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HomeMy Public PortalAboutC-21-140 - SHANE A. SELLORIA - LARRY ITLIONG - SPA CITY OF CARSON — All fields are required to be completelyfilled out.if not applicable,enter N/A. INTERNAL CONTRACT ROUTING SLIP FROM:JOSE EMMANUEL TINGSON DOCUMENT TYPE:SERVICE PROVIDER EXT.310-830-9991 N/A APPROVAL DATE:N/A ITEM NO:N/A VENDOR NAME:SHANE SELLORIA SERVICES/PRODUCT:ENTERTAINMENT TERM OF CONTRACT:10/21/2021 tHrougn 10/24/2021 AMOUNT OF CONTRACT:N/A SINGLE-SIDED DOCUMENT?[XlYES PAGE COUNT: DEPT:_CS/RECREATION ATTORNEY ASSIGNED:N/A PRE-APPROVAL/PRE-CITY SIGNATURES CHECKLIST ASSISTING STAFF ACTION REQUIRED |COMPLETION (INITIALS)_ DIRECTOR Confirm approval to proceed. CONTRACT OFFICER Confirm funds are budgeted and/or available. CONTRACT OFFICER Preparation of specifications.: This includes coordinating with Risk Management on the Insurance/Bond requirements. PURCHASING Advertise bids,compliance with bid requirements;including posting on City’s websi t N/A *RFP/RFQ must include form contract. PURCHASING OR Evaluate bids/proposals and determine recommended bidder(s).N/A CONTRACT OFFICER CONTRACT OFFICER Complete contract negotiations/finalize contract(including atta hm N/A &CITY ATTORNEY Attorney's Office. CONTRACT OFFICER Present appropriate contract form to the recommended vend :LO *Verify correct agencytitles/corps.are listed.(ie:City Council-yor vs.CRA-Chairman) CONTRACT OFFICER Verify compliance with business license requirements,obtain:3.original signatures of N/A vendor,and request W-9 (once received,submit:w-9 topurchasing). *Signatures must be notarized for every original*_ CONTRACT OFFICER Verify corporate status,state of Incorporationandd Principles.N/A &RISK MANAGEMENT CONTRACT OFFICER Request insurance documents for approval with Risk Management for all contracts. Verify approval of insurance requirements with Risk Management. *Communication through e-mail is preferred..Please provide the written agreement,certificate of insurance as well as all endorsement forms. CONTRACT OFFICER Provide W-9 to Purchasi n gendaThursday if contract is on the upcoming agenda. *Non-Council items:pro ‘9 Purchasing on date submitted to City Clerk’s Office. PURCHASING OR Present Department's,recs mmendation to legislative body to award/approve contract,if N/A CONTRACT OFFICER applicable.Os ee POST-APPROVAL/POST-VENDOR SIGNATURES CHECKLIST :CONTRACT OFFICER Collect’@nd assembleinsurance (initialed by Risk Management),*Certificate of Insurance with @ endorsement miust be attached to be processed;even on amendments* CONTRACT OFFICER Collect’and assemble bond requirements and forms.*Public Works contracts MUST attach N/A verification‘the’bond has been executed by an admitted surety insurer* CONTRACT OFFICER ansmit 2 complete original sets with this routing slip to the City Clerk’s Office for further N/A **Note any special services needed,including all prior Contracts,Amendments or Awards. CITY CLERK Verify approval/routing slip completion;obtain signatures:City Attorney,City official,and N/A City Clerk. CITY CLERK Provides electronic copy and original of executed contract to Contract Officer,City Clerk’s N/A Office retains 1 original and enters into Laserfiche PUBLIC WORKS Tyler Entry and Release for City Clerk approval N/A CITY CLERK Tyler approval;email staff upon completion N/A CONTRACT OFFICER Create a requisition in Tyler for Purchasing to issue a Purchase Order.S &PURCHASING *Vendor is not to proceed with work until the Purchase Order is approved. CONTRACT OFFICER Provide Notice to Proceed to vendor.N/A CONTRACT OFFICER Tickler contract expiration and insurance expiration N/A FINANCE Process contract purchase order and provide copies to department.N/A CONTRACT OFFICER Process progress payments.@ CONTRACT OFFICER Process contract completion forms.N/A *Notice of Completion to City Clerk’s Office CHOOSE ONE FOR INTERNAL SIGNATURE PROCESSING: []Route for City Attorney>Mayor or Chair WITHOUT NOTARY>Clerk L]Route for City Attorney>City Manager WITHOUT NOTARY>Clerk C]Route for City Attorney>Mayor or Chair WITH NOTARY>Clerk []Route for City Attorney>City Manager WITH NOTARY>Clerk XX Other:INPUTIN TYLER SPECIAL COMMENTS/INSTRUCTIONS/REQUESTS: STVILINI aHotuasv][_] SIVLLINT “ON LOVYLNOS >SIVILINI ——.5 ois-1sodL_]ois-3ud L_] AINO 3Sf)3914540 S,1Y31D ALID YO4 AINO JSP)3d1ddO S,NYATD ALID YOY XINO 3Sf}SADIANSS TVHLN3)YO4 Before submitting your application packet makesure each of the belowindicateditemshavebeenattachedorcompleted.