HomeMy Public PortalAboutC-21-142 - MARLYN GUIUAN - LARRY ITLIONG - SPA
CITY OF CARSON —INTERNAL CONTRACT ROUTING SLIP
All fields are required to be completely filled out.If not applicable,enter N/A.
FROM:JOSE EMMANUEL TINGSON
DOCUMENT TYPE:SeRvicE PROVIDER
EXT.310-830-9991
N/A APPROVALDATE:N/A ITEM NO:N/A
VENDOR NAME:MARLYN GUIUAN SERVICES/PRODUCT:ENTERTAINMENT
TERM OF CONTRACT:10/21/2021 tHroucn 10/24/2021 AMOUNT OF CONTRACT:N/A
SINGLE-SIDED DOCUMENT?[XIYES
PAGE COUNT:
_PRE-APPROVAL/PRE CITY SIGNATURES C ECKLIST
ASSISTING STAFF _ACTION REQUIRED
DEPT:_CS/RECREATION ATTORNEY ASSIGNED:N/A
DIRECTOR Confirm approval to proceed.
“|COMPLETION(INITIALS)_
CONTRACT OFFICER Confirm funds are budgeted and/or available.
CONTRACT OFFICER Preparation of specifications.
This includes coordinating with Risk Management on the Insurance/Bond requiremer
PURCHASING Advertise bids,compliance with bid requirements;including posting on City’s websi 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 att N/A
&CITY ATTORNEY Attorney’s Office.
CONTRACT OFFICER Present appropriate contract form to the recommended vend
*Verify correct agencytitles/corps. are listed.(ie:CityCouncil-Mayor vs.CRA-Chairman)Lo
CONTRACT OFFICER Verify compliance with business license requirements,obtain3 original signatures of N/A
vendor,and request W-9 (once received,submit w-9.tc purchasing).
*Signatures must be notarized for every original*2
CONTRACT OFFICER Verify corporate status,state of incorporationand Principles.N/A
&RISK MANAGEMENT 3
CONTRACT OFFICER Request insurance documents for approval with Risk Management for all contracts.
Verify approval of insurance requirements withRisk Management.
*Communication through e-mail is:preferred:.Please provide the written agreement,certificate of 4
insurance as well as all endorsementforms.
CONTRACT OFFICER Provide W-9 to Purchasing 6n.Age da‘Thursday if contract is on the upcoming agenda.Zz
*Non-Council items:provide W-9 to,Purchasing on date submitted to City Clerk’s Office.
PURCHASING OR Present Departme mendation to legislative body to award/approve contract,if N/A
CONTRACT OFFICER applicable.:
oe POST-APPROVAL/POST-VENDOR SIGNATURES CHECKLIST_oe
CONTRACT OFFICER bléinsurance (Initialed by Risk Management),*Certificate of Insurance with
attached to be processed;even on amendments*MY
CONTRACT OFFICER d assemble bond requirements and forms.*Public Works contracts MUST attach N/A
ind has been executed by an admitted surety insurer*
CONTRACT OFFIGER ismit 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 1 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.O
&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.fo
CONTRACT OFFICER Process contract completion forms.~N/A
*Notice of Completion to City Clerk’s Office
CHOOSE ONE FOR INTERNAL SIGNATURE PROCESSING:
LC}Route for City Attorney>Mayor or Chair WITHOUT NOTARY>Clerk
CL]Route for City Attorney>City Manager WITHOUT NOTARY>Clerk
C1 Route for City Attorney>Mayor or Chair WITH NOTARY>Clerk
L]Route for City Attorney>City Manager WITH NOTARY>Clerk
Other:INPUTIN TYLER
SPECIAL COMMENTS/INSTRUCTIONS/REQUESTS:
SHINaHoiuasv7[_]
STVILINI “ON LOVYLNOD ~“SIVLLUNI
rT.)ois-1sodL_]oO ois-3ud L_]
AINO JSP)3D S$NY3ITD ALID YO4 AINQ 4Sf)3914dO S,NYATD ALID HOS AINO ASP)SADIAYAS TWHLN3D YO4
Checklist
Before submitting your application packet make sure each of the below
indicated items have been attached or completed.
