447 WEBSITE: www.thsra.org
Change in procedure for entry forms
Everyone will need to fill out the following “Contestant Approval Form” and submit it with or prior to our
first entry form.
You will no longer have to get “EACH” entry form signed by the principle or notarized; however, you MUST
take this form to your school and have it signed by your superintendent or principle. You will also need to take
this form to have it notarized. This form will stand good for your seasons entry forms as long as this form is on
file with the secretary. Entry forms will not be accepted without it on file. You, your parents or guardians
will also have to sign before submitting to secretary.
PARENTS: You will need to check the “X” box for all events that you are allowing your contestant to
compete in as well as initial and date this box. If contestant enters an event that has NOT been checked by
parent approval the computer WILL NOT accept the entry. Therefore, if you are considering entering other
events at a later date (such as cutting) then you need to check and approve those events as well.
If you have any questions give me a call or email.
Susan Baldwin
THSRA Secretary
936-590-4447
texashighschoolrodeo@gmail.com
Contestant Approval Form:
The following must be filled out completely and signed for contestant to be eligible to compete.
CONTESTANT NAME: _________________________ GRADE _____ MEMBER#_________
ADDRESS_______________________________CITY_______________ST________ZIP______
CELL #’S Parent_________________________ Contestant ______________________________
PARENT APPROVES CONTESTANT TO ENTER THE FOLLOWING EVENTS ONLY:
X
Initial
Date
X Initial
Date
Bareback Riding
Queen Contest
Saddle Bronc Riding
Barrel Racing
Bull Riding
Pole Bending
Tie Down Roping
Breakaway Roping
Steer Wrestling
Goat Tying
Boys Cutting
Girls Cutting
Team Roping
Team Roping
Reined Cow Horse
Reined Cow Horse
Shooting – Trap/Rifle
Shooting - Trap/Rifle
I do certify that the above named student meets the Grade and Conduct qualifications of our State Rodeo Association Standards which
is passing at least 70% of the classes taken.
School Name ___________________________________________ Phone # _________________________________
____________________________________________
Superintendent, Principal or National Director / Date
_______________________________________________
Parent -HOMESCHOOL RECORDS ON FILE / Date
BOTH PARENTS & CONTESTANT MUST SIGN:
We, the undersigned, (parent/guardians/contestant) give the nearest or local HOSPITAL, and the physicians on the medical staff,
permission to administer necessary treatment of injuries incurred while participating in the THSRA REGIONAL RODEO. We
understand that each contestant must be and is covered by medical insurance. We hereby release the aforesaid hospital, physicians
and the producers from all liability.
X_______________________________,X__________________________________,X_______________________________
Parent
Parent
Contestant
STATE OF TEXAS
§
COUNTY OF ____________ §
This instrument was acknowledged before me on the _______ day of ______, 20____ by
____________________________&_________________________&________________________
(Seal)
____________________________________
Notary Public Signature
NOTARY PUBLIC, State of Texas
My Commission Expires: ______________
REGION VI-‐THSRA CONTESTANT CCONTACT INFORMATON CONTESTANT NAME:____________________________________________ PARENTS NAME: ____________________________________________(FATHER) ____________________________________________(MOTHER) PARENTS EMAILS: ________________________________________(FATHER) ________________________________________(MOTHER) _________________________________________(CONTESTANT) CELL PHONE: _____________________________________________(FATHER) _____________________________________________(MOTHER) ____________________________________________(CONTESTANT) THSRA
2016/2017 Adult Membership Form
$10.50 per adult
Name
Date
Address
City
State
Phone
Cell
Zip
Email
Name of Contestant
THSRA
2016/2017 Adult Membership Form
$10.50 per adult
Name
Date
Address
City
State
Phone
Cell
Email
Name of Contestant
Zip
REGION 7 2016-17
STUDENT EVENT DIRECTOR NOMINATION FORM
We are going to try something different this year on the Student Event Director Nominations and Voting. First we need
to explain that this is a very important position and requires someone that knows and understands the rules of the
event. According to the rule book we must have one student and adult event director during each event that is ran.
Therefore, you must compete in that event in order to be nominated or nominate yourself. When you compete you will
have someone fill in your position and then as soon as you are through you will take your position. You will be
responsible for getting the clipboard from the previous event director before the event starts. You will watch every run
and be ready for any protest or question a contestant has from their run and the judge’s decision. You will also write
down the times of each run – at the end of the event you will ask the Judge for their sheets and you will immediately
bring your sheets and the judges sheets to the announcer stand so all the times can be verified before posting.