(FOR COMMUNITY SERVICES OFFICE USE ONLY) ae Service Provider Application Agreement SL.Invoice for Future Event Date! N/A.Business License (if applicable) hte Proof of Insurance/Certificate of Insurance “a Waiver,Release,Hold Harmless,Agreement Not toSue,Indemnification,and Photo Release “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 madeuntiltheconclusionoftheEvent,at earliest. 532227.5 CFN AS OF 1-22-2020 (Date) (Company) (Company Address) (City,State ZIP) Insurance Requirements ra f .Dear Chane.Se}|onc ;(Enter Provider’s Name) Please be advised pursuantto yourdesire to work with the City of Carson,you are required tosubmitthefollowing: ~Compliant Certificates of Liability Insurance (to be maintained for the duration of servicesagainstclaimswhichmayarisefromorinconnectionwiththeservices),evidencing thecoverage(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 Carson reserves the right to modify these requirements based on the nature of thetisk,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 FormCG0001coveringCGLonan“occurrence”basis,including property damage,bodily injuryandpersonal&advertising injury with limits no less than $1,000,000 per occurrence and$2,000,000 aggregate. Additional Insured StatusTheCityofCarson,and its elected and appointedofficials,employees,volunteers and agents,aretobecoveredasadditionalinsuredswithrespecttoliabilityarisingoutoftheirworkoroperationsperformedatoronbehalfoftheCity-sponsored event including materials,parts,orequipmentfurnishedinconnectionwiththeevent. 532227.5 CFN AS OF 1-22-2020 4 532227.5 CFN AS OF 1-22-2020 City of Carson Community Services Department Service Provider Application Agreement Check one (staff use): ___ Carson Event Center___ Human Services ___ Recreation ___ Transportation Event:___________________________ Event Location: _______________ Event Date:__________ Name of Service Provider: ___________________________________________________________ Business Form/Entity Type (if individual, sole proprietorship, corporation, or limited liability company, specify here): _________________________________________________________________________________ Business Form/Entity Type (if general partnership, limited partnership, limited liability partnership, or other, specify here): _________________________________________________________________________________ Business Entity State of Incorporation (if applicable): ___________________ Type of Service: ___________________________________________________________________ Contact Person: ____________________________ Phone #: (____) _______________________ Emer. Contact: ____________________________ Phone #: (____) _______________________ Billing Address: ___________________________________________________________________ Number Street ___________________________________________________________________ City State ZIP Proof of Insurance (check one)? ___Yes ___No If no, would you like to purchase special event insurance through the City (check one)? __Yes __No Special Instructions / Notes: __________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ If Service Provider wishes to request any special accommodation neededto facilitate provision of theservices,please identify it here or contact the staff memberreferenced on Page |of this application: Total Service Fee $1 00.00 NOTE:If service provider is unable to providethe services as proposedor requestedor the CityofCarsoncancelstheserviceforanyreason,the associated fees will not be paid. [remainderofpage intentionally left blank] 532227.5 CFN AS OF 1-22-2020 Further Terms of Service Provider Application Agreement: The undersigned signatory of Service Provider (Service Provider being the above-referenced personorentityseekingtoprovideservicesattheabove-referenced event,includingall its officers,agents,employees and volunteers)hereby represents and warrants that he or she is duly authorized byServiceProvidertoexecuteanddeliverthisapplicationonbehalfofServiceProvider,and that by soexecutingthisapplication,and in consideration for the City’s review of this