HomeMy Public PortalAboutC-21-155 - AUDIOTECH PRODUCTIONS - COUNTRY WESTERN FAIR SPA
CITY OF CARSON —INTERNAL CONTRACT ROUTINGSLIP
Alll fields are required to be completely filled out.{f not applicable,enter N/A.
FROM:JOSE PINA
DOCUMENT TYPE:Service PROVIDER
DEPT:_CS/RECREATION ATTORNEY ASSIGNED:N/A
N/A APPROVALDATE:N/A ITEM NO:N/A
EXT.310-549-3962
VENDOR NAME:AUDIOTECH PRODUCTIONS SERVICES/PRODUCT:PA SERVICES
TERM OF CONTRACT:11/18/2021 tHroucH 11/21/2021 AMOUNT OF CONTRACT:N/A
SINGLE-SIDED DOCUMENT?[XIYES
PAGE COUNT:
oe ce S _PREAEFROVAL/P E-CITY SIGNATURES cH KU 1 —
ASSISTING STAFF ACTION REQUIRED |.|COMPLETION (INITIALS)
DIRECTOR Confirm a roval to proceed..pp p 1 fe
CONTRACT OFFICER Confirm funds are budgeted and/or available.J.
CONTRACT OFFICER Preparation of specifications..“
This includes coordinating with Risk Management on the Insurance/Bond requirem &
PURCHASING Advertise bids,compliance with bid requirements;including posting on City’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 atta 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 syor vs.CRA-Chairman)bo
CONTRACTOFFICER Verify compliance with business license requirements,-obtain’3 original signatures of “N/A
vendor,and request W-9 (once received,submit w-9.to urchasing).
*Signatures must be notarized for every original*.5
CONTRACT OFFICER Verify corporate status,state of Incorporation and\d Principles.N/A
&RISKMANAGEMENT |g
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 p
insurance as well as all endorsementforms.
CONTRACTOFFICER Provide W-9 to Purchasing on.Ag da’‘Thursdayif contract is on the upcoming agenda.p
*Non-Council items:prov Purchasing on date submitted to City Clerk’s Office.
PURCHASING OR Present Department,\dation to legislative body to award/approve contract,if ~N/A
CONTRACT OFFICER applicable./
oo “POST-APPROVAL/POST-VENDOR SIGNATURES CHECKLIST |ee
CONTRACT OFFICER Collect@nd surance (Initialed by Risk Management),*Certificate of Insurance withay)
e ttached to be processed;even on amendments*77
CONTRACT OFFICER Collect and ass le bond requirements and forms.*Public Works contracts MUSTattach N/A
verification the:bond has been executed by an admitted surety insurer*
CONTRACTOFFIGER it 2 complete original sets with this routing slip to the City Clerk’s Office for further N/A
g.
‘Note any special servicesneeded,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.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.@)
ACONTRACTOFFICERProcesscontractcompletionforms.N/A
*Notice of Completion to City Clerk’s Office
CHOOSE ONE FOR INTERNAL SIGNATURE PROCESSING:
(]Route for City Atto
[]Route for City Atto
LJ Route for City Atto
L]Route for City Atto
rney>Mayor or Chair WITHOUT NOTARY>Clerk
rney>City Manager WITHOUT NOTARY>Clerk
rney>Mayor or Chair WITH NOTARY>Clerk
rney>City Manager WITH NOTARY>Clerk
Other:INPUT IN TYLER
SPECIAL COMMENTS/INSTRUCTIONS/REQUESTS:
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\Conea Service Provider Application
City of Carson
Community Services Department
Dear Applicant,
Onbehalf of the City of Carson,I would like to thank you for 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
ofthese forms does not guarantee that you will be provided the business opportunity you seck.
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 attachments dircetly to the following address:
City of Carson
Atm:Jose Pifa
(Event Coordinator's Name)
Dominguez Park -21330 Santa Fe Ave.Carson,CA.90810
(Enter Event Coordinator's address (i.c.,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,
Jose Pifla
(Name)
Recreation Center SupervisorIt
(Title)
$32227,5 CEN AS OF 1-22-2020
t
a
Checklist
Before submitting your application packet make sure each of the below
indicated items have been attached or completed.
