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HomeMy Public PortalAboutC-23-206 - STEVEN D SHOEMAKER - 2023 MARIACHI FIESTA SPAMike City of Carson Community Services Department Life, 1 . Service Provider Application 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: Dani Cook or Jason Wong (Event Coordinator’s Name) 801 E. Carson Street, Carson, CA 90745 (Enter Event Coordinator’s address (i.e., city hall, corporate yard, or specific park address) Email: cook @carsonca.gov (Enter event coordinator’s email address) Should you have any questions, please feel free to contact the staff member listed below . Truly, Dani Cook (Name) Human Services Program Manager (Title) 532227.5 CFN 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) Service Provider Application Agreement Invoice for Future Event Date! Business License (if applicable) Proof of Insurance/Certificate of Insurance OR Waiver Requested Waiver, Release, Hold Harmless, Agreement Not to Sue, Indemnification, and Photo Release » pep RR Current Copy of W-9 Form (if not on file already) 09/22/2023 1 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 6-14-2023 June 22, 2023 (Date) Steve Shoemaker (Company) Steve Shoemaker (Company Address) 6057 Greenleaf Ave Whittier Ca 90601 (City, State ZIP) Insurance Requirements Steve Shoemaker Dear , (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, unless a waiver of insurance requirements is requested (by checking the box in the application below) and approved by the City’s Risk Manager in his or her sole discretion. Failure to submit such required forms or obtain waiver approval 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. The City’s Risk Manager, in his or her discretion, may waive these requirements on a case-by-case basis, but the City cannot and will not add entertainers (i.e., persons, such as singers, dancers, or comedians, whose job is to entertain others) as additional insureds on the City’s insurance (regardless of whether or not a waiver is granted), and therefore City’s insurance will not cover any liability of entertainers in the event of a loss. Entertainers: By submitting this application, you: (i) acknowledge that the City’s insurance will not cover your or your business’ liability in the event of a loss; (ii) assume the risk of performing services without City’s insurance coverage, and without any insurance coverage in the event City grants you a waiver of the service provider insurance requirements below or you fail to comply with such requirements; and (iii) agree to release and hold harmless the City from any claims or liability related to same. MINIMUM SCOPE AND LIMIT OF INSURANCE 532227.5 CFN AS OF 6-14-2023 4 General Liability Insurance: Coverage shall be at least as broad as Insurance Services Form CG 00 O01 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 6-14-2023 City of Carson Community Services Department Service Provider Application Agreement Check one (staff use): [| Carson Event Center| | Human Services [ | Recreation [| Transportation lachi Fi Carson Event Cent Hevent Mariachi Fiesta Event Location: CaS" Event Centers, ot Date: 09/22/2023 Steve Shoemaker Name of Service Provider: Business Form/Entity Type (if individual, sole proprietorship, corporation, or limited liability company, specify here): Sole Propriertorship Business Form/Entity Type (if general partnership, limited partnership, limited liability partnership, or other, specify here): Business Entity State of Incorporation (if applicable): Live Sound and Technical Production for Events Type of Service: GuntaeEPeson: Steve Shoemaker Phone #: (562) 322-6698 Emer. Contact: _ Jill Hudson Phone #: (_ 562) 273-5764 Billing Address: 6057 Greenleaf Ave 01007.0001/532227.8 Street Whittier Ca 90601 City State ZIP Proof of Insurance (check one)? Yes [_] No If no, you must request a waiver of insurance requirements. Do you request a waiver of insurance requirements? (check yes if you checked no in the two boxes above) L Yes No F . We need 6: individual 20 amp circuits for the exclusive use for the sound system. Special Instructions / Notes: We request access to the venue to load in, and set up, at 12:30 PM (PST) on the day of the event. 532227.5 CFN AS OF 6-14-2023 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 $1,250.00 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 6-14-2023 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, and Indemnification” agreement submitted concurrently herewith, which is incorporated herein by reference. 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 6-14-2023 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): SERVICE PROVIDER: Steve Shoemaker Sy 07/17:23 (Signature of Service Provider’s Authorized Representative) (ate) Steven D Shoemaker (Printed Name of Service Provider’s Authorized Representative) (Space below this line for City use only) APPLICATION APPROVAL: CITY OF CARSON Ak Lac Pay GF4-13 (Signdture of City Manager or Designee) (Date) 532227.5 CFN AS OF 6-14-2023 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 6-14-2023 10 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 6-14-2023 Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification 11 IL, Fhe $lptwe kif , (“individual”) [on behalf of ap ffnt i late tify ("Extibitor) and as a bona fide agent of Exhibitor duly authorized to execute this Waiver, Release, Hold Harmless, Agveement 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 Mariachi Flesta (“Event”) on September 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. If