_117-26_DISTRICTS_AFF__BWC__COI.pdf

PDF 1 MB Posted

Attached to
Competitive Selection OH|DOT11726-4
Contract number
DOT11726-4
Issued by
Ohio

About this file

This document is a compilation of administrative and compliance forms for Lunsford Group LLC, a company located in Norwalk, Ohio. The package includes an Affirmation and Disclosure Form related to state contract services, a Certificate of Ohio Workers' Compensation, a W-9 Request for Taxpayer Identification Number and Certification, and a Certificate of Liability Insurance. The documents are primarily associated with the Ohio Department of Transportation (ODOT), specifically for ODOT Districts 3, 4, and 12.

The certificate of liability insurance from Neil P Kadey Insurance shows commercial general liability and automobile liability coverage for Lunsford Group LLC, with policy limits of $1,000,000 per occurrence and aggregate. The workers' compensation certificate is valid from 07/01/2025 to 07/01/2026, and the liability insurance policies are set to expire between 7/13/2025 and 8/26/2026. The W-9 form indicates the company's tax classification as an individual/sole proprietor or single-member LLC, with an Employer Identification Number of 85-1462575. While specific contract details are not explicitly outlined, the documents suggest Lunsford Group LLC is prepared to provide services to ODOT with appropriate insurance and tax documentation.

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Other files

File Type Posted
_Pricing_Document__117-26_Pricing_2025-08-14.xlsx XLSX spreadsheet
117-26.pdf PDF
Lunsford_COI_ODOT.pdf PDF
Signature.pdf PDF

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Text version

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)

File details come from the government source that posted it. Updated .