3-Parker County Vendor Packet - Bids.pdf

Direct Line: 817.598.6140 Parker County Purchasing Fax: 817.598.6191

1112 Santa Fe Dr. Weatherford Texas 76086

Dear Vendor:

Please complete and return the enclosed Vendors/Bidders List Application form. Upon receipt of the Application, We will input the information provided into our system and assign you a vendor number in order for county departments to make purchases from you. When you return all documentation requested your company will be added to our Vendor List. Please include a completed W-9 Form.

Please note Parker County is tax exempt, therefore no taxes should be assessed to any purchases. Parker County’s Tax Identification Number is 756001109.

Thank you for your cooperation in this matter. If you have any questions, please do not hesitate to contact us at 817.598.6140.

Sincerely, Parker County Purchasing Dept

Enclosures

Parker County

TERMS AND CONDITIONS

1. CONFLICT OF INTEREST: No public official shall have an interest in this contract, in accordance with Texas Local Government Code Chapter 171.

2. ETHICS: The bidder shall not offer any benefits, gifts, or enticements of any nature to any official, agent or employee of Parker County.

3. FUNDING: Funds for payment have been provided through the Parker County budget approved by the Commissioner’s Court for this fiscal year only. Texas law prohibits the obligation and expenditure of public funds beyond the fiscal year for which a budget has been approved. Therefore, anticipated orders or other obligations that may arise past the end of the current Parker County fiscal year shall be subject to budget approval.

4. LATE BIDS: Bids must be received by the Purchasing Department before the hour and date specified. Bids received after that time will be disqualified and returned to the sender. Parker County is not responsible for tardiness or non-delivery of documents by mail or courier. All NO BIDS shall be marked as such and timely returned. Failure to do so will result in deletion from the Vendor list.

5. NON-APPROPRIATION: Notwithstanding any provisions contained herein, this contract is expressly contingent upon the availability of funding for each item and obligation contained herein for the term of the agreement and any extension thereto. In the event that either no funds or insufficient funds are appropriated for the payments due under this contract for the period covered by such budget or appropriation, the contract shall terminate without penalty to Parker County.

6. DELIVERY: All delivery and freight charges (F.O.B. Parker County designated location) are to be included in the bid price.

7. BID AWARD: Bids may be awarded on the lump sum or unit basis, whichever is in the best interest of Parker County. Bids that are by unit price must be extended and the total shown. In case of errors in extension, unit prices will be taken.

8. Pursuant to Texas Local Government Code section 262.0276, the Parker County Commissioner’s Court has adopted a policy which requires vendors’ taxes to be current as of the date bids or proposals are due. Bidders with delinquent taxes on the due date are ineligible for award.

9. Any clarification or questions concerning bids should be directed to the County Purchasing Department prior to bid opening.

10. MINIMUM STANDARDS FOR RESPONSIBLE BIDDERS: A bidder must affirmatively demonstrate the bidder’s responsibility by meeting the following requirements:

a. have adequate financial resources, or the ability to obtain such resources as required;

b. be able to comply with the proposed delivery schedule

c. have a satisfactory record of performance, and;

d. have a satisfactory record of integrity and ethics.

Parker County may request information sufficient to determine bidder’s ability to meet the minimum standards listed above.

11. The bidder shall provide with its bid all documentation required by the invitation to bid.

Failure to comply may result in bid rejection. Bids must be signed by an authorized representative and show the full name and address of the bidder.

12. ADDENDA: Any alteration to, or interpretation of, the invitation to bid will be made by the Parker County Purchasing Department in the form of an addendum. Addenda will be sent by mail, email or fax to all who are known to have received a bid invitation. Bidders shall acknowledge receipt of such addenda. For verification addenda must be signed by the vendor and returned with the IFB/RFP response.

13. ALTERING BIDS: Bids cannot be altered or amended after opening time. Any alterations made before opening time must be signed by the bidder or its agent.

14. WITHDRAWAL OF BID: A bid may not be withdrawn or cancelled by the bidder without the permission of the County for a period of 90 days following the deadline for receiving bids. By submitting a bid, bidder agrees to leave its bid open for 90 days. The Commissioner’s Court reserves the right to reject any or all bids.

15. SALES TAX: Parker County is exempt from Federal Excise Tax and State Sales Tax. A certification for this exemption is available upon request. Accordingly, tax should not be included in bid price or invoice.

16. CONTRACT: A contract may be awarded to the lowest and best bidder as established by state law. This bid, when accepted by the Parker County Commissioner’s Court, shall constitute a contract between the successful bidder and Parker County. The contract shall be governed by these Terms and Conditions and the bid shall be incorporated by reference.

17. CHANGE ORDERS: No oral statement shall modify or otherwise change or affect the terms, conditions, or specifications stated in the contract resulting from this invitation to bid. All change orders to the contract will be made in writing to the Parker County Purchasing Department, and approved by Parker County Commissioner’s Court.

18. If during the life of the contract, the successful bidder’s net prices to other customers for items awarded herein are reduced below the contracted price, the bidder agrees to extend the benefits of such reduction to Parker County.

19. ASSIGNMENT: The successful bidder may not sell, assign, transfer or convey the resulting contract, in whole or in part, without the prior written consent of Parker County.

20. TERM OF CONTRACT: The contract arising from the invitation to bid shall remain in effect until it is fulfilled by the delivery and acceptance of the products and the performance of the services specified in the invitation to bid. This contract shall remain in effect until contract expires or delivery and or performance of services ordered terminated by either party with a thirty (30) day written notice. The successful bidder must state therein the reasons for such cancellation. Parker County reserves the right to award cancelled contract to next lowest and best bidder as it deems to be in the best interest of the county.

21. TERMINATION FOR DEFAULT: In the event of a breach or default by the bidder, Parker County reserves the right to enforce the performance of this contract in any manner authorized by law or deemed in the best interest of the County. Parker County reserves the right to terminate the contract immediately in the event the bidder:

a. fails to meet schedules;

b. defaults in the payment of any fees, or;

c. otherwise fails to perform in accordance with these specifications.

Breach of Contract or default authorizes Parker County to exercise any or all of the following rights:

a. take possession of the assigned premises and any fees accrued or becoming due to date;

b. take possession of all goods, fixtures and materials of the bidder and foreclosure its lien against such personal property, applying the proceeds toward fees due or thereinafter become due, and;

c. award the contract to the next lowest and best bidder as deemed in the best interest of the County.

In the event the successful bidder fails to perform, keep, or observe any of the terms and conditions herein, Parker County shall give the bidder written notice of such default. If the default is not cured within two working days of receipt of such notice, default will be declared and the bidder’s rights shall terminate.

22. NOTICES: All notices to be given to the bidder by Parker County shall be deemed given on the day after such notice has been deposited in the United States mail in Parker County, Texas by Registered or Certified Mail, with sufficient postage affixed, addressed to the bidder at the address provided by the bidder. This provision shall not prevent the issuance of actual notice in any other manner.

23. DESCRIPTIONS: Any catalog, brand name, or manufacturer reference used in the bid request is descriptive not restrictive. It is intended to indicate the type and quality desired.

Bids on brands of like nature and quality will be considered.

24. EXCEPTIONS/SUBSTITUTIONS: All bids meeting the intent of this invitation to bid will be considered. Bidders excepting to the specifications or offering substitutions shall state the exceptions in the section provided in the invitation or by attachment as part of the bid.

The absence of such a list shall indicate that the bidder has taken no exception and the bidder agrees to perform in strict compliance with the invitation. Parker County reserves the right to accept any, all, or none of the exceptions or substitutions.

25. SAMPLES: When requested, samples shall be furnished at no cost to Parker County.

After notification to the bidder, such samples must be retrieved from the County within two weeks. Samples not retrieved timely shall be deemed donated to the County.

26. ITEMS/WARRANTY: All items must be new and in first class condition, unless otherwise specified. The design, strength, and quality of materials must conform to the highest manufacturing standards. Items supplied under this contract are subject to the County’s approval. The bidder warrants that all items and services conform to the specifications in the invitation to bid. The bidder further agrees that none of the warranties stated in the Texas Business and Commerce Code may be waived and that the items supplied under this contract shall be free from all defects in material, workmanship, and title. Any items found defective or not meeting specifications shall promptly be and replaced by the successful bidder at no expense to the County. If a defective or non-conforming item is not retrieved by the bidder within one week after notification of its status as defective or non-conforming, the item will be deemed donated to the County. This will not relieve the bidder of its responsibility to provide a properly functioning replacement that conforms with the bid specifications.

27. REMEDIES: The successful bidder and Parker County agree that both parties have all rights, duties and remedies allowed by state law.

28. VENUE: This agreement will be governed and construed according to the laws of the State of Texas and is performable in Parker County, Texas.