Signatory in an entertainer (i.e., a person, such as a singer, dancer, or comedian, whose job is to entertain others), then regardless of whether any waiver of insurance requirements is granted, Signatory: (i) acknowledges and agrees that Signatory will not be added to City’s insurance as an additional insured, and therefore City’s insurance will not cover any liability of Signatory or Signatory’s business in the event of a loss; (ii) assumes the risk of performing services without City’s insurance coverage, and without any insurance coverage in the event City grants a waiver of the service provider application agreement insurance ‘requirements or Signatory fails to comply with such requirements; (iii) waives, releases and discharges the City and each City party from any claim related to same; and (iv) agrees to hold City and each City Party harmless from any claim or liability related to same. 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 acknowledges and represents that it has read and understands the above, and that is voluntarily agrees to its ter’ 5 Z—, SIGNED: B- . ORGANIZATION: Steve Shoemaker Sound Name: Steven Shoemaker DATE: 08/09/23 01007.0001/781805.1 AS OF 6-14-2023 ACORLI CERTIFICATE OF LIABILITY INSURANCE �---- DATE (MM/DD/YYYY) 09/05/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Sargeant Insurance Agency, LLC. 7740 Painter Avenue #210 Whittier CA 90602 ACT Cathy Van Wyke-Stahl NE (A/C, No, Ext): (818) 561-2600 FAX No): (818) 436-5988 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A, NAUTILUS INSURANCE COMPANY 17370 INSURED Steven Shoemaker 6057 Greenleaf Avenue Whittier CA 90601 INSURER B: CLEAR SPRING PROPERTY AND CASUALTY COI 15563 INSURER C : INSURERD: INSURER E : INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRL TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY X X NN1562321 08/17/2023 08/17/2024 EACH OCCURRENCE $ 1,000,000.00 CLAIMS -MADE X OCCUR DAMAGE TO RENTE PREMISES (Ea occur ence) $ 100,000.00 MED EXP (Any one person) $ 5,000.00 PERSONAL&ADVINJURY $ 1,000,000.00 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES PRO JECT PER: LOC GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS-COMP/OPAGG $ 2,000,000.00 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/ N N/A CWC001139300 09/12/2022 09/12/2023 X PER STATUTE OTH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Carson is hereby named additional insured by agreement in a written contract or agreement, as it relates to operations of named insured only. See Additional Insured- Waiver of Transfer of rights of recovery Endorsement L815. CERTIFICATE HOLDER CANCELLATION City of Carson 701 E Carson Street Carson CA 90745 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ARVU — ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Steve Shoemaker Bill To: City of Carson Invoice # 147865765 801 E Carson Street Carson Ca 90745 Invoice Date: 07/17/2023 For: Mariachi Festival 2023 Item # Description Qty Column1 Column2 Price 1:00 Sound System 1 2:00 Sound Engineer 1 3:00 Sound Assistant 1 i Ss is { - Ss 5 f r $ i‘ ‘ 2 Invoice Subtotal Tax Rate Sales Tax ; mat N/A Other Deposit Received Not Required Make all checks payable to Steve Shoemaker. : id ‘| Total Amount Due on Sept 22, 2023 Upon Arrival W-9 Form (Rev. October 2007) Department of the Treasury Internal Revenue Service Name (as shown on your income tax return) Steven D Shoemaker Business name, if different from above Request for Taxpayer Identification Number and Certification Give form io the requester. Do not send to the IRS. Check appropriate box: 4] Individual/Sole proprietor C] Other (see instructions) > O Corporation CO Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) > _....-. payee O Partnership a Exempt Address (number, street, and apt. or suite no.) 6057 Greenleaf Ave Print or type Requester’s name and address (optional) Gity, state, and ZIP code Whittier Ca 90601 List account number(s) here (optional) See Specific Instructions on page 2. Ena Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 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 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 554: 15 | 7779 or Employer identification number 2m 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. l|am not subject to backup withholding because: (a) | am 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. 1amaU.S. citizen or other U.S. person (defined below). 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 retum. 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 4. Sign Signature of Here U.S. person > 4E—- Bho General Instructions Section references are to the Internal Revenue Code unless otherwise noted. 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, 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 withholding, 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 withholding tax on foreign partners’ share of effectively connected income. Note. If 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. Cat. No. 10231X Date r/Cl6ZOZ2 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 e@ 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 on any foreign partners’ share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner ina 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 withholding on your share of partnership income. The person who gives Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases: ® The U.S. owner of a disregarded entity and not the entity, Form W-9 (Rev. 10-2007)