application,ServiceProviderisboundbytheseterms. Service Provider understands and agrees to comply with the City’s “Service Provider Rules &Regulations,”which are set forth below and incorporated herein by this reference. Service Provider agrees to indemnify andrelease City in connection with its proposed services inaccordancewiththe“Waiver,Release,Hold Harmless,Agreement Not to Sue,Indemnification,andPhotoRelease”submitted concurrently herewith. Service Provider agrees to maintain all required insurance coverages and comply with all associatedinsurance‘requirements as set forth on the above “Insurance Requirements”page,which isincorporatedhereinbyreference.Service Provider agrees that all required policies shall contain,orbeendorsedtocontain,an agreement by Service Provider to waiveall rights of subrogation andcontributionagainsttheCity,its elected or appointed officers,officials,employees and agents,foralllossesandliabilitiespaidunderthetermsofanypolicywhicharisefromtheactivitiesoroperationsof,or the services performed by,Service Provider,regardless of any prior,concurrent,or subsequentnon-active negligence by the City. In the event there is more than one person or entity named in this Service Provider ApplicationAgreementastheServiceProvider,then all obligations,liabilities,covenants and conditionshereundershallbejointandseveral. This Service Provider Application Agreement,unless and until accepted,approved,and executed bytheCityManagerordesignee,is only an application for provision of services to City,and does notconstituteanapprovalorauthorizationforServiceProvidertoperformorprovideanyservicetoCity. Neither Service Provider nor any of its agents or employees shall be deemed agents or employees oftheCity,nor a memberof a joint enterprise with the City.Neither Service Provider nor any of itsagentsoremployeesshallatanytimeorinanymannerrepresentthatServiceProvideroranyofitsagentsoremployeesareagentsoremployeesofCity,or thatit is a member of a joint enterprise withCity.Subject to the requirements of this Service Provider Application Agreement,neither the Citynoranyofitsemployeesshallhaveanycontroloverthemanner,mode or means by which ServiceProvider,its agents or employees,perform the services set forth herein. In the event that part of this Agreementis declared invalid or unenforceable by a valid judgment ordecreeofacourtofcompetentjurisdiction,such invalidity or unenforceability shall not affect any of 532227,5 CFN AS OF 1-22-2020 the remaining portions of this Agreement which are hereby declared as severable and shall beinterpretedtocarryouttheintentofthepartieshereunder. Service Provider acknowledges that the City of Carson’s consideration of Service Provider'sapplicationtoprovidetheabove-referenced services is on the express condition that Service Providerrepresentsandwarrantsthatitisandwillbeincompliancewithallapplicablerestrictionsontheuseofintellectualproperty,including copyright laws,in connection with the services proposed to beprovided.Service Provider shall indemnify,defend,and hold harmless the City 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 that Service Frovider seeks and is willing toprovidetheabove-referenced service(s)on the date and time of the above-referenced event. This Service Provider Application Agreement has been executed on the dates written below. APPLICATION SUBMISSION (set signature required:no electronic signatures):shane A SelloriaSERVICEPROVIDER: (Signatur of Service Provider's Aud:orzed Representative)(Dare) EVELYN C.Se LUNIA (Printed Name of Service Providec's Authocized Representative) (Space belowthis Jine for City use only) APPLICATION APPROVAL: CITY OF CARSON Y =)L (Signature of City Manager or Designee) ee nee 4322275 CEN AS OF 1-22-2020 Service Provider Rules &Regulations 1.SERVICE PROVIDER APPLICATION:Upon acceptance,approval,and execution of aserviceproviderapplicationbytheCityofCarson(“City”),these rules and provisions shallbecomebindingandapartoftheServiceProviderApplicationAgreementbetweentheapplicant(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 theCity,on the other hand.Any additions and amendments thereto that maybe established or putintoeffectbytheCity,and provided in writing to the Provider,shall also become binding and apartoftheServiceProviderApplicationAgreement. 