(FOR COMMUNITY SERVICES OFFICE USE ONLY)
x Service Provider Application Agreement
4 Invoice for Future Event Date!
__A/*Business License (if applicable)
Nie Proofof Insurance/Certificate of Insurance
if Waiver,Release,Hold Harmless,Agreement Notto
Sue,Indemnification,and Photo Release
fo 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 Is
approved,then the IFED will be processed as an Invoice for services rendered for the Event.No payment will be made
until the conclusion of the Event,at earliest.
532227.5 CFN AS OF 1-22-2020
T
E
T
E
D
O
S
TA
T
I
O
N
I
O
R
E
D
?
C
R
A
s
P
s
S
I
e
e
a
P
R
E
A
R
E
T
E
A
C
Y
S
E
P
T
SHS Raetne araSpeeNEEpeepe,tae ee ct &fee ina vex aaa
2/73 Bar(Date)
(Company)
OG FUurtENCe SLac€
(Company Address)
Geéevbare,Crt TY 2 VY
(City,State ZIP)
Insurance Requirements ;
Dear parts,Chnuinad ,(Enter Provider's Name)
Please be advised pursuantto your desire to work with the City of Carson,you are required tosubmitthefollowing:
¥CompliantCertificates 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 therisk,prior events,insurance coverage,or other special requirements.
MINIMUM SCOPE ANDLIMIT OF INSURANCE
General Liability Insurance:Coverage shall be at least as broad as Insurance Services FormCG0061coveringCGLonan“occurrence”basis,including property damage,bodily injuryandpersonal&advertising injury with limits no less than $1,000,000 per occurrence and$2,000,000 aggregate.
Additional Insured Status
The City of Carson,andits elected and appointed officials,employees,volunteers and agents,aretobecoveredasadditionalinsuredswithrespecttoliabilityarisingoutoftheirworkoroperationsperformedatoronbehalfoftheCity-sponsored event including materials,parts,orequipmentfurnishedinconnectionwiththeevent.
5322275 CFN AS OF1-22-2020
City of Carson
Community Services Department
Service Provider Application Agreement
4 r{Check one (staff use):lu i )arson Event Center|_|Human Services
|W|
Recreation
[
|Transportation
Event:Lary Itliong 10/23/21EventLocation:Event Date:
Veterans Park
Name ofService Provider:MIAREL sal Cn,vas
Business Form/Entity Type (if individual,sole proprietorship,corporation,or limited liabilitycompany,specify here):
SL Cerp
Business Form/Entity Type (if general partnership,limited partnership,limited liability parmership,or other,specify here):
Business Entity State of Incorporation(if applicable):CEE
Type of Service Fyrané at SWC cr$pp eC RITE NTN DERI
Contact Person:/4A Gert ool Phone 4:(Ly,2)OS P-T BY
Emer.Contact:Vame Phone #:(s)fy C o2-§Tpy
Billing Address:/O/G Froerence /lLace
Number Street
QLEN OALE Cn Sy hy
City State ZIP
Proofof Insurance (check one)?L_lves [Mo
If no,would you like to purchase special event insurance through the City (check one)?[Wes PANo
Special Instructions /Notes;“7S 4 pug 4 et Bme hb.solve7 (a Pot Ape oh Gorrotir'ty haart «2 fche marp
5 'f 7
fiOty»|Garcon wll Pra Ae Wwsurane
532227.5 CFN AS OF 1-22-2020
If Service Provider wishes to request any special accommodation neededto facilitate provision of theservices,please identify it here or contact the staff member referenced on Page |of this application:
Total Service Fee T\oO.SO
NOTE:If service provider is unable to provide the services as proposedor requested or the CityofCarsoncancelstheserviceforanyreason,the associated fees will not be paid.
[remainder ofpage intentionally left blank]
§32227,5 CEN AS OF 1-22-2020
3%
W
E
a
e
ee
o
p
e
R
e
i:gH
aia;5
=g
®Pa
PO
O
P
Y
P
S
U
S
o
e
2ee
d
e
e
FA
E
E
R
I
E
T
E
E
T
E
T
E
R
D
E
A
T
E
C
P
E
T
B
P
C
C
E
E
n
e
r
E
a
n
B
U
T
E
p
e
r
p
y
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 bythis reference.
