1-Affirmation_and_Disclosure_Lunsford_Group_LLC.pdf

3. Location where state data will be located, by Contractor:

(Address) (Address, City, State. Zip)

Name/Location(s) where state data will be located by subcontractor(s):

(Name) (Address, City, State, Zip)

(Name) (Address, City. State, Zip)

(Name) (Address, City, State, Zip)

(Name) (Address, City, State, Zip)

(Name) (Address, City, State, Zip)

Contractor also affirms, understands and agrees that Contractor and its subcontractors are under a duty to disclose to the State any change or shift in location of services performed by Contractor or its subcontractors before, during and after execution of any contract with the State. Contractor agrees it shall so notify the State immediately of any such change or shift in location of its services. The State has the right to immediately terminate the contract, unless a duly signed waiver from the State has been attained by the Contractor to perform the services outside the United States.

On behalf of the Contractor, l acknowledge that I am duly authorized to execute this Affirmation and Disclosure Form and have read and understand that th is form is a part of any Contract that Contractor may enter into with the State and is incorporated therein.

By:

Contractor

Print Name:

Date:

Version 2/20 Page 2 of2

4/6/2025

ACORD

CERTIFICATE OF LIABILITY INSURANCE I

DATE (MM/DDIYYYY)

� 7/25/2024

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

HALL INSURANCE SERVICES

36 Benedict Ave

Norwalk, OH 44857

INSURED

Lunsford Group LLC

3203 St Rt 113 W

Norwalk, OH 44857

COVERAGES CERTIFICATE NUMBER·

CONTACT

Jodi Reisina NAME:

r.��N�. c--. /419)663-3600 it1l��ss: areatrates®hall-ins.net

INSURER/SI AFFORDING COVERAGE

INSURER A: ERIE INSURANCE

INSURER B:

INSURER C:

INSURER D:

INSURER E:

INSURER F:

I r.o� No1:

REVISION NUMBER·

(419\663-7135

NAIC#

26263

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.

INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR ,.,en w"n POLICY NUMBER IMM/DDIYYYY\ IMM/DDIYYYY\

COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000

� CLAIMS-MADE [X] OCCUR

DAMAGE TO Rt:N I Eu

$ 1 000 000 1-- PREMISES /Ea occurrence\

1-- MED EXP (Any one person) $ 5 000

A I--

Q61-0130176 8/26/2024 8/27/2025 PERSONAL & ADV INJURY $ 1 000 000

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2 000 000 P9 POLICY □ r:;rgr □ LOC PRODUCTS - COMP/OP AGG $ 2 000 000

OTHER: $

AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 000 000 I-- !Ea accident\

ANY AUTO SODIL Y INJURY (Per person) $ -

A

OWNED SCHEDULED

Q07-7330272 7/23/2024 7/23/2025 SODIL Y INJURY (Per accident) $

I-- AUTOS ONLY

X

AUTOS

HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY /Per accident\

X UMBRELLA LIAS

�OCCUR EACH OCCURRENCE $ 1 000 000

A EXCESS LIAS CLAIMS-MADE Q32-2670409 7/13/2024 7/13/2025 AGGREGATE $ 2 000 000

OED I I RETENTION $ $

WORKERS COMPENSATION I �ffTUTE I I OTH•

AND EMPLOYERS' LIABILITY ER

Y / N

ANY PROPRIETOR/PARTNER/EXECUTIVE □ E.L. EACH ACCIDENT $

OFFICER/MEMBER EXCLUDED? N / A

(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ g�St�rtir8� 'S':'/;PERATIONS below E.L. DISEASE - POLICY LIMIT $

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)

CERTIFICATE HOLDER

ACORD 25 (2016/03)

CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

All rights reserved.

The ACORD name and logo are registered marks of AC RD

Form W-9 Request for Taxpayer Give Form to the

(Rev. October 2018) Identification Number and Certification requester. Do not

Department of tt>e T reasu,y Internal Revenue Service ► Go to www.irs.gov/FonnW9 for instructions and the latest information.

send to the IRS.

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

Matthew J Lunsford 2 Business name/disregarded entity name, if different from above

Lunsford Group LLC c-i 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

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

C 0 lndividuaVsole proprietor or 0 C Corporation 0 S Corporation 0 Partnership 0 TrusVestate 0

• Ill

GI C a. 0 single-member LL C Exempt payee code �f any) u □ Limited liability company. Enter the tax classttication (C=C corporation, S=S corporation, P=Partnership) ►

.. ::, Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reparting 0 ..

. i i LLC If the LLC is classttied as a single-member LLC that is disregarded from the owner unless the owner of the LLC is code (if any) .. - another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that Cl. .g is disregarded from the owner should check the appropriate box for the tax classificat,on of its owner.

·u

□ Other (see Instructions) ► IADol,ts re .ccou,,ts ffllll'/fatNK/ outs.·dti ffle Us., 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optionaQ Ill al 3203 W SR 113 6 City, state, and ZIP code

Norwalk, OH 44857 7 List account number(s) here (ophonaQ

-�-':T •• Taxcayer Identification Number (TIN) Enter your TIN in. the app_ropriate box. The TIN provided must match the name given on line 1 to avoid backup w1thhold1ng. For 1nd1v1duals, this 1s generally your social secunty number (SSN). However, for a resident alien, sole proprietor, ex disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

I Social security number I

ITJJ -[D -I I I I l or

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Employer identification number

8 5 - 1 4 6 2 5 7 5

Certification Under penalties of pe�ury, 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. Fcx real estate transactions, item 2 does not apply. Fcx mortgage interest paid, acquisition ex abandonment of secured property, cancellation ol debt, contributions to an individual retirement arrangement ORA/, and generally, payments o�er than 1r1temst and dividends, you are not required o • n the certification, but you must provide your correct TIN. See the instructions lex Part II, later.

S H

1gn Signature of • , / ,1 J -,✓ � } r �-/ ere U.S.person► '-1(Vt� v-[--r::, Date► 3/30/2025

General Instructions

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

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of Form

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

• Form 1099-INT (interest earned or paid)

Cat. No. 10231X

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

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

• Form 1099-B (stock a 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}, 1 098-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, later.

Form W-9 (Rev. 10-2018)