2.PAYMENT/CANCELLATION:If the Provider is unable to perform or cannot provide theservicesasrequested,or the City cancels the service for any reason,the associated fees forservicewillnotbepaid. 3.CANCELLATION:No refunds will be given unless the subject event is cancelled by theCity’s Community Services Department.Applications may be denied or events cancelled infavorofCityprograms. 4.PROPERTY LOSS OR DAMAGES:TheCity is not responsible for any damage to,loss ortheftoftheProvider’s property,or that of Provider’s agents,employees or invitees. 5.CHARACTER OF ENTERTAINMENT:The Provider shall observe,obey and comply withallapplicablelocal,state and federal laws,and all applicable policies,rules,regulations andtermsandconditionsgoverninguseofCityfacilities.The Provider will forfeit all rents or otherfeespaidifejectedfrompremisesforviolationsofsame.Ejection shall not release Providerfromanyobligationsforthepaymentofrentsorotherfeesnotyetpaidundersuchpermitoradditionallyincurred.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 tochangewithoutnoticetoProviderunlessthechangeaffectsapermitalreadyissuedtoProvider. Provider shall be solely responsible for the orderly conduct of all persons using the premises byitsinvitation,either expressed or implied,during all times covered by the Service ProviderApplicationAgreement.The City reserves the right to eject or cause to be ejected from thepremisesanypersonorpersonsduetounlawfulconduct. 6.RESPONSIBILITY:The Provider shall provide all material,equipment,and personnelnecessaryforprovisionoftheservicedescribedinthisagreement. 7.MOVE-IN/MOVE-OUT:Move-in to the event area will be set for each venue.Unlessotherwisestated,Provider will be required to keep its area fully set up and manned until theeventisofficiallyover.Please note that these times are subject to change. 8.SAFETY:Standingonchairs,tables or other rental equipmentis prohibited.This equipmentisnotengineeredtosupportyourweight.The City of Carson,its employees,agents,or officers willnotberesponsibleforinjuriesorfallscausedbytheimproperuseoffurniture.Please assist inoureffortstoprovideaSAFEWORKINGENVIRONMENT. 532227.5 CFN AS OF 1-22-2020 9.VOLUME/LIGHT CONTROL:The City reserves the right to regulate the volume or intensityofanyandallnoiseorlightgeneratingmechanisms(including,but notlimited to,loudspeakers,radios,television sets,musical instruments,entertainers,or blinking or flashing lights)in thereasonablejudgmentoftheCity. 10.FLAMMABLE MATERIALS -—All decorations,props andelectrical equipment must befireprooforoffireretardantmaterials,must meet City requirements and are subject to removal.Candles and other open flame devices will not be permitted except as authorized on thisagreement;subject to Fire Department regulations. 11.COPYRIGHT INFORMATION:Provideris responsible for licensing fees as required bylaw.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 therequiredlicensesandpermitsapplicabletoProvider’s use or activity . 13.OBLIGATION FOR CLEANLINESS:Provider agrees that the facility and any othersurroundingCityproperty(including parking lots)used by the Provider must be left in a cleanandorderlycondition(equal to or better than the condition existing prior to the event).Ifadditionalmaintenanceisrequired,other than the normal cleaning process,the Provider will bechargedadditionalfeesbasedonthecostofsuchmaintenance. 14.DISPUTES:All points not covered by the Service Provider Rules &Regulations are subjecttothedecisionoftheappropriateCityrepresentative. 15.FLOOR MANAGEMENT:The City will appoint a Floor Manager who is authorized toenforcetheserulesandregulations. 16.SPACE ASSIGNMENT:Event spaceis assigned to providers at the sole discretion of theCity.Concerns regarding competitive or specific types of providers should be communicated totheCityatthetimeofapplication. 