I know that being a student director can be a real pain – but it is an honor to be even be nominated from your peers
because that is saying that they look up to you for understanding the rules in that event. If you have always wanted to
be an event director and never nominated here is your chance – please either nominate yourself or someone for the
events that you will be participating in. I will contact those that will be placed on the ballot to make sure they are willing
to do the job. Then when you check into the first rodeo (everyone has to check in to get your number) you will vote on a
ballot and they will be counted during the general meeting and announced at the end of the meeting.
PLEASE NOMINATE SOMEONE OR YOURSELF IN THE EVENTS THAT YOU PARTICIPATE IN:
POLES__________________________________
TIE DOWN _________________________________________
BREAKAWAY_____________________________
STEER WRESTLING___________________________________
BARRELS_________________________________
TEAM ROPING HEADER_______________________________
T/R HEELER_______________________________
GOAT TYING________________________________________
ROUGH STOCK _____________________________
GIRLS CUTTING______________________________________
BOYS CUTTING______________________________
NOMINATED
BY:___________________________________________________(Required) MAIL BACK
WITH MEMBERSHIP AND ENTRY FORM BY AUGUST 15, 2016 -
TEXAS JR HIGH & TEXAS HIGH SCHOOL RODEO ASSOCIATION
REGION VI
July 2016
RODEO ENTRY INFORMATION
All of the TJHRA & THSRA Region VI rodeos for the 2016-17 rodeo season are
scheduled to be held at JB WELLS AREANA, GONZALES, TX. All rodeos will begin
at 9:00 am. The first rodeo on September 10, 2016 will begin with a very important
mandatory contestant and parent meeting. Everyone entered and in the rodeo must
attend the meeting. We will be going over all the rules, voting for student officers and
student event directors. Following this meeting we will give the girls time to warm up
for the poles. Let’s get our year started out with a great start!
The dates, postmark deadlines and late deadlines are as follows:
RODEO
1&2
3&4
5&6
7&8
9 & 10
11&12
RODEO DATE
September 10 &11
Oct 8 & Oct 9
November 12&13
January 14 &15
February 11&12
March 11 &12
POSTMARK DATE
Aug 29, 2016
September 26, 2016
October 31, 2016
January 2, 2017
January 30, 2017
February 27, 2017
LAST DAY IN HAND
September 6, 2016
October 3, 2016
November 7, 2016
January 9, 2017
February 5, 2017
March 6, 2017
CUTTING
#1 & #2
#3 & #4
#5
#6 & #7
#8
#9 & #10
#11 & #12
CUTTING DATES
August 12 & 13, 2016
October 1 & 2, 2016
October 2, 2016
Dec 30 & 31, 2016
January 1, 2017
Jan 21 & 22, 2017
February 4 & 5, 2017
POSTMARK DATE
August 3, 2016
September 19, 2016
September 19, 2016
December 19, 2016
December 19, 2016
January 9, 2017
January 23, 2017
LOCATION
Gonzales, TX
Gonzales, TX
Gonzales TX
Gonzales, TX
Gonzales, TX
Gonzales, TX
Gonzales, TX
CUTTING #5 WILL BE A DOUBLE JUDGE CUTTING WITH CUTTING #4
COW REIGNING
REIGNING DATES POSTMARK DATE
1
2
TO BE ANNOUNCED IN AUGUST
3
AWARDS & STATE SIGN UP TBA
LOCATION
If your entries are not postmarked by the deadline dates, a $40 late fee for each entry
POSTMARKED. I MUST HAVE IN MY POSSESSION! There will be no
exceptions as far as the deadline dates are concerned!
Along with the entry form, it also serves as the school form and medical release.
CONTESTANT APPROVAL FORM – if you have this filled out and filed at the
Region 6 Office you will only have to turn in grades at the beginning of membership –
midterm – and then at the state finals! NO GRADES OR SIGNATURES WILL BE
REQUIRED WITH EACH ENTRY – GRADES WILL BE REQUIRED AFTER 1ST
SEMESTER!
that you are competing in. If your entry is not completed when received it will be
returned to you and you take the chance of not being able to compete if I do not receive it
back by the deadline. The entry blank must also be signed by the school by your school
superintendent, principal, or counselor verifying your passing grades (you must be
passing four subjects) before each rodeo participating in, or if you can get your grades
off the internet you may use these attached to the entry blank, instead of signatures.