29. PATENTS/COPYRIGHTS: The successful bidder agrees to protect Parker County from claims involving infringement of patents and /or copyrights and will indemnify Parker County for such claims.

30. PURCHASE ORDERS: A purchase order shall be generated by Parker County to the successful bidder. The number from this purchase order must appear on all invoices.

31. INVOICE: The successful bidder shall submit an invoice showing the bidder’s name and address, the name and address of the bidder’s receiving department or delivery location, the purchase order number, and a description of the items delivered.

32. PAYMENT: Payment will be made within 30 days upon acceptance of merchandise and satisfactory operation of equipment, or performance of services, in accordance with the Texas Prompt Payment Act, Texas Government Code Chapter 2251.

33. THE SUCCESSFUL BIDDER SHALL defend, indemnify and hold harmless Parker County and its officials, agents, and employees from all claims of any nature brought on account of any injuries or damages received during the performance of any contract resulting from the award of this bid. Bidder shall pay any judgment, including costs, which may be obtained against the County arising from such claim.

34. SILENCE OF SPECIFICATIONS: The apparent silence of these specifications as to any detailed description of, or the apparent omission of, an item shall be regarded as meaning that only the best commercial practices are to prevail. All interpretations of these specifications shall be made on that basis.

35. INSURANCE: In bids involving services provided on Parker County premises, the successful bidder shall at his own expense, before commencing work, or not later than 10 days following notification of award, provide the Parker County Purchasing Department with certified copies of all insurance policies showing coverage in force throughout the term of the contract in the following amounts:

a. Commercial General Liability insurance with minimum combined single limits of

$1,000,000 per occurrence and $1,000,000 general aggregate for bodily injury and property damage, which coverage shall include products/completed operations, with a $1,000,000 products/completed operations aggregate.

Coverage must be written on an occurrence form. If coverage is written on a claims made basis, a retro date no later than the inception date of the contract (or prior thereto), must be applicable during the term of contract and for at least two years after termination of the contract. Contractual liability coverage must be maintained with respect to the per occurrence limit. A per project aggregate endorsement must also be included.

b. Worker’s Compensation insurance at statutory limits.

c. Commercial Automobile Liability insurance with minimum limits of

$100,000/$300,000/$100,000 per occurrence or $500,000 combined single limits for bodily injury and property damage, including owned, non-owned, and hired vehicle coverage.

The required limits may be satisfied by any combination of primary, excess, or umbrella insurance, provided the primary policy meets the above requirements and the excess umbrella is following form. Each policy shall include, by endorsement to the policy, a statement that notice of cancellation, or of a material change in coverage, shall be given to Parker County by certified mail 60 days prior to the event.

A comprehensive general liability insurance form may be used in lieu of a commercial general liability insurance form. In this event, coverage must be written on an occurrence bases, with limits of $1,000,000 per occurrence, combined single limit, and coverage must include a broad form comprehensive general liability endorsement, coverage for products/completed operations, and broad form contractual liability covering the obligations included in the contract.

36. Entire Agreement; Order of Precedence. The Parker County Terms & Conditions, Order Form, the Terms & Conditions, and the Incorporated Documents constitute the complete Agreement between the parties and supersede any prior discussion or representations regarding the Customer’s purchase and use of the Services.

To the extent any conflict exists between the terms of the Agreement, the documents will govern in the following order or precedence: (1) the Parker County Terms & Conditions

(2) the Order Form, (3) the Vendor Terms & Conditions, and (4) the Incorporated Documents. No other purchasing order or similar instrument issued by either party in connection with the Services will have any effect on the Agreement or bind the other party in any way.

THESE ARE GENERAL TERMS AND MAY BE SUPERSEDED BY MORE

DETAILED SPECIFICATIONS

I ____________________________,_________________________ (Print Name) (Title) have read and agreed to the terms and conditions set forth by Parker County.

