HomeMy Public PortalAboutSundial Reconstruction ProjectAGREEMENT BETWEEN OWNER AND CONTRACTOR FOR
CONSTRUCTION CONTRACT
(SUNDIAL RECONSTRUCTION PROJECT)
THIS AGREEMENT, is by and between McCall Redevelopment Agency (hereinafter, "OWNER") and Mel Shields,
LLC, (hereinafter, "Contractor"):
NOW THEREFORE, the parties to this Contract, in consideration of the mutual covenants and stipulations set out,
agree as follows:
ARTICLE 1. CONTRACT DOCUMENTS
The Contract Documents which comprise the entire agreement between the OWNER and the Contractor concerning
the work to be performed are this Contract, pages one (1) through (4) and the following:
1. Bid Documents titled, Legacy Park Sundial Reconstruction Project, dated 3-3-11.
2. Standard General Conditions of the Construction Contract, 2010 ISPWC (Idaho Standards for Public
Works Construction) Division 100 (not attached) (pages 1 to 52, inclusive).
3. Bid/Proposal of the Contractor, dated February 18, 2011, to be physically attached to this Contract;
4. The Construction Plans (4 sheets), dated 3- 3- II by OTAK, Inc.;
5. Performance and Payment Bonds and Insurance Certificates, to be physically attached to this Contract;
6. The following which may be delivered or issued on or after the Effective Date of the Agreement and are
not attached hereto:
a. Notice of Award
b. Notice to Proceed.
c. Written Amendments.
d. Work Change Directives.
e. Change Orders.
7. Addenda issued prior to opening of bids, to be physically attached to this contract;
8. WH-5 - Public Works Contract Report for Idaho State Tax Commission
9. W9
There are no Contract Documents other than those listed in Article 1. This Contract may only be amended by change
order as provided in the General Conditions.
ARTICLE 2. WORK
The Contractor shall complete the entire work as specified, indicated and required under the Contract Documents.
The Work is generally described as follows: Legacy Park Sundial Reconstruction Project.
ARTICLE 3. ARCHITECT/ENGINEER, MCCALL PARKS AND RECREATION DIRECTOR
1.01 The project has been designed by Otak, Inc. (Architect/Engineer), which is to act as the OWNER's
representative, assume all duties and responsibilities, and have the rights and authority assigned to
"Engineer" in the Contract Documents in connection with the completion of the work in accordance
with the Contract Documents and the General Conditions of the Idaho Standards for Public Works
Construction (ISPWC).
1.02 The McCall Parks and Recreation Director (Director) will be the Owner's representative, along with
the Engineer. The Director will serve as the "Project Manager" and approving agency for the project
and serve a liaison between the Architect/Engineer and the OWNER.
Page 1 of 4
ARTICLE 4. CONTRACT TIME/SUBSTANTIAL COMPLETION
The Contractor shall begin work in conformance with the Contract Documents and shall complete the work prior to
the date of completion. The project site will be available to the Contractor for project implementation when weather
conditions permit during Spring 2011, and only after approval of the Parks and Recreation Director.
The work to be performed pursuant to this Contract shall be substantially complete on or before May 315`, 2011 and
ready for final payment in accordance with Paragraph 14.07 of the General Conditions on or before June 15th, 2011.
Adjustment of the contract time can be made in accordance with the provisions of the Contract Documents as
directed by the project Engineer/Architect, Director of Parks and Recreation, or the OWNER.
ARTICLE 5. CONTRACT SUM
The OWNER shall pay the Contractor for completion of the Work in accordance with the Contract Documents using
current funds for the amount of SIXTY THOUSAND FOUR HUNDRED NINTY EIGHT DOLLARS ($60,498.00).
ARTICLE 6. INDEPENDENT CONTRACTOR
The parties warrant by their signature that no employer -employee relationship is established between the Contractor
and the OWNER by the terms of this contract. It is understood by the parties hereto that the Contractor is an
independent contractor and as such neither it nor its employees, agents, representatives or subcontractors, if any, are
employees of the OWNER for purposes of tax, retirement system, or social security (FICA) withholding.
ARTICLE 7. SCOPE OF SERVICES
The Contractor shall perform all services required by the Contract Documents. All work shall be completed in
accordance with the specifications and plans established for this project.
