993B3 Proposal Submission Pkg.pdf

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Provision 4-3: Representations and Certifications ( 2019)

a. Type of Business Organization. The offeror, by checking theapplicable blocks, represents that it:

(1) Operates as:

[_] a corporation incorporated under the laws of the state of _______; or country of ___________if incorporated in a country other than the United States of America.

[_] an individual;

[_] a partnership;

[_] a joint venture;

[_] a limited liability company;

[_] a nonprofit organization; or

[_] an educational institution; and

(2) Is (check all that apply)

[_] a small business concern;

[_] a minority business (indicate minority below):

[_] Black American

[_] Hispanic American

[_] Native American

[_] Asian American:

[_] a woman-owned business; or

[_] none of the above entities.

(a) A small business concern for the purposes of Postal Service purchasing means a business, including an affiliate, that is independently owned and operated, is not dominant in producing or performing the supplies or services being purchased, and has no more than 500 employees, unless a different size standard has been established by the Small Business Administration (see 13 CFR 121, particularly for different size standards for airline, railroad, and construction companies). For subcontracts of $50,000 or less, a subcontractor having no more than 500 employees qualifies as a small business without regard to other factors.

(b) Minority Business. A minority business is a concern that is at least 51 percent owned by, and whose managementand daily business operations are controlled by, one or more members of a socially and economically disadvantaged minority group, namely U.S. citizens who are Black Americans, Hispanic Americans, Native Americans, or Asian Americans. (Native Americans are American Indians, Eskimos, Aleuts, and Native Hawaiians. Asian Americans are U.S. citizens whose origins are Japanese, Chinese, Filipino, Vietnamese, Korean, Samoan, Laotian, Kampuchean (Cambodian), Taiwanese, in the U.S. Trust Territories of the Pacific Islands or in the Indian subcontinent.)

(c) Woman-owned Business. A woman-owned business is a concern at least 51 percent of which is owned by a woman (or women) who is a U.S. citizen, controls the firm by exercising the power to make policy decisions, and operates the business by being actively involved in day-to- day management.

(d) Educational or Other Nonprofit Organization. Any corporation, foundation, trust, or other institution operated for scientific or educational purposes, not organized for profit, no part of the net earnings of which inures to the profits of any private shareholder or individual.

(3) Is (check all that apply)

[_] a Postal Service employee or a business organization substantially owned or controlled by such an individual

[_] a spouse of a Postal Service employee or a business organization substantially owned or controlled by such an individual

[_] another family member of a Postal Service employee or a business organization substantially owned or controlled by such an individual

[_] an individual residing in the same household as a Postal Service employee or a business organization substantially owned or controlled by such an individual.

(Note: Offers from any of the sources listed in subparagraph a.3, may not be considered for an award pending review and recommendation by the Postal Service Ethics Office.)

b. Parent Company and Taxpayer Identification Number

(1) A parent company is one that owns or controls the basic business polices of an offeror. To own means to own more than 50 percent of the voting rights in the offeror. To control means to be able to formulate, determine, or veto basic business policy decisions of the offeror. A parent company need not own the offeror to control it; it may exercise control through the use of dominant minority voting rights, proxy voting, contractual arrangements, or otherwise.

(2) Enter the offeror’s U.S. Taxpayer Identification Number (TIN) in the space provided. The TIN is the offeror’s Social Security number or other Employee Identification Number (EIN) used on the offeror’s Quarterly Federal Tax Return, U.S. Treasury Form 941, or as required by Internal Revenue Service (IRS) regulations. Offeror’s TIN:

(3) IRS Form W-9, Request for Taxpayer Identification Number and Certification. You must complete a copy of IRS Form W-9 and attach it to this certification.

(4) Check this block if the offeror is owned or controlled by a parent company:

(5) If the block above is checked, provide the following information about the parent company:

Parent Company’s Name:

Parent Company’s Main Office:

Address:

No. and Street:

City: _______________State: _______ ZIP Code:

Parent Company’s TIN:

(6) If the offeror is a member of an affiliated group that files its federal income tax return on a consolidated basis (whether or not the offeror is owned or controlled by a parent company, as provided above) provide the name and TIN of the common parent of the affiliated group:

Name of Common Parent:

Common Parent’s TIN:

c. Certificate of Independent Price Determination

(1) By submitting this proposal, the offeror certifies, and in the case of a joint proposal each party to it certifies as to its own organization, that in connection with this solicitation:

(a) The prices proposed have been arrived at independently, without consultation, communication, or agreement, for the purpose of restricting competition, as to any matter relating to the prices with any other offeror or with any competitor;

(b) Unless otherwise required by law, the prices proposed have not been and will not be knowingly disclosed by the offeror before award of a contract, directly or indirectly to any other offeror or to any competitor; and

(c) No attempt has been made or will be made by the offeror to induce any other person or firm to submit or not submit a proposal for the purpose of restricting competition.