17,RULE CHANGES:The City reservesthe right to make reasonable changesto 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 AS OF 1-22-2020 10 Waiver,Release,Hold Harmless,Agreement Not to Suc,Indemnification,and Photo Release 1,Evelyn Selioria,,(“individual [on behalf ofShaneASelloria__“Service Provider”),and as a bona fide agent of Service ProviderdulyauthorizedtoexecutethisWaiver,Release,Hold Harmless,Agreement Not to Sue and Indemnificationagreement(“Agreement”)on behalf of Service Provider){individual and Service Provider hereinaftercollectivelyreferredtoas“Signatory,and the tern “Signatory”Includes Service Provider's officers,officials,employees,ageits and volunteers),seek acceptance by the City of Carson of an application to provide servicesInvatLarryIdiang(“Evant)on Octoder 23,2022 (“Date”), Signatory understands that accidents and Injuries can arise out of the Event:knowing the risks,nevertheless,and in consideration of the acceptance of an application to provide a service at the Event on the Date,Signatory hereby waives,releases and discharges anyandall claims for damages for death,personal Injury,orpropertydamagewhichSignatorymayhave,or which hereafter accrue to Signatory,against the Ciey pfCarson,its clected and appointed officers,officials,employees,agents and volunteers (collectively "City”),and from and against any and all liability arising out of or connected in any way with Signatory's participationinorpresenceattheEvent,even though that Hability may arise out of negligence or carelessness on the part ofCity,It is further understood and agreed thatthis Agreementis to be binding on Signatory’s heirs and assigns. Signatary hereby grants City the right to photograph or video-record Signatory during or in connection withtheEvent,and to use Signatory's photographed or video-recorded likeness,and any image,silhouette,orteproductionofthevoiceorappearanceofSignatorytakenduringorinconnectionwiththeEvent(“Likeness”),for any purpose,including publicity and promotion of City and its events,and creation orproductionofmaterialsinanyformforsuchpurpose,with no claim of entitlement te any Hcense fee or royaltyofanykindfromCity.Signatory hereby waives any right to the intellectual propertyof Signatory’s Likeness,The rights granted by Signatory hereunder shall not expire, Signatory further agrees to indemnify,defend and hotd harmless City from and against any and all claims,Habilities,losses,damages,expenses,dnd costs (including without Umltation costs and fees of ugation)ofeverynature(including,but not Limited to,property damage,bodily injury,or death),whether imposed by laworotherwise,sustained or alleged to be sustained by any person or entity (whether they be members of thepublicvisitingtheEvent,employeesof the Clty,other service providers at the Event,or otherwise),occurringat,arising ftom,or connected with Signatory’s preparation ar performance of services at the Event,Signatory’sactions,inactions,or use of facilities at the Event,or any equipment,machinery or items displayed or used bytheSignatoryatorfortheEvent,except for such claim,liability,loss,damage,expense,or cast which wascausedbythesolenegligenceorwillfulmisconductoftheCity, Bysigning below,1 acknowledge and represent that I have read and understand the above,and that Ivoluntarilyagreetoitsterms, Signed: Ook then (rrsjfex NAME:Evelyn Selloria ORGANIZATION: Date:10/1 aia 532227,5 CFN AS OF 1-22-2020 Form W-9 (Rav.October 2018) Dépactmert of the TreasInternalRevenuaSonica 9 ohare ;S alori'g 2 Business namefdigteqarded entity name,1 different irom above Request for Taxpayer Identification Number and Certification ®Go to wiw.irs.gov/FormW9 for instructions and the latest Information. atiown gn your mR tux retum}.Nama le ot on this ine:do net leave this line blank Give Form to the requester.Do not send to the IRS. following seven boxes. Ginigle-mambas LLO []Other teee instructions}> rncivicduatisote proprator or Oo ©Corperation C 3 Carperation (J Partnership al Trustestale [1]Limited linbilty company.Enter the tax clausifioution (CHO corporation,SwS corporation,PePartership)Note:Check the appropriate box in ihe line above for the tax classification af the single-mamber ewnar,Do not oheck | Exemption fram FATCA reportingLLGIFthoLLGIsclassitiedamasinglememberLLCthatisdisragardedfromtheownerunisestheownereftheLLGJaanotherLLCthetlsnotdlaregardedfromtheownerforU.S.federal tax purposes.Othanvlss,#singla-mambor LLC thatiscigragantedfromtheownershodcheckthaappropdateboxforthetaxclassificationoftaoumar. 3%Chock appropetate box for federal (ax classifleation of the ptrson whess nama ls ontored on line 1,Check only one of tha | 4 Exemptlone (coder apply ony tocertainentifes,#01 ndividuals:sae Inetruntions on page 3}: Exampt payee cade af any] code (if any) Pepiea 10 ececurny main isioad cut 40 O54 Pr i n t or ty p e . Se e Sp e c i f i c In s t r u c t i o n s on pa g e 3. 