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HomeMy Public PortalAboutC-21-046 - VIRGINIA CARMELOForm W-9 Request for Taxpayer Give Form to the(Rov.Dex requester.Do notmerAapseear:Osan hatin identification Number and Certification interne.t tha TragsuryIndersslRevenunSevier fr ' |1 Name (as shown Gn your isams tax returm).Marne bs reQuires on this line;do nol leave this lie blank. eh ee becAayrAe\tt [hor\\ 4petd 2 Busnes namudisreqarccd ently name,of different fram above 3 Check epuropriate bux tor teduiid tax ctasesfiention:uct:only ene of the following seven boxes 1 Intions (Codes apply an not indivicisdls:soe oo m mh a a s ==] 5 -_—Sosa -7 =op .i-Inidividdun L|CCarperston [7]$Comoration [|Parton [|Trustisitate stan en pusgn ‘3:7 .:f 2M:ec ingles nuthin fia‘antes ae x ~Exounpt pores code:(if anysBp2L]Limited Latility comparry.Enter the tax claasifiction (C=C corporation,S-S componation,Peourtnursnip)&paye (any aoO :Yamin |Exes ion frorn PATCA nap . 3 =Note.For a angie monsber L1G thar a disregarded,de not coeck LLC;stmck the aparnoriste bex in the line shove far |Exemption from bATCA rapes ngathetaxclasaifieaitinnofthestajlememberownerondeffartav: :es eta==Cy]Ottiar (seve 4 ALORS)&:Apple tr ancouTy,Westar convue tar ONGoSAdetess(nummer,steel,and aot.or nuit no.)Requester:name and address tapianalygrapeae5san,4aiLt*n 4 SU NeW hy Oe Lek |oy pee _:__}w |8 City,ditule,and ZIP code o hery ‘7 (/or Py Vd Meo,£12 Boel 7 Last account mumderdts}here (optical) Fr i Taxpayer Identification Number (TiN).;/Enter your TIN in the aoprapriate box.The:TIN provicied must match the nme given on fine 1 to avoid |_Social socunty numberbackupwithholding.Tor individuals,this is generally your sociat security number (SSN).However,for amaidentdion,sale proprietor,or disregarded entity,see the Part |instructions an page 3.Far otherentities,itis your employer identification number (EIN).If you do not have a number,see How to getaTINonpage3.or Employer identificaton number jNote.1 the account is in more than one name,soe the instructions for line 1 and the chart on page 4 forguidetinesonwhosenumbertoenter, Certification Under panaties of perjury,|certify that: 1 The number shown on this tarsis thy Carract faxpayaer identification number for |am waiting for a number ia be issued to me};and2.fam net subject to backup withholding because:(a)|arm exempt tran backup withholding,or (b)|have not been notified by the intemal Revenue:Service (RS)that |am subject to backup withholding as 4 result of a failure to repor all interest or dimicencis,or (c)the IAS has notified me that |amnelongersubjecttobackupwithholding;and 3.Jama US.cRizen or other US,Peson (defined!below):end 4,The FATCA code(s)entered on this form (if any)indicating thal lam exempt fram FATOA reperting is corract.Cenificatien instructions.You must cross ott item 2 above ff you have beer notified by the IRS thet you are currently subject to backup withholdingbecauseyouhavefailedtoreportallinterestanddividendsonyourtaxretum.For rea!estate iransactons,Rem 2 does aot apply.Far mortgayeinterestpaid,acquisition or abandonrenal of secured property,cancellation of debt,contributions to an indivicual retirement urangement (IRA),andgenerally,payments other than interest ane dividends.you are nat required to sign the certification,but you must provide your correct TIN.See theinstructionsonpage3. Sign Signature of )“cd j ,,.4HereUS.poronh ff Ld wide [gh boy (Gf Date®fe OO Ak General Instructions >*Vor 1098 [heme morgage interest),1098-£{student leas interest),1098-7 (tuiligan}Secbon references are to the Intemal Revenus Code unless otherwise noted.»Fon1099-6 feanceed cult)Future developments,Intonation about developments stecting Farm W-9 (sect *Fann 1099-4 tasquicition or Lent of secured property) 35 legndation enacted atlerwe metearas ith ig at wees.Ing.arretted. Use Form W-S ory tf youarePurposeofForTT}Provide yeu covet TIM, Mf you do mat reduen Form W-9 bo fo bockup withhotding.Gee Wikat ee S.Berson (including a resident alien,te moquranier Wana TIN,vow a Gohl fer cutyescst Skip wiltvietcemy?an page 2. An seiadual ar ectity (Form Wea Tequestien whe tn raquinsd to file ar intermationfelonwiththeIRSmustobtain whet may Ge your social serurit (URN),adeaton taxpayer gentifcsrwasitticationnumber(EIN),ta Teport On an information retum the amount paid taYOu,oF other ames mpoanabk:on an infarmatian rstumn,Esamples of intonationretumsinclude,Sut are not finsited to,the followaricy:2.Certity thet you are not suty:*Porn TOS9-INT fintereat eaned ar preity 3.Coton exmnption froer backup wrhheiding if you are a US.OXEMp!pave,Lfspplicaits,you am aise certifying Y US.person,your allocable shure ofAnypoytnersupmawfromaUS.