ARTICLE 8. HOLD HARMLESS/INDEMNIFICATION
In addition to other rights granted the OWNER by the Contract Documents, the Contractor shall indemnify and save
harmless the Architect and the Owner, its officers and employees, from all suits, actions, or claims of any character
brought because of any injuries or damages received or sustained by any person, persons, or property on account of
the operations of the Contractor or his subcontractors; or on account of or in consequence of any neglect in
safeguarding the work; or through use of unacceptable materials in constructing the work; or because of any act or
omission, neglect, or misconduct of the Contractor or his subcontractors; or because of any claims or amounts
recovered from any infringements of patent, trademark or copyright; or from any claims or amounts arising or
recovered under the Workmen's Compensation Act or any other law, ordinance, order or decree.
ARTICLE 9. CONFLICT OF INTEREST
The Contractor covenants that it presently has no interest and will not acquire any interest, direct or indirect, in the
project which would conflict in any manner or degree with the performance of its services hereunder. The
Contractor further covenants that, in performing this Contract, it will employ no person who has any such interest.
Should any conflict of interest arise during the performance of this Contract, Contractor shall immediately disclose
such conflict to the Project Manager, Architect and the OWNER.
ARTICLE 10. ENTIRE AGREEMENT, MODIFICATION AND ASSIGNABILITY
This Contract and the exhibits hereto contain the entire agreement between the parties, and no statements, promises,
or inducements made by either party, or agents of either party are valid or binding unless contained herein. This
contract may not be enlarged, modified or altered except upon written agreement signed by the parties hereto. The
Contractor may not subcontract or assign its rights (including the right to compensation) or duties arising hereunder
Page 2 of 4
other than as contemplated by the Contract Documents, without the prior written consent and express authorization
of the OWNER.
ARTICLE 11. ADHERENCE TO LAW REQUIRED
All applicable local, state and federal statutes and regulations are hereby made a part of this contract and shall be
adhered to at all times. Violation of any of these statutes or regulations by the Contractor shall be deemed material
and shall subject the Contractor to termination of this contract for cause. No pleas of misunderstanding or ignorance
on the part of the Contractor will in any way serve to modify the provisions of this requirement. The Contractor and
his surety shall indemnify and save harmless the OWNER, the City of McCall and its employees, agents or
representatives against any claim or liability arising from or based on the violation of any such laws, codes,
ordinances, or regulations, whether by himself, his employees, or his subcontractors.
ARTICLE 12. LEGAL FEES
In the event either party incurs legal expenses to enforce the terms and conditions of this contract, the prevailing
party is entitled to recover reasonable attorney's fees and other costs and expenses, whether the same are incurred
with or without suit.
ARTICLE 13. SPECIAL WARRANTY
The Contractor warrants that nothing of monetary value has been given, promised or implied as remuneration or
inducement to enter into this Contract. The Contractor further declares that no improper personal, political or social
activities have been used or attempted in an effort to influence the outcome of the competition, discussion, or
negotiation leading to the award of this Contract. Any such activity by the Contractor shall make this Contract null
and void.
ARTICLE 14. COMMUNICATIONS
Such communications as are required by this contract shall be satisfied by mailing or by personal delivery to the
parties at the following address:
Contractor: N^\-•\�\c�S L-LC
Q D�..ok ale
�e�•r...���.��c1. �310\5
Owner: McCall Redevelopment Agency
216 E. Park Street
McCall_, Idaho 83638
IN WITNESS WHEREOF, said Contractor and the OWNER or City have caused this Contract to be executed on the
day and year first above written.
Contractor: Owner:
by: Rick Fereday, MRA Chairman
ATTEST:
f
BessieJo
Page 3 of 4
Approved As To Form:
William F. Nichols, City Attorney
ACKNOWLEDGMENT
On this day of Mare.6 , 2010, before me, a Notary Public of the State of Idaho,
personally ap eared k04,1Q. Shie.i -3 , in his official capacity as tzh-f-.a 66-
known to me to be the erson described in the above document and acknowledged to me he executed the same.
SEAL
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Page 4 of 4
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NoPublic residi°r(g at (tom,
My Commission expires o?
ACKNOWLEDGMENT
On this
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known to me to be the
SEAL
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Appmved As To Form:
William F. Nichols, City Attorney
da of __ , 2010, before me, a Notary Public of the State of Idaho,
Skt , in his official opacity as Lo-k-4).‘, Y
descn'bed in the above document and acknowledged to me he executed the same.