(FOR COMMUNITYSERVICES OFFICE USE ONLY)
_v__Service Provider Application Agreement
__/__Invoice for Future Event Date'
Business License (if applicable)
__f _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 Isapproved,then the iFED will be processed as an invoice for services rendered for the Event,No payment will be madeuntiltheconclusionoftheEvent,at earliest.
$32227.5 CEN AS OF 1-22-2020
of¢/2]
(Date)
PUDIOTECH PRODUCTIO
(Company)
21227 SHOE VE
(Company Address)
COMLSOM CA GO7US
(City,State ZIP)
Insurance Requirements
Dear ARTAU IMGIET—;
(Enter Provider’s Name)
Please be advised pursuant to your desire to work with the City of Carson,you are required to
submit the following:
~Compliant Certificates of Liability Insurance (to be maintained for the duration of services
against claims which mayarise 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 pravided or the event takes place.Failure te submit such required forms shail he 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 ofthe
risk,prior events,insurance coverage,or other special requirements.
MINIMUM SCOPE AND LIMIT OF INSURANCE
General Liability Insurance:Coveruge shail be at least as broad as Insurance Services Form
CG 00 Of 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 agenis,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
equipmentfurnished in connection with the event.
532227,5 CFN AS OF 1-22-2026
City of Carson
Community Services Department
Service Provider Application Agreement
Check one (staff use):
[|Carson Event Center|_|Human Services Recreation []Transportation
Event:Country Western Fair Event Location:Dominguez Park Event Date:‘eor2021
Nameof Service Provider;DUDIOTECH PRODUCTION
Business Form/Entity Type (if individual,sole proprietorship,corporation,or limited liability
company,specify here):
LM OIVIDUAL
Business Form/Entity Type (if general partnership,limited partnership,limited liability partnership,
or other,specify here):
SOLE PrRoPriec TorgHuie
Business Entity State of Incorporation (if applicable):
Type of Service:PA SG2uickes
Contact Person:PyasTAU I |MENEZ Phone #:(3/0)953 -7059
Emer.Contact;_ROSE PNM SUH Phone #:(424/)_979 -9200
Billing Address:2122.7 SHEARER?AVE
Number Street
Cnrspr{OA GO74s—
City State zip
Proof of Insurance (check one)?[res [No
Hf no,would you like to purchase special event insurance through the City (check one)?(Wes [No
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 memberreferenced on Page |of this application:
Total Service Fee ¢1500.00
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.
[remainderofpage intentionally lefi blank]
§32227.5 CEN AS OF 1-22-2020
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,for all
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
hereunder shall 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 approvalor authorization for Service Provider to perform or pravide 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 nor any of its
agents or employees shall at any time or in any mannerrepresent that Service Provider or any ofits
agents or employees are agents or employees of City,or that it is a member ofa 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 employces,perform the services set forth herein,
Tn the cvent 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 CEN 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):
SERVICE PROVIDER:AUDICTECH PRODUCT!On/
Wi 4/4/21{Signature of Sérvite Provider's Authiioted Representative)(Dare)
TIMMES
(Printed NamearService Provider's Authorized Representative)
(Space below this line for City use only}
APPLICATION APPROVAL:
CITY OF aN)
(Signature ofCity Manuger ofPesignes)
532227.5 CFN AS OF 1-22-2020
Service Provider Rales &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 shal!
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
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,employeesor 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 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 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 cach venue.Unless
otherwise stated,Provider will 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 on chairs,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 injurics or falls caused by the improper use of furniture.Please assist in
our efforts to provide a SAFE WORKING ENVIRONMENT.
$32227,5 CPN AS OF 1-22-2020
9,VOLUME/LIGHT CONTROL:The Cityreserves the right to regulate the volumeor intensily
of any and all noise or light generating mechanisms (including,but not limited to,loudspeakers,
radios,television sets,musical instruments,entertainers,or blinking or flashing lights)in the
reasonable judgment ofthe City.