5 Address (number,street,and apt.or suite no.)See Instructions,Requestername and addreas (aptional}lobe Chi'cagg Aves 6 City,state and ZIP code ~Bellflower A 406 7 Ust aceaunt numbers}have foptionsl} Taxpayer Identification Number (TIN) Enter your TIN In the appropriate box.The TIN provided must match the name given on lina 4 to avold Soci]security number —|backup withholding,Forindividuals,this is ganarally your soclal security number (SSN).However,far a rTresidentalien,sole proprietor,or disregarded entity,see the instructions for Part |,later.For other G 216]-(p |~l6 0 2 7entitles,it Is -your employer identification number (EIN).H yau do not have a qumber,sea How to get aTIN,later. Note:If the account is in mare tnan ene name,sec the Instructions for line 1.Also see What Name and Lempioy iNumberTo Give the Requester for guidelines on whose number to enter, ieee |Gertification Under penalties of perjury,|certify that: 1.The number shown on this form [s rey correct taxpayer Identification number for |ann warting for a number to be issued to me}and2.lam not subject to backup withholding because;fa)|am exempt Irom backup withholding,or (b)I have not been notified by tha Internal RevenueService(IRS)that |am subject to backup withholding as a result of a fallure to report all Interest or dividands,or (¢)tha IRS has notified mea that {amnolongasubjecttobackupwithholding:and ' a.lama U.S.citizen or other U.S,parson (defined below}:and 4,The FATCA code(s)entered on this form (lf any}indicating that |ami exempl trom FATCA reporting is correct. Certification instructions,Yau musi cross out item 2 above If you have been notified by tha IRS that you are currently subjact tp backup withholding becauseyouhavefailedtoreportallintarastanddividendsonyourlexrelum,For real estata transactions,item 2 dos nol apply.For mortgage interest pald,acquisition of abandonment of secured property,cancellation of debt,contributions to an individual retiramect asrangament (|AA),and generally,paymentsotherthanimerastanddividends,yous not required to sign the certification,but you must provide your oanact TIN.See the instructions for Part Il,later, Sign Signature of Pret Dalek [©12.YA Here |US.person General Instructions ‘tunes)1099-Dl¥(dividends,including those from stocks or mutual oe references are to the Intemal Revenue Code unless albanvisea *og ee (various typss al Invama,prizes,awards,or gross .proceedsFuturedevelopments,For the latest information about davelogmentsrelatedtoFormW-9 and its instructions,such as legislation enacted after they were published,go lo www.ire.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requestar}who Is required to file aninfermationreturnwiththe[AS must obtain your correct taxpayeridentificationnumber(TIN)which may be your scclal security number(SSN),Individual taxpayer Kentificatlon number (ITIN},adoptionfaxpayerIdentificationnumbar(ATIN),or annplayer 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 ratums Include,but are not ilmited to,the following. «Form 1099-INT (intarest earned or pald) Cat.No.10231X «Form 1099-8 (stock or mutual fund sales and certain othertransactionsbybrokers} *Form 1089-S {proceeds from real estate tansactions} *Form 1089-K (merchant eard and third partly notwork transactions) *Form 1086 (home mortgage Interest},1098-E (student loan interest),1098-T (tuition) *Form 1099-0 (canceled debt) »Form 1098-A (acquisition or abandonment of saoured property} Use Form W-9 only If you are a U.S.persan fneluding a residentallan),to provide your correct TIN,. if you do not return Farm W-9 to the requestar with @ TIN,you mightbesubjecttobackupwithholding,See Whal Is backup withholding,fatar, Foon W~9 (Rev.10-2015 Shane A.Selloria 16630 Chicago Ave. Bellflower,CA 90706 BILL TO: City of Carson Attn:Accounts Payable 801 E.Carson Street Carson,CA 90745 Phone:310-830-7600 QUANTITY 1 'Performer;Ventriloquist for Larry Itliong Day,10/23/21 DESCRIPTION SHIPPING &HANDLING | Make all checks payable to Shane A.Selloria THANK YOU FOR YOUR BUSINESS! INVOICE INVOICE #100 DATE:10/23/21 _UNIT PRICE TOTAL 100.00 —100.00 — “SUBTOTAL 100.00 SALES TAX 0.00 0.00 TOTAL DUE |100.00 |