HomeMy Public PortalAboutC-21-148 - CHRISOL LOMELI - COUNTRY WESTERN FAIR SPA
CITY OF CARSON —INTERNAL CONTRACT ROUTINGSLIP |
All fields are required to be completely filled out.If not applicable,enter N/A.
FROM:JOSE PINA
DOCUMENT TYPE:SERVICE PROVIDER
EXT.310-549-3962 DEPT:_CS/RECREATION ATTORNEY ASSIGNED:N/A
N/A APPROVALDATE:N/A ITEM NO:N/A
VENDOR NAME:CHRISOL LOMELI SERVICES/PRODUCT:PERFORMER/DANCER
TERM OF CONTRACT:11/18/2021 tHrougu 11/21/2021 AMOUNT OF CONTRACT:N/A
SINGLE-SIDED DOCUMENT?[XIYES PAGE COUNT:
ASSISTING STAFF|
“ACTION REQUIRED —__ |COMPLETION (INITIALS)
DIRECTOR Confirm approval to proceed.J CONTRACT OFFICER Confirm funds are budgeted and/or available.
CONTRACT OFFICER Preparation of specifications.ee
This includes coordinating with Risk Management on the Insurance/Bond requirements.%
PURCHASING Advertise bids,compliance with bid requirements;including posting on City’s website.N/A
*RFP/RFQ must include form contract.
PURCHASING OR Evaluate bids/proposals and determine recommended bidder(s).N/A
CONTRACT OFFICER oo
CONTRACT OFFICER Complete contract negotiations/finalize contract (including attachments)with City N/A&CITY ATTORNEY Attorney’s Office.s ae
CONTRACT OFFICER Present appropriate contract form to the recommended Vv dor.*Wp)
*Verify correct agency titles/corps.are listed.(ie:City.Council--Mayor vs.CRA-Chairman)
CONTRACT OFFICER Verify compliance with business license requirements in’3,original signatures of N/A
vendor,and request W-9 (once received,submi asing)
*Signatures must be notarized for every original*,
CONTRACT OFFICER Verify corporate status,state of Incorporation ;N/A
&RISK MANAGEMENT x
CONTRACT OFFICER Request insurance documents for apprev:
Verify approval of insurance require .L
*Communication through e-mail i lease provide the written agreement,certificate of
CONTRACT OFFICER Provide W-9 to Purchasing on.Agi hursday if contract is on the upcoming agenda.@
*Non-Council items:provide W-9 to.hasing on date submitted to City Clerk’s Office.
PURCHASING OR Present Department’s.rec mmendation to legislative body to award/approve contract,if ~N/A
CONTRACT OFFICER applicable.:
LL.: BOSTAPPROVAL/POST-VENDOR SIGNATURES CHECKLIST _oe
CONTRACT OFFICER Collect and assembleiinsurance (initialed by Risk Management),*Certificate of Insurance with fl)
endorsement must beattached 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 .“Transmit 2 complete original sets with this routing slip to the City Clerk’s Office for further N/Aaprocessing.
<<**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/ACityClerk.
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
CONTRACTOFFICER Create a requisition in Tyler for Purchasing to issue a Purchase Order.Wy
&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.hy
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
C]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:INPUT IN TYLER
SPECIAL COMMENTS/INSTRUCTIONS/REQUESTS:
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City of Carson
Community Services Department
Service Provider Application
Dear Applicant,
Onbehalf of the City of Carson,I would like to thank youfor taking the time to explore business
opportunities with the City by applying to provide services for an event at a City facility.As part
of our application process,you must complete,sign,and return the following forms.Submission
of these forms does not guarantee that you will be provided the business opportunity you seek.
Your prompt assistance in submitting the requested documentation to the City staff member
listed below will be appreciated and will help expedite the application process.Please send your
completed application and attachmentsdirectly to the following address:
City of Carson
Attn:Jose Pifia
(Event Coordinator’s Name)
Dominguez Park -21330 Santa Fe Ave.Carson,CA.90810
(Enter Event Coordinator’s address (i.e.,city hall,corporate yard,or specific park address)
Email:jpina@carsonca.gov
(Enter event coordinator’s email address)
Should you have any questions,please feel free to contact the staff memberlisted below .
Truly,
dose Pifia
(Name)
Recreation Center Supervisor Il
(Title)
532227.5 CFN AS OF 1-22-2020
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)
J Service Provider Application Agreement
fo Invoice for Future Event Date’
Business License (if applicable)
\
I
V
E
On ouiilt Proof of Insurance/Certificate of Insurance
Waiver,Release,Hold Harmless,Agreement Not to
Sue,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 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 CEN AS OF 1-22-2020
je/i2 free (
(Date)‘;
Cherise |Lome!~Se lenamo§Band
(Company)
(20S pleat Lt.