�1 A_ N ublic resid�(g aty.#40617My Commission expires
Page 4 of 4
CNA 3/1/2011 3:33:20 PM PAGE 3/006 Fax Server
Western Surety Company
POWER OF ATTORNEY - CERTIFIED COPY
Bond No 71063289
Know All Men By These Presents, that WESTERN SURETY COMPANY, a corporation duly organized and existing under the laws
of the State of South Dakota, and having its principal office in Sioux Falls, South Dakota (the "Company"), does by these presents make,
constitute and appoint. Shea Linn Webster
its true and lawful attorney(s)-in-fact, with full power and authority hereby conferred, to execute, acknowledge and deliver for and on its
behalf as Surety, bonds for.
Principal: Mel Sh_elds, LLC
Obligee: City of Mc Call
Amount:
$500,000.00
and to bind the Company thereby as fully and to the same extent as if such bonds were signed by the Senior Vice President, sealed with
the corporate seal of the Company and duly attested by its Secretary, hereby ratifying and confirming all that the said attomey(s)-in-fact
may do within the above stated limitations. Said appointment is made trader and by authority of the following bylaw of Western Surety
Company which remains in full force and effect.
"Section 7. All bonds, politics, undertakings, Powers of Attorney or other obligations of the corporation shall be executed in the
corporate name of the Company by the President, Secretary, any Assistant Secretary, Treasurer, or any Vice President or by such other
officers as the Board of Directors may authorize. The President, any Vice President, Secretary, any Assistant Secretary, or the Treasurer
may appoint Attorneys in Fact or agents who shall have authority to issue bonds, policies, or undertakings in the name of the Company.
The corporate seal is not necessary for the validity of any bonds, policies, umdertakings, Powers of Attorney or other obligations of the
corporation. The signature of any such officer and the corporate seal may he printed by facsimile."
All authority hereby conferred shall expire and terminate, without notice, unless used before midnight of
01 1 but until such time shall be irrevocable and in full force and effect.
September 15
In Witness Whereof, Western Surety Company has caused these presents to be signed by its Senior Vice President, Paul T. Brunet;
and its �eoka�;wlEt3o be affixed this 1 U t day of MA r Ch 2011
4
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WEST.' R ►• SURECOMPANY
Paul T. Bruflat/Senior Vice President
On this 1:2 t day of March , in the year 2011 , before me, a notary public, personally appeared
Paul T. Bruflat, who being to me duly sworn, acknowledged that he signed the above Power of Attorney as the aforesaid officer of
WESTERN SURETY COMPANY and acknowledged said instrument to be the voluntary act and deed of said corporation.
♦14►titiu�r�wti..�rw� }
s D. KRELLfat +
NOTARY PUBLIC
• SOUTH DAKOTA
gti
My Co▪ mmission Expires November 30, • 2012
I the undersigned officer of Western Surety Company, a stock corporation of the State of South Dakota, do hereby certify that the
attached Power of Attorney is in full force and effect and is irrevocable, and furthermore, that Section 7 of the bylaws of the Company as
set forth in the Power of Attorney is now in force.
In testimony whereof, I have hereunto set my hand and seal of Western Surety Company this
March 2011
Form F5306-9-2006
ary Public - South Dakota
1st day of
WEST ' R SURE GY COMPANY
Paul T. Bruflat/Senior Vice President
CNA 3/1/2011 3:33:20 PM PAGE 4/006 Fax Server
‘Ti
Western Surety Company
PERFORMANCE BOND
Bond Number: 71063209
KNOW ALL PERSONS BY THESE PRESENTS, That we Mel Shields, LLC
125 Jughandle Dr., Mc Call, ID 83638
referred to as the Principal, and
as Surety, are held and firmly bound unto Ci =Y
Western Surety Company
of
, hereinafter
of Mc Call
Of 216 E. Park St., Mc Call, ID 83638 , hereinafter
referred to as the Obligee, in the sum of Sixty Thousand Four Hundred Ninety -Eight and 00/100
Dollars ($ 60,498.00 ) for the payment of which we bind ourselves, our legal representatives, successors
and assigns, jointly and severally; firmly by these presents.
WHEREAS, Principal has entered into a contract with Obligee, dated the day of
,forTc,gacv Park Sian Dial R•^ccartruction Projrct
NOW, THEREFORE, if the Principal shall faithfully perform such contract or shall indemnify and save harmless
the Obligee from all cost and damage by reason of Principal's failure so to do, then this obligation shall be null
and void; otherwise it shall remain in full force and effect.