#or busiiz a3 OO Suubiest to we By signing the tied-car torn,you: 1.Gortify that the TIM you ure giving o&carmel (or you are y1Gbeinsusci,fing for &number tcl to backup withholding,ar *Form 1656-DIY idividenus,incluchsy thase from stocks ar ermal furs) ©Fcert TO8S-MISC ivan:Iypses Of meen,prites,awards,or (PEERS Procaesctg}withholding box on feregn partners’siwire of Stectivuly connecting income,ant®Form 1099-8 Gstock or mutual fund!sales and cenain other transactions by 4.Cechly that FATOA codels)entered on this torn (8 arsy}incc=sting that you are brakers}éxempl from the FATCA reporting*Formn 1065-5 (pr farge 2 foc lurther intorrrielian cormect.See Whial is FATOAroparting?on cde hom revi estate transact) *Poem 109S-K (merctuint cord and third Burty network traractions| Cat,Na.10941 Farm W-S new,12-2014} a aEASON.as City of CarsonASRCae..Vi —<4,\Community Services Department e Service Provider Application :‘Hssgaene 7 fie Oy MosGEES./;AE UNUN-“Dear Applicant, Onbehalf of the City of Carson,I would like to thank youfor taking the time to explore businessopportunitieswiththeCitybyapplyingtoprovideservicesforaneventataCityfacility.As partofourapplicationprocess,you must complete,sign,and return the following forms.Submissionoftheseformsdoesnotguaranteethatyouwillbeprovidedthebusinessopportunityyouseek.Your prompt assistance in submitting the requested documentation to the City staff member listedbelowwillbeappreciatedandwillhelpexpeditetheapplicationprocess.Please send your completed application and attachments directly to the following address: City of Carson Attn:[Event Coordinator’s Name] [Enter Event Coordinator’s address (i.e.,city hall,corporate yard,or specific park address] Email:[Enter event coordinator’s email address] Should you have any questions,please feel free to contact the staff member listed below . Truly, [Name] [Title] 532227.5 CFN qChecklist REPEATSAIOER Before submitting your application packet make sure each of the belowindicateditemshavebeenattachedorcompleted. (FOR COMMUNITY SERVICES OFFICE USE ONLY) ‘Service Provider Application Agreement Invoice for Future Event Date! N A Business License (if applicable)oy gw Proof of Insurance/Certificate of Insurance A Waiver,Release,Hold Harmless,Agreement Not to Sue,Indemnification,and Photo Release A Current Copy of W-9 Form(if not on file already) The date of the Event shall be listed on the Invoice for Future Event Date (IFED).If the Service Provider Application isapproved,then the IFED will be processed as an invoice for services rendered for the Event.No payment will be made untiltheconclusionoftheEvent,at earliest. 532227.5 CFN [Enter Date] [Enter Company Name] [Enter Company Address] [Enter City,State ZIP] Insurance Requirements Dear [Enter Provider’s Name]: Please be advised pursuant to yourdesire to work with the City of Carson,you are required tosubmitthefollowing: v Compliant Certificates of Liability Insurance (to be maintained for the duration of servicesagainstclaimswhichmayarisefromorinconnectionwiththeservices),evidencing the coverage(s)as indicated below. Certificates of insurance,as well as additional insured and waiver of subrogationendorsementsinfavoroftheCity,must be submitted in their entirety before any servicesareprovidedortheeventtakesplace.Failure to submit such required forms shall be causeforCityofCarsontorejectorterminateanyserviceproviderapplicationagreement. The City of Carsonreserves the right to modify these requirements based on the nature of therisk,prior events,insurance coverage,or other special requirements. MINIMUM SCOPE AND LIMIT OF INSURANCE General Liability Insurance:Coverage shall be at least as broad as Insurance Services Form CG00OIcoveringCGLonan“occurrence”basis,including property damage,bodily injury andpersonal&advertising injury with limits no less than $1,000,000 per occurrence and $2,000,000 aggregate. Additional Insured Status The City of Carson,and its elected and appointed officials,employees,volunteers and agents,aretobecoveredasadditionalinsuredswithrespecttoliabilityarisingoutoftheirworkoroperationsperformedatoronbehalfoftheCity-sponsored event including materials,parts,or equipmentfurnishedinconnectionwiththeevent. 532227.5 CFN af c s . City of CarsonCommunityServicesDepartmentServiceProviderApplication Agreement Checkaxe (st affuse): &.Carson Event Center Human Services I Recreation ___Transportationay}Event:by -\y Gece _Event Location:__Event Daie: nb Ns Tata Nameof Service Provider:|s /WEAN HAL TF Business Form/Entity Type Qf individual,sole Proaprictorship.corporation.or limited lability J type (I |I scompany,Specify here}: yew 7j Susiness Form/Entity Type (iorother,specify here): Fgeneral partnership.limited parmership,limited hability partnership, Business Entity State ofIncorporation (if applicable) Type of Service: my \.i ic os t Lf ~;i ae ‘ Contact Person:Vitelt hace (ete wielo _Phone #:(7]LY )_44 {-{S JO _wl Emer.Contact;Phone #:(4)fn Ie qo cars 7c fe uel eae .osBillingAddress:|15 |brede wai re yo C shh etNunuber Sueetfst.