All entry fees, late fees, and any returned checks must be paid before the rodeo starts or
you will not be allowed to rodjeo..
Medical draw outs will be honored only I am notified before the rodeo starts. I will
need a vet release if draw out involves your horse. If your horse is injured during the first
rodeo, you must fax in a vet release by the following Monday from your vet to receive a
refund..
If you would like to get my emails, please make sure I have your email address. There
will be a place on your membership application for it. Or email me and I will add you
region6thsra@gmail.com.
PLEASE SIGN UP FOR REMIND 101 VERY
IMPORTANT!!!
If you ever have a question or something just clarified, please do not hesitate to contact
me, or any other director. You may call or text me at 281-468-8973. You may also email
me at region6thsra@gmail.com.
I know some of this seems kind of harsh, but believe me, if we all follow the rules that
are coming from the NHSRA rule book everything runs so much smoother and there are
no questions. Remember High School rodeo, is trying to get you ready for your next step
in rodeo.
Thanks and lets all have a great rodeo season!!!
Nena Boettcher
TJHRA & THSRA
RegionVI Secretary
281-468-8973
region6thsra@gmail.com
thsra6.com
Like our facebook page: thsra6
BLOOMER TICKET DUE AT OCTOBER 9TH RODEO
LIVE AUCTION NOVEMBER 12 , 2016!!!DODGE TICKETS & STATE AD DUE NOVEMBER 12TH RODEO
OFFICIAL ENTRY BLANK – QUALIFYING REGION VI RODEO 2016-17
Starting Time for Rodeos: 9:00 AM
Mail Entries to:
THSRA REG VI
Nena Boettcher
P.O. Box 833
East Bernard, TX
77435
281-468-8973
Rodeo #
1&2
3&4
5&6
7&8
9 & 10
11 & 12
Rodeo Date
Sept. 10 & 11
Oct 8 & Oct 9
Nov 12 & 13
Jan 14 & 15
Feb 11 & 12
Mar 11 & 12
Arena: JB WELLS ARENA, GONZALES, TX
Entry Deadline
Aug. 29, 2016
Sept 26, 2016
Oct 31, 2016
Jan 2, 2017
Jan 30, 2017
Feb 27, 2017
Last Day to Enter w/late fee
Sept 6, 2016
Oct 3, 2016 BLOOMER TICKET DUE
Nov 7, 2016 DODGE TICKETS/STATE AD
Jan 9, 2017 1st Semester Report Card
Feb 5, 2017
Mar 6, 2017
Contestant Name:
Address:
Phone #:
City:
Cell #
Zip:
Email:
This entry form is for Rodeo #
and Rodeo#
WHEN ENTERING TWO RODEOS ADD ENTRY FEES TOGETHER
GIRLS EVENTS
1. Barrel Racing
2. Pole Bending
3. Breakaway
4. Goat Tying
1ST RODEO
$40.00
$40.00
$55.00
$55.00
2ND RODEO
$40.00
$40.00
$55.00
$55.00
TOTAL
PARENT SIGNATURE
BOYS EVENTS
1. Bareback
2. Bull Riding
3. Saddle Bronc
4. Calf Roping
5. Steer Wrestling
1ST RODEO
$75.00
$75.00
$75.00
$55.00
$55.00
2ND RODEO
$75.00
$75.00
$75.00
$55.00
$55.00
TOTAL
PARENT SIGNATURE
TOTAL
PARENT SIGNATURE
COMBINED EVENTS FOR BOYS AND GIRLS
1. Team Roping
$55.00
$55.00
Header:
TOTAL ENTRY FEES:
OFFICE CHARGE:
LATE FEE:
TOTAL DUE:
Heeler:
TWO RODEOS=$50 OFFICE CHARGE, ONE RODEO=$25 OFFICE CHARGE)
(TWO RODEOS = $80 LATE FEE, ONE RODEO=$40 LATE FEE if it’s not
postmarked by the due date. ABSLUTELY NO EXCEPTIONS!)
I certify that this student meets the National High School Rodeo Association’s GRADE AND CONDUCT qualifications.