(Company Address)
Corona,CA.FL OTE)
(City,State ZIP)
Insurance Requirements
(Enter Provider’s Name)
Please be advised pursuant to your desire to work with the City of Carson,you are requiredto
submit the following:
¥Compliant Certificates of Liability Insurance (to be maintained for the durationof services
against claims which may arise from or in connection with the services),evidencing the
coverage(s)as indicated below.
Certificates of insurance,as well as additional insured and waiver of subrogation
endorsements in favor of the City,must be submitted in their entirety before any services
are provided or the event takes place.Failure to submit such required forms shall be cause
for City of Carson to reject or terminate any service provider application agreement.
The City of Carson reserves the right to modify these requirements based on the nature of the
risk,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
CG 00 O!1 covering CGL on an “occurrence”basis,including property damage,bodily injury
and personal &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 appointedofficials,employees,volunteers and agents,are
to be covered as additional insureds with respect to liability arising out of their work or
operations performed at or on behalf of the City-sponsored event including materials,parts,or
equipment furnished in connection with the event.
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
Country Western Fair Event Location:Dominguez Park Event Date:H/e2or202
Chrisol Lomeli
Event:
Name of Service Provider:
Business Form/Entity Type (if individual,sole proprietorship,corporation,or limited liability
company,specify here):
sole proprietorship
Business Form/Entity Type (if general partnership,limited partnership,limited liability partnership,
or other,specify here):
Business Entity State of Incorporation (if applicable):
Band
Type of Service:
Chrisol Lomeli 909-247-7708
Contact Person:Phone #:()
Gladys Lomeli 909-287-6230
Emer.Contact:Phone #:()
1205 Heather Ct.
Billing Address:
Number Street
Corona,CA 92878
City State Zip
Proof of Insurance (check one)?[_lves [VNo
Ifno,would you like to purchase special event insurance through the City (check one)?[lves [VINo
Special Instructions /Notes:
§32227.5 CFN AS OF 1-22-2020
If Service Provider wishes to request any special accommodation needed to facilitate provision of the
services,please identify it here or contact the staff member referenced on Page |of this application:
$2500
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 ofpage intentionally left blank]
532227.5 CFN AS OF 1-22-2026
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 deliver this 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,”which are 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,which is
incorporated herein by reference.Service Provider agrees 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 under the 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
hereundershall be joint and several.
This Service Provider Application Agreement,unless and until accepted,approved,and executed by
the City Manager or designee,is only an application for provision of services to City,and does not
constitute an approval or authorization for Service Provider to perform or provide any serviceto 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 nor any 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 memberof a 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 whichService
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
$32227.5 CFN AS OF 1-22-2020
the remaining portions of this Agreement which are hereby declared «as severable and shall be
interpreted to carry out the intent of the parties hereunder.
Service Provider acknowledges that the City of Carson’s consideration of Service Provider’s
application to provide the above-referenced services is on the express condition that Service Provider
represents and warrants that it is and will be in compliance with all applicable restrictions on the use
of intellectual property,including copyright laws,in connection with the services proposed to be
provided.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 to
provide the above-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):
Chrisol LomeliSERVICEPROVIDER:
10/12/2021
(Signature of Service Provider's Authorized Representative)(Date)
Ch risel Lomeli
(Printed Name of Service Provider's Authorized Representative)
(Space belowthis line for City use only)
APPLICATION APPROVAL:
CITY OF CARSON ’LeCy {l /3/DY
(Signature of City Manager or Designee).(Bate)
§32227.5 CFN 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 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 may be established or putintoeffectbytheCity,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 theservicesasrequested,or the City cancels the service for any reason,the associated fees for
service will notbe paid.
3.CANCELLATION:Norefunds 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:The City is not responsible for any damageto,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 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 Providershall 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 conductofall 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.
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 not limitedto,loudspeakers,radios,television sets,musical instruments,entertainers,or blinking or flashing lights)in the
reasonable judgmentof the City.
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 this
agreement,subject to Fire Departmentregulations.
11.COPYRIGHT INFORMATION:Provider is 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 be
charged additional fees based on the cost of such maintenance.
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 to
enforce these rules and regulations.
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:The City reserves the right to make reasonable changes to the foregoing
rules,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.
$32227.5 CFN AS OF 1-22-2020
10
Waiver,Release,Hold Harmless,Agreement Not to Sue,Indemnification,and Photo Release
|,Chrisol Lomeli ,(“individual”)[on behalf ofSelenamos(“Service Provider”),and as a bona fide agent of Service Provider
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 servicesin/at COUNTRY WESTERN FAIR (“Event”)on NOVEMBER 20,2021 (“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 andall 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 thoughthat liability may arise out of negligence or carelessness on the part of
City.It is further understood and agreed that this Agreement is 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 noclaim of entitlementto anylicense fee or royalty
of any kind from City.Signatory hereby waives anyrightto the intellectual property of Signatory’s Likeness.
Therights granted by Signatory hereunder shall not expire.
Signatory further agrees to indemnify,defend and hold harmless City from and against any and all claims,
liabilities,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 oritems displayed or used by
the Signatory at or for the Event,except for such claim,liability,loss,damage,expense,or cost which was
caused by the sole negligence or willful misconduct of the City.