10.FLAMMABLE MATERIALS All decorations,props and electrical equipment must be
fireproof or of fire retardant materials,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.
1].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 any
copyrighted and/or trademarked name or logo which has not been specifically authorized under
license from the trademark holder.
12,PERMITS AND LICENSE:Provider shall procure at its own cost and expense all the
required licenses and permits applicable to Provider’s usc 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
and orderly condition (equal to or better than the condition existing prior to the event).If
additional maintenance is required,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 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 changesto 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 CEFN AS OF 1-22-2020
10
Waiver,Release,Hold Harmless,Agreement Not to Sue,Indemnificadon,and Photo Release
LPT ST (MeN ,(“individual”){on behalf of
ALDICTECH PROULTICYY (“Service Provider"),and as a bonafide agent of Service Provider
duly authorized to execute this Waiver,Release,Hold Harmless,Agreement Not to Suc and Indemnification
agreement (“Agreement”)on behalf of Service Provider](individual and Service Provider hereinafler
collectively referred to as “Signatory,”and the term“Signatory”includes Service Provider’s officers,officials,
employces,agents and volunteers),seck acceptance by the City of Carson of an application to provide servicesin/at COUNTRY WESTERN FAIR (“Event”)on NOVEMBER20,2021 (“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 al!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 andall liability arising out of or connected in any way with Signalory’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 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 cvents,and creation or
production of materials in any form for such purpose,with no claim of entitlement to any license fee or royalty
of any kind from City.Signatory hereby waives any right to the intellectual property of Signatory’s Likeness.
The rights granted by Signatory hereundershall 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 oralleged to be sustained by any person or entity (whether they be members ofthe
public visiting the Event,employees of the City,other service providers at the Event,or otherwise),occurting
at,atising from,or connected with Signatory’s preparation or perfarmance of services at the Event,Signatory’s
actions,inactions,or use of facilities 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 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:P AT
SS
NAME:ARAB JT IMEN ES
ORGANIZATION:DtipjiOFH PRODUCTION
Date:3 /9g />f
$32227.5 CFN .AS OF 3-22-2020
Arjay Jimenez
21227 Shearer Ave
Carson,Ca 90745
T:310.953.7059
E;djarjayi2@gmail.com
DATE:
INVOICE #:
CUSTOMER ID:
City of Carson
801 E.Carson St
Carson,Ca 90745
T:310.830.4185
E:jpina@carson.gov
INVOICE
11/20/21
112021
ee es SiltLLOr)bee ee ee peerSLUeae
Caunrty Western Falr @ Dominguez Park,PA Services,PRO PA Package-1 $1,500.60
SUBTOTAL $1,500.00
TAXABLE $:
fey iatseee antieee ee Penn ae ere TAX RATE 5 >
1.Total payment duein 30 days TAX DUE $:
2.Please include the invoice number on your check OTHER $:
TOTAL DUE $1,500.00
Make all checks payable to:
AudioTech Production
If you have any questions about this invoice,please contact
Arjay Jimenez,P#:310.953.7059,E:djarjayl2Z@gmail.com
Thank You For Your Business!
com W-9 Request for Taxpayer Give Form to the
Rev.October 2618)Identification Number and Certification requester,Do nat
Departrantof the Treasury send to the IRS.internal Ravers Service »Go to www.irs.gov/FormW9 for Instructions end the latest Information.
7 Names (as strewn on your Income tax return},Nana is required on this dno;do not [save this line blank,
ARJAY FERRER JIMENEZ
2 Business name/disragarded aniity name,if different from above
AUDIOTECH PRODUCTION
3 Check sepropitete box for federal tex classification of the percon whosa nama is antored on line 1.Check only one ofthe 4 Exemptions (codes apply only lo
follawing saven boxes.cortaln ontiles,not Individuals;seeinstructionsonpags3):[7]individualisole proprieloror (C]comp Osc i 0 ps p CD trusts
singla-member LLC Exempi payes code {if any)
United uabitity company,Enter the tax classi (G#0 comorailon,SeS lon,PePar p>
Note:Chack the appropriais box In the fine sbove for tha tax classification of the singla-member awner,Do not check Exemption from FATCA reponing
LLC if tha LLC is classified as a single-member ULC thalis disregarded from the owner unless the owner of the LLC is coda (if any)
another LLC that Is nol disregarded from the owner for U.S,federal tax purposes.Olhorwise,a single-mamber LLC that!any,
is disregarded from the owner should check the appropriate box for the tax classification of 1s owner.