Service Provider agrees to indemnify and release City in connection with its proposed services inaccordancewiththe“Waiver,Release,Hold Harmless,Agreement Notto Sue,Indemnification,andPhotoRelease”submitted concurrently herewith.
Service Provider agrees to maintain all required insurance coverages and comply with all associatedinsurancerequirementsassetforthontheabove“Insurance Requirements”page,which isincorporatedhereinbyreference.Service Provider agrees that all required policies shall contain,orbeendorsedtocontain,an agreement by Service Provider to waive all rights of subrogation andcontributionagainsttheCity,its elected or appointed officers,officials,employees and agents,for alllossesandliabilitiespaidunderthetermsofanypolicywhicharisefromtheactivitiesoroperationsof,or the services performedby,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 ofservices to City,and does notconstituteanapprovalorauthorizationforServiceProvidertoperformorprovideanyservicetoCity.
Neither Service Provider nor any ofits agents or employees shall be deemed agents or employees oftheCity,nor a member ofa joint enterprise with the City.Neither Service Provider nor any of itsagentsoremployeesshallatanytimeorinanymannerrepresentthatServiceProvideroranyofitsagentsoremployeesareagentsoremployeesofCity,or that it 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 notaffect any of
§32227.5 CFN AS OF 1-22-2020
i
‘B
E
R
G
A
G
E
T
AS
A
A
T
9
0
S
S
B
Y
c
e
t
e
e
c
e
e
n
y
a
M
E
L
E
o
s
anee
S
T
SNE
A
B
G
I
L
AL
U
G
S
E
C
A
L
Y
t
MU
BA
L
ti
l
AN
B
U
0
o
g
a
7
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 Provider 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(wet signature required;no electronic signatures):
SERVICE PROVIDER:ABR L yl Qurtasres
Lie~ro/13/r)/Service Provider's Authorized Representative)(Date)
L
(Printed Name of Service Provider's Authorized Representative}
(Space belowthis line for City use only)
APPLICATION APPROVAL:
CITY OF CARS
(Signature of Cy Managerar Designes)e)
532227.5 CEN
AS OF 1-22-2020
Service Provider Rules &Regulations
1.SERVICE PROVIDER APPLICATION:Upon acceptance,approval,and execution of a
service provider application by the City of Carson (“City”),these rules and provisions shall
becomebinding 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
favor of City programs.
4,PROPERTY LOSS OR DAMAGES:TheCity is not responsible for any damage to,loss or
theft of the Provider’s property,or that of Provider’s agents,employees orinvitees.
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 forfeit 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 changeaffects 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 person or persons due to unlawful conduct.
6.RESPONSIBILITY:The Provider shall provide all material,equipment,and personnel
necessary for provision of the service described in this agreement.
7,MOVE-IN/MOVE-OUT:Move-in to the event area will be set for each venue.Unless
otherwise stated,Provider will be required to keep its area fully set up and manned until the
eventis officially over.Please note that these times are subject to change.
8.SAFETY:Standing on chairs,tables or other rental equipmentis prohibited.This equipmentis
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.
§32227,5 CFN AS OF1-22-2020
M
y
i
e
EG
E
O
S
D
T
I
P
a
6
‘ee
r
S
E
T
A
L
E
IG
E
N
S
T
I
N
T
W
E
9.VOLUME/LIGHT CONTROL:The City reserves the right to regulate the volumeor 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 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 Providerwill bechargedadditionalfeesbasedonthecostofsuchmaintenance.
14.DISPUTES:All points not covered by the Service Provider Rules &Regulationsare subjecttothedecisionoftheappropriateCityrepresentative.
15,FLOOR MANAGEMENT:The City will appoint a Floor Manager who is authorized toenforcetheserulesandregulations.
16.SPACE ASSIGNMENT:Event space is assigned to providers at the sole discretion of theCity.Concerns regarding competitive or specific types of providers should be communicated totheCityatthetimeofapplication.
17.RULE CHANGES:TheCity reserves the right to make reasonable changes to the foregoingrules,event hours and move-in/move-out alTangements at any time without notice to Provider,unless the changeaffects a permit already issued to Provider.