ANY PROCEEDING, legal or equitable, under this Bond may be instituted in any court of competent jurisdiction
in the location in which the work or part of the work is located and shall be instituted within two years after
Contractor Default or within two years after the Contractor ceased working or within two years after the Surety
refuses or fails to perform its obligations under this Bond, whichever occurs first. If the provisions of this
Paragraph are void or prohibited by law, the minimum period of limitation available to sureties as a defense in the
jurisdiction of the suit shall be applicable.
NO RIGHT OF ACTION shall accrue on this Bond to or for the use of any person or corporation other than the
Obligee named herein or the heirs, executors, administrators or successors of the Obligee.
SIGNED, SEALED AND DATED this
Form F4597
2011 .
�t day of March
Mel Shields, LLC
Seal,
�, " ' ebs ter Attorney -in -Fact
CNA 3/1/2011 3:33:20 PM PAGE 5/006 Fax Server
ool
Western Surety Company
PAYMENT BOND
Bond Number:
71063289
KNOW ALL PERSONS BY THESE PRESENTS, That we Mel Shields, LLC
17` Jughandle Dr., Mr. Call, TD 83638
referred to as the Principal, and Western Surety Company
as Surety, are held and firmly bound unto city of
Mr_. Call
of
, hereinafter
Of 216 E. Park St., Mc Call, ID 83638 , hereinafter
referred to as the Obligee, in the sum of sixty Thousand Four Hundred Ninety -Eight a.nd 00/100
Dollars ($ 60, 498. 00 ) for the payment of which we bind ourselves, our legal representatives, successors
and assigns, jointly and severally, firmly by these presents.
WHEREAS, Principal has entered into a contract with Obligee, dated day of
,for Legacy Park Sun Dial Reconstruction Project
copy of which contract is by reference made a part hereof.
NOW, THEREFORE, if Principal shall, in accordance with applicable Statutes, promptly make payment to all
persons supplying labor and material in the prosecution of the work provided for in said contract, and any and all
duly authorized modifications of said contract that may hereafter be made, notice of which modifications to Surety
being waived, then this obligation to be void; otherwise to remain in full force and effect.
No suit or action shall be commenced hereunder
(a) After the expiration of one (1) year following the date on which Principal ceased work on said contract it
being understood, however, that if any limitation embodied in this bond is prohibited by any law
controlling the construction hereof such limitation shall be deemed to be amended so as to be equal to
the minimum period of limitation permitted by such law.
(b) Other than in a state court of competent jurisdiction in and for the county or other political subdivision of
the state in which the project, or any part thereof, is situated, or in the United States District Court for the
district in which the project, or any part thereof, is situated, and not elsewhere.
The amount of this bond shall be reduced by and to the extent of any payment or payments made in good faith
hereunder.
SIGNED, SEALED AND DATED this =st day of March 201_
Mel Shields LLC
(Seal)
Shea Linn Webster Attorney -in -Fact
CNA 3/1/2011 3:33:20 PM PAGE 6/006 Fax Server
ACKNOWLEDGMENT OF SURETY
STATE OF Idaho (Attorney -in -Fact) Bond No 710E3289
COUNTY OF Ada ss
On this ‘72 day of /2/.:1 rC% J , before me, a notary public in
and for said County, personally appeared Shea Linn Webster
to me personally known and being by me duly sworn, did say, that he is the Attorney -in -Fact of WESTERN SURETY COMPANY,
a corporation of Sioux Falls, South Dakota, created, organized and existing under and by virtue of the laws of the State of South
Dakota, that the said instrument was executed on behalf of the said corporation by authority of its Board of Directors and that
the said Shea Linn Webster
acknowledges said instrument to be the free act and deed of said corporation and that he has authority to sign said instrument
without affixing the corporate seal of said corporation.
IN WITNESS WHEREOF, I have hereunto subscribed any name and affixed my official seal at
Boise Idazo , the day and year last above written.