+ON e&ays—triahein Ca be §O __8Ciy‘Stahe ZipProofofInsurance(cirele oney?Yes (Na} Ifno,would you like to purchase special event insurance through the City (circle oney?Yes ‘NOSpecialInstructions/Notes: 522227.5 CEN If Service Provider wishes to request any speciat accommodation needed tofacilitate provision ofthe services,please identifyit here or contact the staff member referenced on page |ofthis application; aw ieing ,yoow TD OF Wahioe .Werte Total Service Fee = NOTE:If service provider is unable to provide the services as proposed or requested or the City of Carson cancels the service for any reason,the associated fees will not be paid. [remainder of page intentionallyleft blank} Further Terms of Service Provider Application Agreement: The undersigned signatory of Service Provider (Service Provider being the above-referenced person or entity seeking to provide services at the above-referenced event,including all its officers,agents, employees and volunteers)hereby represents and warrants that he or she is duly authorized by Service Provider to execute and deliverthis application on behalf of Service Provider,and that by so executing this application,and in consideration for the City’s review of this application,Service Provider is bound by these terms. Service Provider understands and agrees to comply with the City’s “Service Provider Rules & Regulations,”whichare set forth below and incorporated herein by this reference. Service Provider agrees to indemnify and release City in connection with its proposed services in accordance with the “Waiver,Release,Hold Harmless,Agreement Not to Sue,Indemnification,and Photo Release”submitted concurrently herewith. Service Provider agrees to maintain all required insurance coverages and comply withall associated insurance requirements as set forth on the above “Insurance Requirements”page,whichis incorporated herein by reference.Service Provideragrees that all required policies shall contain,or be endorsed to contain,an agreement by Service Provider to waive all rights of subrogation and contribution against the City,its elected or appointed officers,officials,employees and agents,forall losses and liabilities paid underthe terms of any policy which arise from the activities or operations of,or the services performed by,Service Provider,regardless of any prior,concurrent,or subsequent non-active negligence by the City. In the event there is more than one person or entity named in this Service Provider Application Agreement as the Service Provider,then all obligations,liabilities,covenants and conditions hereunder shall be joint and several. This Service Provider Application Agreement,unless and until accepted,approved,and executed by the City Manageror designee,is only an application for provision of services to City,and does not constitute an approval orauthorization for Service Provider to perform orprovide any service to City. Neither Service Provider nor any of its agents or employees shall be deemed agents or employees of the City,nor a member of a joint enterprise with the City.Neither Service Provider norany of its agents or employees shall at any time or in any manner represent that Service Provider or any of its agents or employees are agents or employees of City,or that it is a memberofa joint enterprise with City.Subject to the requirements of this Service Provider Application Agreement,neither the City nor any of its employees shall have any control over the manner,mode or means by which Service Provider,its agents or employees,perform the services set forth herein. In the event that part of this Agreement is declared invalid or unenforceable by a valid judgment or decree of a court of competent jurisdiction,such invalidity or unenforceability shall not affect any of 532227.5 CFN YatCe ~- - ] the remaining portions of this Agreement which are hereby declared as severable and shall beinterpretedtocarryouttheintentofthepartieshereunder. Service Provider acknowledges that the Citty of Carson’s consideration of Service Provider'sapplicationtoprovidetheabove-referenced servicesis on the express condition that Service Providerrepresentsandwarrantsthatitisandwillbeincompliancewilhallapplicablerestrictionsontheuseofintellectualproperiy,including copyright laws,in connection with the services proposed to beprovided.Service Provider shall indemnify,defend,and hold harmless the C ity against any penalties,claims,or liabilities arising from or in connection with Service Provider’s noncompliance with same. The undersigned,on behalf of Service Provider,agrees thal Service Provider seeks andis willingtoprovidetheabove-referenced service(s)on the date and timeof the above-referenced event. This Service Provider Application Agreement has been executedon the dates written below. APPLICATION SUBMISSION (wet signature required;no electronic signatures): i> SERVICE PROVIDER:V/ryvat aia (apnelo Signatur:of Senic:Provider's Authanzed Represenuutive ox >(>.MP yWee \oO _ ice Provider's Authoracad Represcutative (space belowthis line for City use anly} APPLICATION APPROVAL: CITY OF Sigaature ofCty Mangper ar Destenge Date Service Provider Rules &Regulations 1.SERVICE PROVIDER APPLICATION:Uponacceptance,approval,and execution ofa service provider application by the City of Carson (‘City’),these rules and provisions shall become binding and a part of the Service Provider Application Agreement betweenthe applicant (being the entity providing a service to City as specified in the service provider application),including its officers,employees,agents and volunteers (“Provider”),on the one hand,and the City,on the other hand.Any additions and amendments thereto that may be established or put into effect by the City, and provided in writing to the Provider,shall also become binding and a part of the Service Provider Application Agreement. 2.PAYMENT/CANCELLATION:If the Provider is unable to perform or cannot provide the services as requested,or the City cancels the service for any reason,the associated fees for service will not be paid. 3.CANCELLATION:No refunds will be given unless the subject event is cancelled by the City’s Community Services Department.Applications may be denied or events cancelled in favorof City programs. 4.PROPERTY LOSS OR DAMAGES:The Cityis not responsible for any damage.to,loss or theft of the Provider’s property,or that of Provider’s agents,employees or invitees. 5.CHARACTER OF ENTERTAINMENT:The Provider shall observe,obey and comply with all applicable local,state and federal laws,and all applicable policies,rules,regulations and terms and conditions governing use of City facilities.The Provider will forfcit all rents or other fees paid if ejected from premises for violations of same.Ejection shall not release Provider from any obligations for the payment of rents or other fees not yet paid under such permit or additionally incurred.The policy of the City is to serve the public in the best possible manner.The Provider shall at all times cooperate to this end. The policies,rules,regulations and conditions governing use of City facilities are subject to change without notice to Provider unless the change affects a permit already issued to Provider. Provider shall be solely responsible for the orderly conduct of all persons using the premises by its invitation,either expressed or implied,during all times covered by the Service Provider Application Agreement.The City reserves the right to eject or cause to be ejected from the premises any personorpersons due to unlawful conduct. 6.RESPONSIBILITY:The Provider shall provide all material,equipment,and personnel necessary for provisionof the service described in this agreement. 7.MOVE-IN/MOVE-OUT:Move-into the event area will be set for each venue.Unless otherwise stated,Providerwill be required to keep its area fully set up and manned until the event is officially over.Please note that these times are subject to change. 8.SAFETY:Standing onchairs,tables or other rental equipment is prohibited.This equipment is not engineered to support your weight.The City of Carson,its employees,agents,or officers will not be responsible for injuries or falls caused by the improper use of furniture.Please assist in our efforts to provide a SAFE WORKING ENVIRONMENT. 532227.5 CFN 9.VOLUME/LIGHT CONTROL:The City reserves the right to regulate the volume or intensityofanyandallnoiseorlightgeneratingmechanisms(including,but not limited to,loudspeakers, radios,television sets,musical instruments,entertainers,or blinking or flashing lights)in thereasonablejudgmentoftheCity. 10.FLAMMABLE MATERIALS -All decorations,props and electrical equipment must be fireproof orof fire retardant materials,must meet City requirements and are subject to removal. Candles and otheropenflame devices will not be permitted except as authorized onthis agreement; subject to Fire Department regulations. 11.COPYRIGHT INFORMATION:Provider is responsible for licensing fees as required by law. Provider may be subject to legal action for the use,display or sale of any item using anycopyrightedand/or trademarked name or logo which has not been specifically authorized underlicensefromthetrademarkholder. 