JC_Vendor_Packet_2015.pdf

MTC VENDOR SELF-CERTIFICATION FORM

Vendor/Company Name Contact Name

Mailing Address

_____________________________________ Phone # ___________________________

_____________________________________ Fax # ___________________________

_____________________________________ E-mail ___________________________

Project Name or Solicitation Number: ____________________________________________________

The North American Industry Classification System (NAICS) code (6-digit) for this company’s industry is:

(1)________________

(2)________________

(3)________________

Section 1- Under FAR 52.219-8, all subcontractors must represent their business category per the attached “Definitions for Small Business Categories” per the stated project’s NAICS code.

Vendor Categories (check all that apply):

____ Small Business

____ Small Disadvantaged

____ Small Women-Owned

____ Small Veteran-Owned

____ Service-Disabled Veteran-Owned

____ HubZone (SBA Certified)

______ Large Business

______ Government

______ Non-Profit

Under Section 16 of the Small Business Act and Title 13 of the Code of Federal Regulations, any person or concern that knowingly misrepresents the small business size status of a person or concern in connection with federal government subcontracting opportunities is subject to penalties, including fines, imprisonment and debarment.

Section 2 - Under FAR 52.209-6, each proposed first-tier subcontractor, whose subcontract will exceed $30,000, must disclose whether as of the time of award of the subcontract, the subcontractor, or its principals, is or is not debarred, suspended, or proposed for debarment by the Federal Government.

The Offerors and/or any of its Principals— Are are not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency;

I certify that I have checked the appropriate categories for my company in Sections 1 & 2.

Signature of company representative Date

Printed Name Title

Feb2015pw patricia.willover Typewritten Text patricia.willover Typewritten Text

DEFINITIONS FOR SMALL BUSINESS CATEGORIES

For “MTC Vendor Self-Certification Form”

Small Business A small business as defined pursuant to Section 3 of the Small Business Act and relevant regulations.

(1) The Small Business Act states that a small business concern is “one that is independently owned and operated and which is not dominant in its field of operation.”

(2) The Act also states that the size standard varies from industry to industry. The Small Business Administration has established a table of size standards based on average annual receipts or average number of employees, which is matched to the North American Industry Classification System (NAICS). The table may be accessed at http://www.census.gov/eos/www/naics.

Small Disadvantaged Business (SDB) A small business concern that represents, as part of its offer that –

(1) It has received certification as a small disadvantaged business concern consistent with 13 CFR part 124, subpart B;

• 13 CFR 124.1001 (c) A firm may represent that it qualifies as an SDB for any Federal subcontracting program if it believes in good faith that it is owned and controlled by one or more socially and economically disadvantaged individuals.

• 13 CFR 124.1002 (c) Which is at least 51 percent unconditionally owned by one or more socially and economically disadvantaged individuals set forth in 124.105.

a) No material change in disadvantaged ownership and control has occurred since its certification;

b) Where the concern is owned by one or more individuals, the net worth of each individual upon whom the certification is based does not exceed $750,000 after taking into account the applicable exclusions set forth at 13 CFR 124.104(c)(2); and

c) It is identified, on the date of its representation, as a certified small disadvantaged business in the database Central Contractors Registration (www.ccr.gov ) Dynamic Small Business Search database maintained by the Small Business Administration, or

(2) It represents in writing that it qualifies as a SDB for any Federal subcontracting program, and believes in good faith that it is owned and controlled by one or more socially and economically disadvantaged individuals, and meets the SDB eligibility criteria of 13 CFR 124.1002.

Women-Owned Small Business A small business concern that

(1) Not less than 51 percent of which is owned by one or more women or, in the case of any public-owned business, not less than 51 percent of the stock of which is owned by one or more women, and

(2) The management and daily business operations of which are controlled by one or more women.

Veteran-Owned Small Business A small business concern that

(1) Not less than 51 percent of which is owned by one or more veterans (as defined in 38 USC 101(2)) or, in the case of any public-owned business, not less than 51 percent of the stock of which is owned by one or more veterans, and

(2) The management and daily business operations of which are controlled by one or more veterans.

Service-Disabled Veteran-Owned Small Business A small business concern that –

(1) Not less than 51 percent of which is owned by one or more service-disabled veterans or, in the case of any public-owned business, not less than 51 percent of the stock of which is owned by one or more service-disabled veterans

a. The management and daily business operations of which are controlled by one or more service-disabled veterans or, in the case of a service-disabled veteran with permanent and severe disability, the spouse or permanent caregiver of such veteran.

(2) “Service-disabled veteran” means a veteran, as defined in 38 USC 101(2), with a disability that is service-connected, as defined in 38 USC 101(16).

HUBZone Small Business A small business concern must appear on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration. (More information about the HUBZone Small Business program and its benefits to qualifying companies can be obtained from the Small Business Administration.)

December2011pw http://www.census.gov/eos/www/naics http://www.ccr.gov/

2/7/2011

Vendors: Please complete the items marked with a single asterisk (*).

VENDOR SET-UP FORM

VENDOR NUMBER ___________________ Date entered ____________

*Vendor Name Entered by ______________

Vendor Class (one-time (students/inmates only), govt., large, non-profit, small, small disadvantaged, women, veteran, service-disabled veteran, HUB, etc.)

*Tax ID (if applicable)** *DUNS#_____________________

*Address

*City

*State *Zip

Vendor Contact Information:

Search Name *Fax

*Legal Name *Acct #

*Contact Name *Email

*Phone *URL (website)

*Payment Terms *FOB

Income Code (if applicable)** *Shipping

REMIT or ALTERNATE LOCATION NAME AND ADDRESS, if different than above

REMIT or ALTERNATE, circle one

Location Code *Alternate Name

*Address *Alternate Contact Name *City *Phone

*State *Zip *Fax

Enter Company# Other Commodity Commodity #/Description *Minority 3-digit code (NAICS)

Date sent Date received Date requested Date received

W-9 Form ________ _______ Business license (as applicable) _________ _________ SBE certification ________ _______ expiration date _______ (if applicable) I nsurance (as applicable) _ ________ _________ MTC T&C’s ________ ex piration date _______

**for 1099 reporting purposes

Form W-9 (Rev. December 2014) 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.

P ri n t o r ty p e

S ee

S p e c if ic

I n s tr u c ti o n s o n p ag e

2.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I 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 generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I 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 instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number or Employer identification number

Part II Certification

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I 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 I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I 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 Here

Signature of

U.S. person Date

General Instructions Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

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, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.

Cat. No. 10231X Form W-9 (Rev. 12-2014)

W9Form

Project Name/Solicit #: