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HomeMy Public PortalAboutC-23-074 - DENINE N. KIRBY - AUTISM AWARENESS WALK SPAMois City of Carson Community Services Department i i . Service Provider Application Better: Dear Applicant, On behalf 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 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 attachments directly to the following address: City of Carson Attn: Eileen Tinnie (Event Coordinator’s Name) (Enter Event Coordinator’s address (i.e., city hall, corporate yard, or specific park address) Email: etinnie@carsonca.gov (Enter event coordinator’s email address) Should you have any questions, please feel free to contact the staff member listed below . Truly, Eileen Tinnie (Name) Human Services Assistant Coordingy (Title) 532227.5 CFN AS OF 3/14/2023 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) Se Service Provider Application Agreement iv Invoice for Future Event Date’ Business License (if applicable) Proof of Insurance/Certificate of Insurance ~~ Waiver, Release, Hold Harmless, Agreement Not to Sue, Indemnification, and Photo Release 4 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 3/14/2023 March 28, 2023 (Date) Denine Nalls-Kirby (Company) 1863 E. Abbottson St. (Company Address) Carson, Ca. 90746 (City, State ZIP) Insurance Requirements Dear Denine Kirby (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: Y Compliant Certificates of Liability Insurance (to be maintained for the duration of 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 01 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 appointed officials, 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 3/14/2023 City of Carson Community Services Department Service Provider Application Agreement Check one (staff use): [] Carson Event Center| v | Human Services [| Recreation [| Transportation April 22, 20: Event: ely GT GSISON AUIS sina Event Location: CSUDH Event Date: pu Name of Ser vi ce Prov i der: Denine Nall s-K irby Business Form/Entity Type (if individual, sole proprietorship, corporation, or limited liability company, specify here): Individual Business Form/Entity Type (if general partnership, limited partnership, limited liability partnership, or other, specify here): Business Entity State of Incorporation (if applicable): Conduct 30minute warm-up(7:55am-8:25am) for Autism Awareness 5K RunWalk, Type of Service: _ Denine Kirby 7 310-569-19 Contact Person: Phone #: ( 5 a Eimer. Contact: “UEta Niroy Phone #; (310-f69-194§ Billing Address: 1863 E. Abbottson Street Number Street Carson, CA 90746 City State ZIP Proof of Insurance (check one)? [v lves [No If NO, please complete the attached insurance waiver form. Special Instructions/Notes: 532227.5 CFN AS OF 3/14/2023 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 1 of this application: Total Service Fee a0.00 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. [remainder of page intentionally left blank] 532227.5 CFN AS OF 3/14/2023 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 with all 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 approval or authorization for Service Provider to perform or provide 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 manner represent that Service Provider or any of its agents or employees are agents or employees of City, or that it is a member of 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 which Service Provider, its agents or employees, perform the services set forth herein. In the event that part of this Agreement is declared invalid or unenforceable by a valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of 532227.5 CFN AS OF 3-14-2023 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): Denine Nalls-Kirby Ke March 28, 2023 (Signature of Service Provider's Authorized Representative) (Date) SERVICE PROVIDER: Denine Nalls-Kirby (Printed Name of Service Provider’s Authorized Representative) (Space below this line for City use only) APPLICATION APPROVAL: CITY OF CARSON Vhirhasl Upiéttzbear, a April 18, 2023 (Signature of City Manager or Designée) CO (Date) 532227.5 CFN AS OF 3-14-2023 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 become binding and a part of the Service Provider Application Agreement between the 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 damage to, loss or theft of the Provider’s property, or that of Provider’s agents, employees or invitees. 5. CHARACTER OF ENTERTAINMENT: The Provider shall observe, obey and comply with all applicable local, state and federal laws, and all applicable policies, rules, regulations and terms and conditions governing use of City facilities. The Provider will 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 each 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 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 3-14-2023 9. VOLUME/LIGHT CONTROL: The City reserves the right to regulate the volume or intensity 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 of the 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 Department regulations. 11. COPYRIGHT INFORMATION: Provider is responsible for licensing fees as required by law. Provider may be subject to legal action for the use, display or sale of any item using 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 use or activity . 13. OBLIGATION FOR CLEANLINESS: Provider agrees that the facility and any other surrounding City property (including parking lots) used by the Provider must be left in a clean 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 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. 532227.5 CFN AS OF 3-14-2023 Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification 10 I, Denine Nalls-Kirby , (“individual”) [on behalf of (“Exhibitor”), and as a bona fide agent of Exhibitor duly authorized to execute this Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification agreement (“Agreement”) on behalf of Exhibitor] (individual and Exhibitor hereinafter collectively referred to as “Signatory,” and the term “Signatory” includes Exhibitor’s officers, officials, employees, agents and volunteers), seek acceptance by the City of Carson of an application to provide services in/at Autism Awareness 5K Run/Walk . (“Event”) on April 22, 2023 (“Date”). Signatory understands that accidents, illnesses, 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 the City of Carson, its elected and appointed officers, officials, employees, agents and volunteers (collectively “City,” and individually, “City Party”), and from and against any and all claims or liabilities to Signatory or any other person or entity, including but not limited to claims or liabilities for bodily injury, illness, death, or property damage, arising out of or connected in any way with Signatory’s participation in, presence at, or performance of services at or for the Event, even though that liability may arise out of negligence or carelessness on the part of City, and Signatory agrees to waive its rights to make any such claims through any action or proceeding against the City or any City Party, However, Signatory understands that this paragraph is not intended to release any party from any act or omission of “gross negligence.” 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 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. Signatory further agrees to indemnify, defend and hold harmless City and each City Party 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 Exhibitors 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 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. In giving the foregoing releases and waivers, Signatory expressly waives any and all rights conferred upon it by the provisions of California Civil Code Section 1542, which Signatory understands reads as follows: “A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her favor at the time of executing the release and that, if known by him or her, would have materially affected his or her settlement with the debtor or released party.” This waiver shall be effective as a bar to any and all actions, fees, damages, losses, claims, liabilities and demands of whatsoever character, nature and kind, that are known or unknown, or suspected or unsuspected, that may arise from or relate in any way to Signatory’s participation in the Event. This Agreement shall be binding on Signatory’s successors, heirs and assigns, and shall not expire. No oral representations, statements or inducements, apart from this written form, have been made with regard to the subject matter of this form. If any portion of this form is declared invalid by a court of competent jurisdiction, the remainder shall continue in full force and effect. By signing below, Signatory acknowledges and represents that it has read and understands the above, and that it voluntarily agrees to its terms. By signing below, Signatory acknow diges and xepreserjts that it has-kead and understands the above, and that is voluntarily agrees to its terms. V SIGNED: \ ed NAME:_\) mine Nal \s- Ofby ORGANIZATION: DATE: A- \L- Vy 01007.0001/781805.1 AS OF 3-14-2023 Please note: The City of Carson’s own insurance will cover the City’s liability but will not cover an Entertainer’s liability. All service providers (including entertainers) are still required to carry insurance. We must require this because it is a condition of the City’s Excess insurance policy. Acknowledgement: 1. Signed: Date: | am an entertainer that will perform at the City of Carson event. | am confirming that | and my business do not have commercial general liability insurance as required by the City of Carson but am still interested to provide services at the event. | acknowledge and agree that in the event of a loss the City of Carson or its insurance carrier will not provide coverage to me or to my business. | further acknowledge and agree that in the event of a loss resulting from my or my business’ wrongful or negligent acts, the City of Carson or its insurer will seek to recover its financial loss from me or my business. | will cooperate in every way with the said recovery efforts. The City of\Carson may, appre ve this request or may reject it at its discretion. wordt Jnr [lag are ae DATE (MMIDDIVYYY) 2 Vo ACORD ‘ , 10/27/2022 PRODUCER Insurance Plus 866-756-5636 Arthur J. Gailagher Risk Management Services, Inc. CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 8430 Enterprise Circle, Suite 200 Lakewood Ranch, FL 34202 _INSURERS AFFORDING COVERAGE NAIC # INSURED . INSURER A: Arch Specialty insurance Company- Surplus _ 21199 Denine L Kirby Lines insurance 1863 E Abbottson St Report all claims via e-mail at sarasota. bsd. operations @ajg. com CARSON, CA 90746 Ins. # 337672 | isurER &: INSURER C: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTAN DING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN [S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REOUCEO BY PAID CLAIMS. iNSR ADDL POLICY EFFECTIVE POLICY EXPIRATION LTR_INSRD TYPE OF INSURANCE POLICY NUMBER DATE (M/DO/YYYY)_DATE (MMIDD: LIMITS GENERAL LIABILITY EACH OCCURRENCE 32,000,000. DAMAGE TORENTED _ X COMMERCIAL GENERAL LIABILITY 10/27/2022 10/27/2023 — premises (Ea occurrence) _ $ 100.000 ciaims mane | X «OCCUR: = #PLPO066026-01 MED EXP (Any one person}, SN/A A / / PERSONAL & ADVINJURY —_ $ 2.000.000 co on GENERALAGGREGATE 5 3.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: : PRODUCTS - COMPIOP AGG _§2,000.000 X_poucy Ro Loc | BUS.PERS.PROP.AGG/DED _$1,000/ $250 AUTOMOBILE LIABLITY COMBINED SINGLE LIMIT g ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY ; _ SCHEDULED AUTOS (Per person} __ HIRED AUTOS BODILY INJURY 5 _ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE 5 (Per accident) GARAGE LIABILITY AUTO ONLY- EA ACCIDENT = 5 _ ANY AUTO OTHER THAN EAACC § AUTO ONLY: AGG i$ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE _ $ OccUR CLAIMS MADE AGGREGATE $ 's _ DEDUCTIBLE 3 RETENTION _§ _S RS ATION We STATU- OTH. WORKERS COMPENSATION TORYLUMITS. ER. AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDE (Mandatory in NH) H yes, describe under FP PR E.L, EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE § E.L, DISEASE - POLICY LIMIT _ $ 2,000,000 per occurrence / $3,000,000 annual OTHER is iatili A Professional Liatility aggregate #PLPO066026-01 10/27/2022 10/27/2023 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS. Not Applicable CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION li Insu rance Approved DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _ 10 DAYS WRITTEN Not App icable NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL By: KI IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. cy A Date: 4/18/2023 AUTHORIZED REPRESENTATIVE No en penn | \ © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORD 25 (2009/01) INSO25 (200901) Invoice Invoice #_ 5102019002. Date: 04/22/2023 __ Name: Denine Nalls-Kirby Address: 1863 E. Abbottson Street, Carson, CA 90746 To: City of Carson 701 E. Carson Street, Carson, CA 90745 Warm Up and Stretching Leader for Annual City of Carson Autism Awareness 5K event on Saturday, April 22, 2023. Cost of Services: $50. Please remit payment as soon as possible. Thank you. Vendor Signature _ Denine Nas-Kinby Date _ 4-22-2023 = Form W. 9 (Rev. August 2013) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Name (as shown on your income tax return) Denine Nalis-Kirby Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification: Individual/sole proprietor -] © Corporation Pr i n t or ty p e C] Other (see instructions) » C] S Corporation Q Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) » Exemptions (see instructions}: Cr] Partnership 0 Trust/estate Exempt payee code (if any) Exemption from FATCA reporting code (if any) Address (number, street, and apt. or suite no.) 1863 E. Abbottson Street Requester’s name and address (optional) City, state, and ZIP code Carson, CA 90746-2901 Se e Sp e c i f i c In s t r u c t i o n s on pa g e 2. List account number(s) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part | instructions on page 3. For other 4/417) -| 8] 6} -1714/011 entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Social security number Employer identification number cine Certification Under penalties 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 me), and 2. | am not subject to backup withholding because: (a) 1am exempt from backup withholding, or (b) | have not been notified by the Internal Revenue Service (IRS) that | am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that | am no longer subject to backup withholding, 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) indicating that | am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Signature of Here U.S. person > A General Instructions Section references are to the internal Revenue Code unless otherwise noted. Future developments. The IRS has created a page on IRS.gov for information about Form W-9, at www.irs.gov/w9. Information about any future developments affecting Form W-9 (such as legislation enacted after we release it) will be posted on that page. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, payments made to you in settlement of payment card and third party network transactions, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withhoiding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the 4/3/2023 withholding tax on foreign partners’ share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: * An individual who is a U.S. citizen or U.S. resident alien, * A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, An estate (other than a foreign estate), or « A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income. Date > Cat. No, 10231X Form W-9 (Rev. 8-2013)