12.PERMITS AND LICENSE:Provider shall procure at its own cost and expense all the required licenses and permits applicable to Provider’s use or activity . 13.OBLIGATION FOR CLEANLINESS:Provider agrees that the facility and any other surrounding City property (including parking lots)used by the Provider must be left in a clean andorderlycondition(equal to or better than the conditionexisting prior to the event).If additional maintenance is required,other than the normal cleaning process,the Provider will be charged additional fees based onthe cost of such maintenance. 14.DISPUTES:All points not covered by the Service Provider Rules &Regulations arc subject to the decision of the appropriate City representative. 15.FLOOR MANAGEMENT:The City will appoint a Floor Manager who is authorized to enforce these rules and regulations. 16.SPACE ASSIGNMENT:Event space is assigned to providers at the sole discretion of the City. Concerns regarding competitive or specific types of providers should be communicated to the City at the time of application. 17.RULE CHANGES:The City reserves the right to make reasonable changes to the foregoingrules,event hours and move-in/move-out arrangements at any time without notice to Provider, unless the change affects a permit already issued to Provider. 532227.5 CFN 10 Waiver,Release,Hold Harmless,Agreement Not fo Suc,Indemnification,and Photo Releasei,Virginia Carmédlo/-_(“individual”)[on behalf ofAXWeijeta(“Service Provider”),and as a bona fide agent of Service Provider duly auth¥rized fo execute this Waiver,Release,Hold Harmless,Agreement Not to Sue and Indemmificationagement(“Agreement”)on behalf of Service Provider}(individual and Service Provider heretnafiercollectivelyreferredtoag“Si snatury,”and the term “Signatory”includes Service Provider's officers,afficials, cinployees,uvents and volunteers},suck acceptance by the City of Carson of an application to provide services%&2 ds p x 4 iinvat_Ci 0-|(Aigo =CLvent™)on 4 Jao 24 Dare”).J Signatoryunderstands that accidents and injuries can anise out ofthe Event;knowing the risks,nevertheless,andinconsiderationaftheacceptanceofanapplication(a provide a service at the Event on the Date,Signatoryherebywaives,releases and discharges any and all claims for damages for death,personal injury.OF propertydamagewhichSignatorymayhave,or which hereafter accrueto Signatory,against the C ity of Carson,its electedandappointedofficers,officials,employees,agents and volunteers (collecuvely “City”),and from and againstanyandallhabilityarisingoutoforconnectedinanywaywithSignatory's participation in or presence at theEvent,even though that lability may arise oul of negligeace or carelessness on the part of City.[tis furtherunderstoodandagreedthatthisAgreement1stobebindingonSignatory’s heirs and assigns, Signatory hereby grants Cirythe right to phatoyraph or yideo-record Signatory during or in connection wath the Event,and to use Signatory’s photographed or video-recorded likeness,and any image,silhouette,orTeproductionofthevoiceorappearanceofSignatorytakenduringorinconnectionwiththeEvent(“Likeness”),for any purpose,including publicity and promotivn of Cityand its events,and creation or praduction of materialsinanyformforsuchpurcpese,with ne claim of entitlement to any license fee or royalty of any kind from City.gnatory hereby waives any right to the intellectual property of Signatory’s Likeness.The nights granted by+ Si Signatory hereunder shatl nat expire. Signatory further 2erces to indemnify,defend and hold harmless City from and against any and all claims,liabilties,losses,damuges,expenses,and costs (including without limitation costs and fees of itieatian}of everynature(including,but not limited to,property damage,bodily injury,or death),whether imposed by law orotherwise,sustained or alleged to be sustained byanyperson or entity (whether they be members ofthe publicvisitingtheEvent,employces of the City,other service providers at the Event,or oth erwisc},occurring at,arisin éfram,ar connected with Signatory’s preparation or performance of services at the Event,Signatory’s actions,inactions,or use of facilities at the Event,or any equipment,machineryor items displayed or used by theSignatoryatorfortheEvent.excepl for such claim,liability,loss,damage,expense,or cast which was causedbythesolenegheenceorwillfulmisconduetoftheCity,:Stree ,J By signing helaw,I acknowledge and represent that I have read zad understand the above,and that [voluntarily aeree to iis terms. Simed:tt rfol L Lit 3 iz NAME:—\/LP oi dehy GA St {ORGANIZATION:—Xp 0 wre toc § 532227.5 CEN