Sign __________________________________________________

Date_______________________________

Parker County Purchasing 1112 Santa Fe Drive Weatherford, Texas 76086

817-598-6140 ---- 817-598-6191 fax

VENDOR / BIDDERS LIST APPLICATION

Date: ________________ Federal ID # or Social Security #:_______________

( ) New Application ( ) Add Commodities ( ) Delete Commodities

Applicant’s Company Name and Address:

Mailing (Remit to) Address if different than above:

Phone: _________________________________ Fax: ________________________________

E-mail address: _______________________________________________________________

Type of Organization:

Individual ( ) Corporation ( ) Minority Owned ( )

Woman Owner ( ) Non Profit Organization ( ) Partnership ( )

How long in business: ______________

Person’s authorized and contact person on bids or quotes and to sign bids, Offers and Contracts:

Name Official Capacity Telephone / Fax

Type of Business:

( ) Manufacturer ( ) Service

( ) HUB Vendor ( ) Wholesale Dealer ( ) Retail Dealer ( ) Other

Type of Product Sold and/or Service Provided:

I herby certify that information supplied herein is correct:

Print or type Name Title Signature

VENDOR REFERENCES

Please list three (3) references, other than Parker County, who can verify the quality of service your company provides. The County prefers customers of similar size and scope of work to this proposal.

REFERENCE ONE

GOVERNMENT/COMPANY NAME: _________________________________________________

LOCATION: ____________________________________________________________________

CONTACT PERSON AND TITLE: ___________________________________________________

TELEPHONE NUMBER: __________________________________________________________

SCOPE OF WORK: ______________________________________________________________

CONTRACT PERIOD: ____________________________________________________________

REFERENCE TWO

GOVERNMENT/COMPANY NAME: _________________________________________________

LOCATION: ____________________________________________________________________

CONTACT PERSON AND TITLE: ___________________________________________________

TELEPHONE NUMBER: __________________________________________________________

SCOPE OF WORK: ______________________________________________________________

CONTRACT PERIOD: ____________________________________________________________

REFERENCE THREE

GOVERNMENT/COMPANY NAME: _________________________________________________

LOCATION: ____________________________________________________________________

CONTACT PERSON AND TITLE: ___________________________________________________

TELEPHONE NUMBER: __________________________________________________________

SCOPE OF WORK: ______________________________________________________________

CONTRACT PERIOD: ____________________________________________________________

Article VII. Conflict of Interest Questionnaire

Chapter 176 of the Texas Local Government Code requires a vendor who enters or seeks to enter into a contract for the sale or purchase of real property, goods, or services with a local governmental entity or local government officer thereof to file a conflicts of interests disclosure questionnaire with the governmental entity prescribed.

A Conflict of Interest Questionnaire Form (CIQ) must be submitted not later than the seventh (7th) business day after the date the vendor begins discussion, negotiation, applies or response to a request for proposal or bids, or correspondence in writing related to a potential contract with the local governmental entity.

Article XIII. Certificate of Interested Parties (Form 1295)

In 2015, the Texas Legislature adopted House Bill 1295, which added section 2252.908 of the Government Code. The law states that a governmental entity or state agency may not enter into certain contracts with a business entity unless the business entity submits a disclosure of interested parties to the governmental entity or state agency at the time the business entity submits the signed contract to the governmental entity or state agency. The law applies only to a contract of a governmental entity or state agency that either (1) requires an action or vote by the governing body of the entity or agency before the contract may be signed or (2) has a value of at least $1 million. The disclosure requirement applies to a contract entered into on or after January 1, 2016.

The Texas Ethics Commission was required to adopt rules necessary to implement that law, prescribe the disclosure of interested parties form, and post a copy of the form on the commission’s website. The commission adopted the Certificate of Interested Parties form (Form 1295) on October 5, 2015. The commission also adopted new rules (Chapter 46) on November 30, 2015, to implement the law.

Filing Process:

On January 1, 2016, the commission made available on its website a new filing application that must be used to file Form 1295. A business entity must use the application to enter the required information on Form 1295 and print a copy of the completed form, which will include a certification of filing that will contain a unique certification number. An authorized agent of the business entity must sign the printed copy of the form and have the form notarized. The completed Form 1295 with the certification of filing must be filed with the governmental body or state agency with which the business entity is entering into the contract.

Briefly stated, all contracts requiring an action or vote by the governing body of the entity or agency before the contract may be signed (regardless of the dollar amount) or that has a value of at least $1 million will require the on-line completion of Form 1295 “Certificate of Interested Parties,” in accordance with Texas Government Code Statute §2252.908. Form 1295 is also required for any and all contract amendments, extensions or renewals. All business entities are required to complete and file electronically with the Texas Ethics Commission using the online filing application.

The governmental entity or state agency must notify the commission, using the commission’s filing application, of the receipt of the filed Form 1295 with the certification of filing not later than the 30th day after the date the contract binds all parties to the contract. The commission will post the completed Form 1295 to its website within seven business days after receiving notice from the governmental entity or state agency.