My commission expires _
i
Form 106-4-2000
je./.1 44/
Notary Public
ACKNOWLEDGMENT OF SURETY
STATE OF IDAHO )
)ss
COUNTY OF VALLEY )
Bond No. 71063289
On this 4th day of March, 2011 before me, Aana L. Vannoy, a notary public in and for the State of
Idaho, personally appeared Mel Shields, known or identified to me to be the person whose name is
subs; ribed to therwithiinstrument and acknowledged to me that he executed the same.
uCt h h
Notary Public or Idaho
My commission expires: 7/10/
1
Residing at McCall, ID
AANA L. VANNOY
NOTARY PUBLIC
STATE OF IDAHO
CITY OF MCCALL PUBLIC WORKS
NOTICE OF AWARD
February 24, 2011
Mel Shields, LLC
P.O. Box 96
Donnelly, Idaho 83615
RE: Sundial Reconstruction Project
The OWNER (McCall Redevelopment Agency) has considered the BID submitted by you for the
above described WORK, and you are hereby notified that your ALTERNATIVE BID has been
accepted for items in the amount of $60,498.00.
You are required by the Information for Bidders to execute the Agreement and furnish the
following:
• Bid/Proposal of the Contractor, dated February 18, 2011;
• Performance and Payment Bonds and Insurance Certificates;
• IRS form W-9;
• Proof of current Idaho Public Works License appropriate for the work
identified in the Contract;
• WH-5 Public Works Contract Report;
(Some of these items may have been provided with the completed Bid/Proposal)
If you fail to execute said Agreement and to furnish said documents, within ten (10) business
days from the date of this Notice, said OWNER will be entitled to consider all your rights arising
out of the OWNER'S acceptance of your BID as abandon. The OWNER will be entitled to such
rights as may be granted by law.
216 East Park Street • McCall, Idaho 83638 • (208) 634-5580 • Fax (208) 634-8990
CITY OF MCCALL PUBLIC WORKS
Page 2
Notice of Award
You are required to return an acknowledged copy of this NOTICE OF AWARD to the
OWNER.
Dated this 24th day of February, 2011.
City of McCall
Owner
By:
Title: Project Manager/Engineer
ACCEPTANCE OF NOTICE
Receipt of the above NOTICE OF AWARD is hereby acknowledged by:
iv\pA as � � } �vn,this �' day of (Arc, rc, ! , 2011.
By: Ai(A.
Title: LAD (l�.�
(please sign the Acceptance of Notice and fax to 208-634-4170 or e-mail to
nstewart@mccall. id. us)
216 East Park Street . McCall, Idaho 83638 . (208) 634-5580 . Fax (208) 634-8990
J�rt sLiet5 f
5.02 BID SCHEDULE
Bid Proposal Form
Sundial Stage at Legacy Park
Bid Items
BASIC BID
BID .
ITEM
SPEC. REF.
I nmi DESCRIPTION
QUAD
TITY
UNIT `
UNIT . `
PRICE
TOTAL
AMOUNT
1
201.4.1.C.1
Removal of Obstructions
1
IS
$ Z7_40
$ �
$ ZZed
$ 4tsed
2
202-43.C.1
Excavation (Sundial Stage)
60
SY
3
207.4.1.E.1
Revetment, for Wall Footing
50
CY
$ e�G7
$ iyL —
$
j 33(�j
$ r-Gg0
$
(Ze�
$ G35o
$
I ( W
4
207.4.1F.1
Install Landscape Boulder
18
EA
5
703.4.13.1
Reinforced Concrete Retaining
Wall
10
CY
6
707.4.2.A.1
Concrete Unit Paver Stage
700
SF
p „�
7
707.43.A.1
Re -lay Existing Concrete Unit
Paved Walkway
165
SF
$ f
(e; (.5�
8
801.4.1.A.1
Drain Rock 3-inch Uncrushed
Aerate Base
13
CY
'535
$ I /5(6
&le>
$ 4g4)
9
1001.4.1.A.1
Sediment Control
1
LS
10
2010.4.1.A.1
Mobilization
1
LS
$ /g000
is q
$ /7GC1,
E i$ 9Se
11
2060.4.1.A.1
Granite Paver Sundial
1
LS
12
2060.4.1.B.1
Granite Paver Number
13
EA
C
; ��
13
2070.4.1.A.1
Relocate Electrical Outlets
2
IS
BASE BID (Sum of Bid Items 1 through 14)
Total (Figures) _
$ �C
(�/ Ge,3
Total (Words):
Si,rTy FkAg /NOUsi1/4/40 /14Reig. IJOCLARA
Bid Items
ALTERNATE BID
BID�M'
3PEC4 BEF
ITEMDIAPRIV1
.. o.. •.. • _ .. .,
QUAN
x'I'I'Y'=.
1Nr.
UNIT '
_P.•....