Minimum requirements: Student must be passing 70% of classes being taken. This must be signed or CURRENT
Computer grade sheet attached to
Signed:
entry! IF YOU HAVE FILLED OUT
Superintendent, Principal or Counselor
AND HAVE ON FILE CONTESTANT APPROVAL FORM
SIGNATURES NOT REQUIRED
BLOOMER TICKET DUE BY October 9, 2016 Rodeo
LIVE AUCTION NOBEMBER 12, 2016!
DODGE TICKETS & STATE ADDUE AT THE NOVEMBER 12, 2016 RODE0
OFFICIAL ENTRY BLANK – QUALIFYING REGION VI CUTTING 2016-17
Mail Entries to:
THSRA REG VI
Nena Boettcher
P.O. Box 833
East Bernard, TX
77435
281-468-8973
Cutting #
#1 & #2
#2 & #3
#5
#6, #7, #8
#9 & #10
#11 & #12
Cutting Date
Aug 12 & 13, 2016
Oct 1 & 2
Oct 2, 2016
Dec 30- Jan 1, 2017
Jan 21 & 22, 2017
Feb 4 & 5, 2017
EntryDeadline
Aug 3, 2016
Sept 19, 2016
Sept 19, 2016
Dec 19, 2016
Jan 9, 2017
Jan 23, 2017
LastDaytoEnterw/latefee
NO LATE FEE Gonzales, TX
Sept 26, 2016 Gonzales TX
Sept 26, 2016 Gonzales TX
Dec.26, 2016 Gonzales, TX
Jan. 16, 2017 Gonzales, TX
Jan 30,2017
Gonzales, TX
CUTTING #5 WILL BE A DOUBLE JUDGED CUTTING WITH CUTTING #4
Contestant Name:
Address:
Phone #:
City:
Cell #
Zip:
Email:
This entry form is for Rodeo #
and Rodeo#
WHEN ENTERING TWO CUTTINGS ADD ENTRY FEES TOGETHER
GIRLSEVENTS
Cutting
1ST CUTTING
2ND CUTTING
PARENT SIGNATURE
BOYSEVENTS
Cutting
1ST CUTTING
2ND CUTTING
PARENT SIGNATURE
OFFICE CHARGE:
LATE FEE:
TOTAL DUE:
TWO RODEOS=$50 OFFICE CHARGE, ONE RODEO=$25
OFFICE CHARGE)
(TWO RODEOS = $50 LATE FEE, ONE RODEO=$25 LATE FEE if it’s not
postmarked by the due date. ABSLUTELY NO EXCEPTIONS!)
I certify that this student meets the National High School Rodeo Association’s GRADE AND CONDUCT qualifications.
Minimum requirements: Student mustbepassing 70% of classes being taken. Thismustbe signed or CURRENT
Computer grade sheet attached to
Signed:
entry!
Superintendent, Principalor Counselor
CITY OF GONZALES
SHRINE OF A GREAT TEXAS HERITAGE
JB Wells Park
Where The Fight For Texas· Liberty Began
July 21, 2016
Attn: Contestants
We are getting ready to kick off the 2016-2017 year for Region 6! JB Wells would like to thanks you for making
us your home another year, and this year we are going to be doing things a little differently in hope to make
your check-in run a little smoother.
This year we will be opening up the office phone lines for the rodeo season reservations on August 10th at
9:00 a.m.
As I said previously we are doing thing differently this year! With that said we will NOT be taking ANY reservations
until this date and time. Do not leave a message on our answering machine or send us an e-mail to let us know
which sites you wish to have. We will only be taking phone calls. Also, we will only allow you to make your own
reservations. We are trying to create an equal reservation opportunity for everyone. We will then return your
call within a few days to book your reservations for the year. Keep in mind; we will probably be loaded with calls
the first day. Therefore, you may not get a call back right away; give us a day or two.
Finally, it is not mandatory, but we do recommend paying for your reservations in advance. This helps us to have
everything unlocked and ready to go for you when you arrive. As in the past we will have someone working until
about 9 p.m. on Fridays for your convenience, if you plan to arrive later than that you must have your stalls and
hook-ups paid in advance. If you do not have a reservation, do not pull into a hook-up site, as it is more than
likely already taken. The same rule applies for stalls, as well. Also make a note of this; we will not be giving any
refunds and not rolling anything over from rodeo to rodeo.