By signing below,I acknowledge and represent that I have read and understand the above,and that I
voluntarily agree to its terms.
Signed:
ae
NAME:Chrisol Lomeli
ORGANIZATION:Selenamos
Date:10/12/2021
532227.5 CFN AS OF 1-22-2020
Form W-9
(Rev.October 2018)
Departmentof the Treasury
Internal Revenue Service
Chriso!l Lomeli
2 Business name/disregarded entity nama,if different from above
Request for Taxpayer
identification Number and Certification
»Go to www.irs.gov/FormW9for instructions and the latest information.
1 Name(as shownon your income tax return).Name is required on this line;do not leave this line blank.
Give Form to the
requester.Do not
send to the IRS.
following seven boxes.
Individuat/sole proprietor or C]C Corporation
single-member LLC
Pr
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or
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.
[_]Other(see instructions)»
CJ S$Corporation
CT Limited liability company.Enter the tax classification (C=C corporation,S=S corporation,P=Partnership)>
Note:Check the appropriate boxin the line abovefor the tax classification of the single-member owner,Do not check Exemption from FATCA reportingLLCiftheLLCisclassifiedasasingle-member LLC that is disregarded from the owner unless the owner of the LLCis
another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification ofits owner.
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions (codes apply only to
certain entities,not individuals:see
instructions on page 3):
Cc Partnership Trust/estate
Exernpt payee code(if any)
code(if any) Applies to accounts mainisined outside ihe U.S.)
5 Address (number,street,and apt.or suite no.)See instructions.
39882 Milkmaid Lane
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3.
Requestar’s name and address (optional)
6 City,state,and ZIP code
Murrieta,CA 92562 7 List account number(s}here (optional)
Taxpayer Identification Number (TIN)
Enter yourTIN in the appropriate box.The TIN provided must match the name given online 1 to avoid
backup withholding.For individuals,this is generally your social security number (SSN).However,for a
resident alien,sole proprietor,or disregarded entity,see the instructions for Part |,later.For other ~-entities,it is your employer identification number (EIN).If you do not have a number,see How to get a
TIN,later.
Note:If the account is in more than one name,seethe instructions far line 1.Also see What Name and
NumberTo Give the Requester for guidelines on whose numberto enter.
|Social security number
6 11 {0 9 {6 7 4 (3 19
or
Employer identHication number
clue Certification
Under penalties of perjury,|certify that:
1.The number shown onthis form is my correct taxpayer identification number (or |am waiting for a number to be issued to me);and2.|am not subject to backup withholding because:(a)|am exempt from backup withholding,or (b)|have not been notified by the internal RevenueService(IRS)that |am subject to backup withholding as a resuit of a failure to report all interest or dividends,or (c)the IRS has notified me that |amnolongersubjecttobackupwithholding;and
3.fama U.S.citizen or other U.S.person (defined below);and
4.The FATCA code(s)entered on this form (if any)indicating that |am exempt from FATCA reportingis correct.
Certification instructions.You must cross out item 2 aboveif you have been notified by the IRS that you are currently subject to backup withholding because
you havefailed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgageinterest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement (IRA},and generally,paymentsotherthaninterestanddividends,you are not requ;to signéne certification,but you must provide your correct TIN.See the instructions for Part fl,later.
Date >5 fa [2021
v
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments.For the latest information about developments
related to Form W-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 to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN)which may be your social security number
(SSN),individual taxpayer identification number(ITIN),adoption
taxpayer identification number (ATIN),or employer identification number
(EIN),to report on an information return the amount paid to you,or other
amount reportable on an information return.Examples of information
returns include,but are not limited to,the following.
*Form 1099-INT (interest earned or paid)
Lo}
Sign Signature of /.
Here U.S.person >
wy CK
*Form 1099-DIV (dividends,including those from stocks or mutual
funds)
*Form 1099-MISC(various types of income,prizes,awards,or gross
proceeds)
*Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
«Form 1099-S (proceeds from real estate transactions)
*Form 1099-K (merchant card and third party network transactions}
*Form 1098 (home mortgage interest),1098-E (student loan interest),1098-T (tuition)
*Form 1099-C (canceled debt)
*Form 1098-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S.person (including a resident
alien),to provide your correct TIN.
Ifyou do not return Form W-9 to the requester with a TIN,you might
be subject to backup withholding.See What is backup withholding,
later.
Cat.No.10231X Form W-9 (Rev.10-2018)
To:City of Carson
Chrisol Lomeli
Selenamos Music
1205 Heather Ci.
Corona,CA 92878
909-247-7708
Date:10/12/2021
INVOICE #CWF112021
Contact:Phone #Payment Terms Due Date
Chrisol Lomeli |909-247-7708 |Check Immediate
Description _.
Selenamos Performance at Country Western Fair $2500|11/20/2021
|Totat:$2500
Thank you for your business!