TOO AL
•.AMOUNT'
11A
2060.4.1.C.1
Alternate Sundial (Refer to sheet
1 of Plans and Special Provisions
ff
iti
for Description)
1
LS
i !t 1
i i 4/95
Alternate Bid Total (Sum of Bid Items 1 through 10, plus Items 11A,12, and 13)
Total (Figures) =
66/ 1'9g
Total (Words • .� / / 11
/VT i i ��4U SAM:) rovtt 110/ UJRL D Al t o ery et If/ i
Legacy Park Sundial Reconstruction Project 7
REV. 2/2/11
Form W-9 (Rev. 11-2005) Page 3
Generally, individuals (including sole proprietors) are not
exempt from backup withholding. Corporations are exempt
from backup withholding for certain payments, such as
interest and dividends.
Note. If you are exempt from backup withholding, you
should still complete this form to avoid possible erroneous
backup withholding.
Exempt payees. Backup withholding is not required on any
payments made to the following payees:
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),
2. The United States or any of its agencies or
instrumentalities,
3. A state, the District of Columbia, a possession of the
United States, or any of their political subdivisions or
instrumentalities,
4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup
withholding include:
6. A corporation,
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register
in the United States, the District of Columbia, or a
possession of the United States,
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year
under the Investment Company Act of 1940,
12. A common trust fund operated by a bank under
section 584(a),
13. A financial institution,
14. A middleman known in the investment community as a
nominee or custodian, or
15. A trust exempt from tax under section 664 or
described in section 4947.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt recipients listed above, 1 through 15.
IF the payment is for ...
THEN the payment Is exempt
for...
Interest and dividend payments
All exempt recipients except
for 9
Broker transactions
Exempt recipients 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Barter exchange transactions
and patronage dividends
Exempt recipients 1 through 5
Payments over $600 required
to be reported and direct
sales over $5,000 '
Generally, exempt recipients
1 through 7
'See Form 1099-MISC, Miscellaneous Income, and its instructions.
'However, the following payments made to a corporation (including gross
proceeds paid to an attomey under section 6045(f), even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from
backup withholding: medical and health care payments, attorneys' fees; and
payments for services paid by a federal executive agency.
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,
(Iour TIN is your IRS individual taxpayer identification number
TIN). 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 -owner LLC that is disregarded as an
entity separate from its owner (see Limited liability company
(LLC) on page 2), enter your SSN (or EIN, if you have one). If
the LLC is a corporation, partnership, etc., enter the entity's
EIN.
Note. See the chart on page 4 for further clarification of
name and TIN combinations.
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 Social
Security Administration office or get this form online at
www.socialsecurity.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 ID Numbers under Related Topics. You
can get Forms W-7 and SS-4 from the IRS by visiting
www.irs.gov or by calling 1-800-TAX-FORM
(1-800-829-3676).
If you are asked to complete Form W-9 but do not have a
TIN, 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. Writing "Applied For" means that you have already
applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign
owner must use the appropriate Form W-8.
Form W-9 (Rev. 11-2005) Page 4
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,
and 5 below indicate otherwise.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt recipients, see
Exempt From Backup Withholding on page 2.
Signature requirements. Complete the certification as
indicated in 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 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.
3
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)
3. Custodian account of a minor
(Uniform Gift to Minors Act)
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
5. Sole proprietorship or
single -owner LLC
The individual
The actual owner of the account
or, if combined funds, the first
individual on the account'
The minor 2
The grantor -trustee'
The actual owner'
The owner 3
For this type of account:
Give name and EIN of:
6. Sole proprietorship or
single -owner LLC
7. A valid trust, estate, or
pension trust
8. Corporate or LLC electing
corporate status on Form
8832
9. Association, club, religious,
charitable, educational, or
other tax-exempt organization
10. Partnership or multi -member
LLC
11. A broker or registered
nominee
12. 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 owner 3
Legal entity 4
The corporation
The organization
The partnership
The broker or nominee
The public entity
'List first and circle the name of the person whose number you fumish. If
only one person on a joint account has an SSN, that person's number must
be furnished.
Circle the minor's name and furnish the minor's SSN.
You must show your individual name and you may also enter your business
or "DBA" name on the second name line. You may use either your SSN or
EIN (if you have one). If you are a sole proprietor, IRS encourages you to
use your SSN.
List first and circle the name of the legal 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
regarding partnerships on page 1.
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.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns
with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or
abandonment of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRS
uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this
information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal
and state agencies to enforce federal nontax 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. Payers must generally withhold 28% of taxable
interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.