2016-2017 Dates are as follows:
September 10-11
October 8-9
November 12-13
January 14-15
February 11-12
March 11-12
We can’t wait to get this next season rolling! If you have any questions regarding this information, please give us
a call (830) 672-6558 or (830) 263-2256.
Thanks
Sami Jo Warren
JB Wells Park Secretary
City of Gonzales
830-672-6558
swarren@cityofgonzales.org
P.O. Drawer 547
2301 Cr 197
Gonzales, Texas 78629
Phone (830) 672-6558
Fax: (830) 672-2813
Texas High Rodeo Association – Region VI
“Today’s Youth Tomorrow’s Champions”
PO Box 833, East Bernard, TX 77435
The National High School Rodeo Association is an international, non-profit organization,
dedicated to the development of sportsmanship, horsemanship, and character in the
youth of our country. Along with the United States, other countries include Australia and
Canada. The organization was created to give junior high school students the
opportunity to participate and compete in this unique and challenging sport. Athletes
compete on a scale comparable to high school, collegiate and professional rodeo
competitors. The NHSRA is an independent student athletic association governing itself
without the supervision of school administrations or assistance from tax dollars.
At the national level, high school contestants have an opportunity to receive college
scholarships totaling more than $100,000.00 each year. In addition to winning
scholarships based on their rodeo skills, academics, and community involvement.
NHSRA members compete at state levels for local recognition and the top four
contestants in each event from each state and province qualify for the National High
Rodeo Association Finals conducted annually in June where more than 1500
contestants compete.
Region VI holds 12 qualifying rodeos each year finishing with the weeklong state finals.
All of our rodeos are held in Gonzales, TX. With contestants competing hailing from
the following counties: Atascosa, Bandera, Bastrop, Bexar, Blanco, Burnet, Caldwell,
Calhoun, Colorado, Comal, DeWitt, Edwards, Fayette, Gillespie, Gonzales, Guadalupe,
Hays, Jim Wells, Kendall, Kerr, Kinney, Kimble, Lavaca, Lee, Live Oak, Llano,
McMullen, Mason, Medina, Menard, Milam, Real, Travis, Uvalde, Victoria, and Wilson.
With the help of sponsors, Region VI is hoping to be able to award trophy buckles and
tack along with 15 event champion saddles. These contestants have to keep their
grades up in order to compete and they also work the rodeos as well as any
fundraisers.
This year the financial challenges we are facing are substantially greater than in the
past. It is through the generous support of families and businesses that have helped
make Region VI fun and rewarding for all who participate.
Please complete the attached form to keep for your records and return one copy to the
above address. Contribution checks should be made out to THSRA Region VI. Thank
you so much for your generosity and support of our children. These children will one
day be the leaders of not only of Texas High School Rodeo but of our great state and
nation.
For tax purposes, our Non-Profit Tax ID# is 74-2093972.
Sincerely,
Bubba Bennight, Region VI High President
Mike Iselt, Region VI. High Vice President
Nena Boettcher, Rodeo Secretary (281) 468-8973
“Today’s Youth Tomorrow’s Champions”
Nena Boettcher- Secretary
PO Box 833, East Bernard, TX 77435
(281) 468-8973 email: region6thsra@gmail.com Website: thsra6.com
__________$1,200.00 - Saddle Sponsor MUST BE
RECEIVED BY Nov 15, 2016 TO HAVE NAME ON SADDLE
Sponsor name on saddle
__________$500.00 - ½ Saddle Sponsor
Sponsor name on saddle – smaller type
__________$250.00 - Buckle Sponsor
__________Cash Donation AMOUNT $______________
All cash donations will go toward the
purchase of year end awards.
MAKE CONTRIBUTION PAYABLE TO:
TEXAS HIGH RODEO ASSOCIATION - REGION VI
COMPANY: ______________________________________________________
NAME: __________________________________________________________
ADDRESS: ______________________________________________________
________________________________________________________________
PHONE: ________________________________________________________
Region VI Member:________________________________________________
THANK YOU FOR YOUR GENEROUS DONATION!
PLEASE MAKE A COPY FOR YOUR TAX RECORDS
THSRA TAX ID: 74-2093972

PROSPECTIVE MEMBERS FROM

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