(2)otner (saa Instructions)>Boolian bo vocals malouhedovtaie the LS}
5 Address (number,streat,and apt.of suite.no,)}Seo instructions.Requester's name and address (optional)
21227 SHEARER AVE
6 Clty,state,and ZIP code
GARSON CA 80745
7 List account number(s}here (optional)
Print
o
r
type.
See
Specific
Instructions
on
page
3.
Taxpayer Identification Number (TIN)
Enter your TIN In (he appropriate box.The TIN provided must match the nama given on line 1 to avold Soctal security number
backup withholding.For individuals,this is generally your soclal security number (SSN).However,for a
resident alian,sole proprietor,or disregarded entity,see the Instructions for Part |,later.For other 6/2)6]-}6)6),-]7)7)4)9entities,itis your employer Identification number (EIN).If you do not have a number,sea How to gat a
TIN,later.or
Note:tf the accountis in mora than one name,see the Instructionsfor line 1.Also ses What Name and LE hdentification number
Numbar To Give the Requester for guidelines on whase number to enter. lad Certification
Under penalties of parjury,{certify that:
1.The number shown on this form is my correct taxpayer identification number (or |am waiting for a number lo ba Issued to ma),and
2.Lar not subject to backup withholding because:(a)1 am exemptfrom backup withholding,or (b)|have not been notified by the intemal Revenue
Service (IRS)that |am subject to backup withholding as a result of a failure to report all interest or dividends,or (c)tha IRS has notified me that |am
no longer subject to backup withholding;and
3.fama U.S,citizen or other U.S.parson (definad below);and
4,The FATCA coda(s}entered on this form (if any}indicating that |arm exempt fram FATCA reporting is correct.
Certification Instructions.You must crass out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have falled fo rport all Interest and dividends on your tax return.Far reat estate transactions,tam 2 doas|not apply.For mortgage interssl paid,
acquisition or aband of erty,HI of deb!indi t 8 ORA),and gotherthaninteractanddividends,you are nat required to aign the oriientlon.but ou must provide your correct TIN,See tha instructions for Part th later.
Signaan [geen OP om»9/9/a]
Hi tGeneralInstructionswnaey1099-DIV (dividends,including those from stocks or mutual
Saction references are to the internal Revenue Code unless otherwise *¢Form 1099-MISG(varlous typesof income,prizes,awards,or grass
tee f pracesds}, , ,
‘ulure developments.For the latest information about devalopments salesrelatedtoFormW-8 and its instructions,such as {fegislation enacted sraeuctloneby broken}rmutual fund and cartain other
after they were published,go lo www.irs.gow/FormW4.=Form 1088-S (proceeds from real estate raneactions)Purpose of Form *Form 1099-K (merchant card andthird party networktransactions)
An individyal or entity (Form W-9 requester}whois requiredto file an *Form 1098 (home mortgage interest),1088-E (student foan interest),information return with the IR'S must obtain your correct taxpayer 1098-T (ition)identification number (TIN]which may be your Social security number *Form 1098-C (canceled debt)
(SSN),individual taxpayer identification number (TIN),adoptiontaxpayeridentificationnumber(ATIN),or amployer Identification number *Form 1088-A (acquisition or abandonment of secured property}IN),to report an an information return the amount paid to you,cr other Use Form W-9 only if you are a U.S,pereon {including a residentamountreportableonaninformationreturn.Exarnples of information allen),te provide your correct TIN.
returns Include,but are not iimited to,the following.if you do not return Form We9 to the requester with a TIN,you might
*Form 1089-INT (interest earned or paid)be subject to backup withholding.Sea What is backup withholding,Jater.
Cal.No,10231X Form W-9 Rov.10-2018)