Information regarding how to use the filing application will be available on this site by January 1, 2016, https://www.ethics.state.tx.us/File/, please follow Instructional Video for Business Entities.

Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 12/22/2017

FORM 1295CERTIFICATE OF INTERESTED PARTIES

OFFICE USE ONLOFFICE USE ONLOFFICE USE ONLOFFICE USE ONLOFFICE USE ONLYYYYY

6 UNSWORN DECLARATION

My name is _______________________________________________________, and my date of birth is _______________________________.

My address is ________________________________________________, ___________________, _______, __________, ______________.

(street) (city) (state) (zip code) (country)

I declare under penalty of perjury that the foregoing is true and correct.

Executed in ___________________ County, State of ______________ , on the _______ day of _______________, 20______.

(month) (year)

Signature of authorized agent of contracting business entity (Declarant)

ADD ADDITIONAL PAGES AS NECESSARY

Name of Interested Party Nature of Interest (check applicable)City, State, Country

(place of business) Controlling Intermediary

Name of governmental entity or state agency that is a party to the contract for which the form is being filed.

3 Provide the identification number used by the governmental entity or state agency to track or identify the contract, and provide a description of the services, goods, or other property to be provided under the contract.

Complete Nos. 1 - 4 and 6 if there are interested parties.

Complete Nos. 1, 2, 3, 5, and 6 if there are no interested parties.

1 Name of business entity filing form, and the city, state and country of the business entity's place of business.

Check only if there is NO Interested Party.

Mus t fi le on lin e a t w ww.et hic s.s tat e.t x.u s/F ile

Adopted 06/29/2007

FORM CIQ

OFFICE USE ONLYThis questionnaire reflects changes made to the law by H.B. 1491, 80th Leg., Regular Session.

This questionnaire is being filed in accordance with Chapter 176, Local Government Code by a person who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the person meets requirements under Section 176.006(a).

By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code.

A person commits an offense if the person knowingly violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor.

CONFLICT OF INTEREST QUESTIONNAIRE

For vendor or other person doing business with local governmental entity

Check this box if you are filing an update to a previously filed questionnaire.

(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.)

Name of person who has a business relationship with local governmental entity.1

Date Received

Name of local government officer with whom filer has employment or business relationship.

Name of Officer

This section (item 3 including subparts A, B, C & D) must be completed for each officer with whom the filer has an employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional pages to this Form CIQ as necessary.

A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the filer of the questionnaire?

Yes No

B. Is the filer of the questionnaire receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer named in this section AND the taxable income is not received from the local governmental entity?

Yes No

C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership of 10 percent or more?

Yes No

D. Describe each employment or business relationship with the local government officer named in this section.

Signature of person doing business with the governmental entity Date

CERTIFICATION OF ELIGIBILITY

(This provision applies if the anticipated contract exceeds $25,000)

By submitting a bid or proposal in response to this solicitation, the bidder/proposer certifies that at the time of submission, he/she is not on the Federal Government’s list of suspended, ineligible, or debarred contractors.

In the event of placement on the list between the time of bid/proposal submission and time of award, the bidder/proposer will notify the Parker County Purchasing Agent. Failure to do so may result in terminating this contract for default.

Authorized Signature

A. In accordance with Chapter 2270, Texas Government Code, a governmental entity may not enter into a contract with a company for goods and services unless the company provides verification that it: (1) does not boycott Israel; and (2) will not boycott Israel during the term of the contract/project. By signing this contract, the person submitting a bid/proposal on behalf of company verifies that the company does not boycott Israel and will not boycott Israel during the term of this contract.

B. In accordance with Chapter 2252.152, Texas Government Code, a governmental entity may not enter into a contract with a company for goods and services unless the company provides verification that it: (1) does not engage in business with Iran, Sudan or Foreign Terrorist Organization during the term of the contract/project. By signing this contract, the person submitting a bid/proposal on behalf of company verifies that the company does not engage in business with Iran, Sudan or Foreign Terrorist Organization during the term of this contract.

Signature Date

Form W-9 (Rev. October 2018) Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Go to www.irs.gov/FormW9 for instructions and the latest information.

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

3.

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 of the person whose name is entered on line 1. 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: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its 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.) See instructions.

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 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.

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.

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 for Part II, later.

Sign Here

Signature of

U.S. person Date

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)

• 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, later.

Cat. No. 10231X Form W-9 (Rev. 10-2018)

8/1/2015