532227.5 CFN AS OF 1-22-2020
—
10
Waiver,Release,Hold Harmless,Agreement Not to Sue,Indemnification,and Photo Release
1 Oars)Crurrugd ;(“individual”)[on behalf of
(‘Service Provider”),and as a bonafide agent of Service Provider
Signed:
duly authorized to execute this Waiver,Release,Hold Harmless,Agreement Not to Sue and Indemnification
agreement (“Agreement”)on behalf of Service Provider](individual and Service Provider hereinafter
collectively referred to as “Signatory,”and the term “Signatory”includes Service Provider's officers,officials,
employees,agents and volunteers),seek acceptance by the City of Carson of an application to provide services
in/at Lary Itong (“Event”)on October23,2021 (“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 any and all claims for damages for death,personal injury,or
property damage which Signatory may have,or which hereafter accrue to Signatory,against the City of
Carson,its elected 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 participation
in or presence at the Event,even though thatliability may arise out of negligence or carelessness on the part of
City.It is further understood and agreed that this Agreementis to be binding on Signatory’s heirs and assigns.
Signatory hereby grants City the right to photograph or video-record Signatory during or in connection with
the Event,and to use Signatory’s photographed or video-recorded likeness,and any image,silhouette,or
reproduction of the voice or appearance of Signatory taken during or in connection with the Event
(“Likeness”),for any purpose,including publicity and promotion of City and its events,and creation or
production of materials in any form for such purpose,with no claim of entitlementto any license fee or royalty
ofany kind from City.Signatory hereby waives any right to the intellectual property of Signatory’s Likeness.
The rights granted by Signatory hereunder shall not expire.
Signatory further agrees to indemnify,defend and hold harmless City from and against any and all claims,
Habilities,losses,damages,expenses,and costs (including without limitation costs and fees of litigation)of
every nature (including,but not limited to,property damage,bodily injury,or death),whether imposed by law
or otherwise,sustained or alleged to be sustained by any person or entity (whether they be members of the
public visiting the Event,employees of the City,other service providers at the Event,or otherwise),occurring
at,arising from, or connected with Signatory’s preparation or performance of services at the Event,Signatory’s
actions,inactions,or use offacilities at the Event,or any equipment,machinery or items displayed or used by
the Signatory at or for the Event,except for such claim,liability,loss,damage,expense,or cost which was
caused bythe sole negligence or willful misconductof the City.
By signing below,|acknowledge and represent that I have read and understand the above,and that I
voluntarily agree to its terms.
‘NAME:i renatysd Custer tra)
pate:/2/73/2/
532227.5 CFN AS OF 1-22-2020
*
PRIAM &MARLYN GUIUAN
We're in the buiness of improving peopleslives!Involce No.2021-01
Invoice Date:October 23,2021
1019 FLORENCE PLACE Bill To:CITY OF CARSONGLENDALE,CA 91204 C/O LARRY ITLIONG
Address:Carson,CA818-434-3432
https://marlynguiuan.freedomequitygroup.com Phone:310-938-6512marlyng1@yahoo.com bs E-mail:larguera@carsonca.gov
Description Units ‘Cost Per Unit Amount iMusicPerformanceinparticipationfortheCommunityEventon10/23/21 $s 100.00
§-
§-
$-
§-
s -
$-
S -
s -
$-
S -
invoice Subtotal 4S 100.00
Tax Rate
Sales Tax
Other
Deposit Received
TOTAL
1
$100.00
Makeall checks payable to [Company Name)
Total due in 15 days.Overdue accounts subject to a service charge of 2%per month.
Thank you for your business!
om W-Q
Rav.October 2018)
Department of the TreasuryintemalRevenueService
Request for Taxpayer
identification Number and Certification
&Go to www.irs.gov/Formi¥9 for instructions and the latest information,
Give Form to the
requester.Do not
send to the IRS. 1 Nama (as shown on your income tax retum}.Name is requiredMenty)GUuiun
2 Business name/disragarded entity name,if different from above
this fina;do not leave this line blank,
following seven boxes.
single-member LLC
Note:Check the
[]_Other (see instructions)
3 Check appropriate bax for federal tax classification of the person whose name fs entered on line 1.Check only one of the
(7)individualsota proprietor or C)¢Corporation (2%conporaton (J Partnarship
(7)Limited liabitty company.Enter the tax classification {C=C corporation,S=S corporation,P=Partnership)>
bax in the fine above for the tax classification of the single-member owner.De not checkLLCiftheLLCisclassifiedasasingle-mamber LLC that is disregarded from the owner unless the owner of the LLCIsanotherLLGthatisnotdisregardedfromtheownerforU.S.federal tax purposes.is disragarded from the owner should check the appropriate bax for the tax classification of its owner.
4 Exemptions(codes appty only tocertainentitles,not individuals;sae
instructions on page 3):
O TrusVestate
Exempt payee coda (if any}
Exemption trom FATGA reporting
Otherwise,a single-member LLC that|Cod®any)
open to eccounts mminaained cute tre U5) 5 Address (number,street,and apt,or sults no.)See instructions.
(WS FIUNnlE PLA
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.
Requester's name and address (optional)
6 City,state,and ZIP codeLi ae 7 Ust account number(s)hers (optional)
KQMQN Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid
security number (SSN).However,for aresidentalien,sole proprietor,or disregarded entity,see the instructions for Part J,later.For other 6 oO b -|3 £~&/entities,it is your employer identification number (EIN).ff you do nat have a number,see How fo geta
backup withholding.For individuals,this is generally your social
TIN,later.
Note:if the accountis in more than one name,see the instructions for line 1.Also see What Name andNumberToGivetheRequesterforguidelinesonwhasenumbertoenter.
GARY Certification
Underpenalties of perjury,|certify that:
1.The number shown on this form Is my correct taxpayer identification number (or |am waiting for a number to be Issued to ma);and2.|am not subject to backup withholding because:(a)|am axempt from backup withholding,or (b)|have not been notified by the Internal RevenueService(IRS)that |am subject to backup withholding as a result ofa failure to report all interest or dividends,or (c}the [AS has notified me that |amnolongersubjectfobackupwithholding;and
3.lama U.S.citizen or other U.S.person (defined below);and
4.The FATCA code(s)entered on this form (if any)indleating that |am exemptfrom FATCA reporting is correct.
Certification instructions.You must crass out itam 2 aboveif you hava been notified by the IRSthat you are currently subject to backup withholding becauseyouhavefailedtoreportallinterestanddividendsonyourtaxratum.Forreal estate transactions,item 2 does not apply.For mortgage interest pald,acquisition or abandonmentof secured property,cancellation of debt,contributions to an individual ratirament arrangement(IRA),and genarally,paymentsotherthanInterestanddividends,yousye Not required to sign the certification,but you must provide your corect TIN.See the Instructions for Part Il,later.
Sign Signature ofHerespat
General Instructions
Section references are {fo the Internal Ravenue Code unless otherwisenoted.
Future developments.For the latest information about developmentsrelatedtoFormW-9 and its instructions,such as legislation enacted
after they were published,go to www.irs.gov/FormW9,
Purpose of Form
An Individual or entity (Form W-9 requester)who is required tofile an
information retum with the IRS must obtain your correct taxpayeridentificatlannumber(TIN)which may be your soclal security number(SSN),Individual taxpayer Identification number (TIN),adoptiontaxpayerKdentificationnumber(ATIN),or employer identification number(EIN),to report on an information retum the amountpald to you,or otheramountreportableonaninformationreturn,Examples of informationretumsinclude,but are not limited to,the following.
*Form 1099-INT (Interest eamed or paid)
Cat.No.10231X
Data fo/i3/}
hina 1099-DIV (dividends,Including those from stocks or mutual
8,
*Form 1099-MISC (various types of Income,prizes,awards,or grossproceeds)
*Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
*Form 1099-S (proceads from real estate transactions}
«Form 1099-K (merchant card and third party network transactions)
«Farm 1098 (home mortgageinterest),1098-E (studentloan interest),1098-T (tuitlon)
«Form 1099-C (canceled debt)
*Form 1099-A (acquisition or abandonmentof secured property)
Use Form W-8 only if you are a U.S.person (including a residentalien),to provide your correct TIN.
if you do not ratum Form W-9 to the requester with a TIN,you mightbesubjecttobackupwithhotding.See What la backup withholding,later.
Form W-9 (Rev,10-2018)
OS
E
S
3
S
T
S
P
B
R
S
T
I
A
R
S
E
e