(2) Each person signing this proposal certifies that:

(a) He or she is the person in the offeror’s organization responsible for the decision as to the prices being offered herein and that he or she has not participated, and will not participate, in any action contrary to paragraph a above; or

(b) He or she is not the person in the offeror’s organization responsible for the decision as to the prices being offered but that he or she has been authorized in writing to act as agent for the persons responsible in certifying that they have not participated, and will not participate, in any action contrary to paragraph a above, and as their agent does hereby so certify;

and he or she has not participated, and will not participate, in any action contrary to paragraph a above.

(3) Modification or deletion of any provision in this certificate may result in the disregarding of the proposal as unacceptable. Any modification or deletion should be accompanied by a signed statement explaining the reasons and describing in detail any disclosure or communication.

d. Certification of Nonsegregated Facilities

(1) By submitting this proposal, the offeror certifies that it does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not and will not permit its employees to perform services at any location under its control where segregated facilities are maintained. The offeror agrees that a breach of this certification is a violation of Clause 9-7: Equal Opportunity in this contract.

(2) As used in this certification, segregated facilities means any waiting rooms, work areas, rest rooms or wash rooms, restaurants or other eating areas, time clocks, locker rooms or other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment area, transportation, or housing facilities provided for employees that are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, or national origin, because of habit, local custom, or otherwise.

(3) The offeror further agrees that (unless it has obtained identical certifications from proposed subcontractors for specific time periods) it will obtain identical certifications from proposed subcontractors before awarding subcontracts exceeding

$10,000 that are not exempt from the provisions of Clause 9-7: Equal Opportunity; that it will retain these certifications in its files; and that it will forward the following notice to these proposed subcontractors (except when they have submitted identical certifications for specific time periods):

Notice: A certification of nonsegregated facilities must be submitted before the award of a subcontract exceeding $10,000 that is not exempt from Clause 9-7: Equal Opportunity. The certification may be submitted either for each subcontract or for all subcontracts during a period (quarterly, semiannually, or annually).

e. Certification Regarding Debarment, Proposed Debarment, and Other Matters

(This certification must be completed with respect to any offer with a value of $100,000 or more.)

(1) The offeror certifies, to the best of its knowledge and belief, that it or any of its principals:

(a) Are ___ are not ___ presently debarred or proposed for debarment, or declared ineligible for the award of contracts by any Federal, state, or local agency;

(b) Have ___ have not ___, within the 3-year period preceding this offer, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property;

(c) Are ___ are not ___ presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in subparagraph (b) above;

(d) Have ___ have not ___, within a 3-year period precedingthis offer, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in conjunction with obtaining, attempting to obtain, or performing a public (Federal, state or local) contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion or receiving stolen property; and

(e) Are ___ are not ___ presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in subparagraph (d) above.

(2) The offeror has has not , within a 3-year period preceding offer, had one or more contracts terminated for default by any

Federal, state, or local agency.

(3) “Principals,” for the purposes of this certification, means officers, directors, owners, partners, and other persons having primary management or supervisory responsibilities within a business entity (e.g., general manager, plant manager, head of a subsidiary, division, or business segment, and similar positions).

(4) The offeror must provide immediate written notice to the contracting officer if, at any time prior to contract award, the offeror learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

(5) A certification that any of the items in e.1 and e.2 of this provision exists will not necessarily result in withholding of an award under this solicitation. However, the certification will be considered as part of the evaluation of the offeror’s capability (see section 2-26.4.2, Supplier Capability the Postal Service’s Supplying Principles and Practices).

The offeror’s failure to furnish a certification or provide additional information requested by the contracting officer will affect the capability evaluation.

(6) Nothing contained in the foregoing may be construed to require establishment of a system of records in order to render, in good faith, the certification required by e.1 and e.2 of this provision. The knowledge and information of an offeror is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

(7) This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under Section 1001, Title 18 U.S.C.

(8) The certification in e.1 and e.2 of this provision is a material representation of fact upon which reliance was placed when making the award. If it is later determined that the offeror knowingly rendered an erroneous certification, in addition to other remedies available to the Postal Service, the contracting officer may terminate the contract resulting from this solicitation for default.

f. Incorporation by Reference. Wherever in this solicitation or contract a standard provision or clause is incorporated by reference, the incorporated term is identified by its title, its provision or clause number assigned to it, and its date. The text of incorporated terms may be found at http://about.usps.com/manuals/pm/welcome.htm. If checked, the following provision(s) is incorporated in this solicitation by reference (Contracting officer will check as appropriate):

[_] Provision 9-1: Equal Opportunity Affirmative Action Program.

[_] Provision 9-2: Preaward Equal Opportunity Compliance Review.

[_] Provision 9-3: Notice of Requirements for Equal Opportunity Affirmative Action.

STATEMENT of WORK and SPECIFICATIONS ADDENDUM

October 2021

For Contract Delivery Service and Combination contracts, the paragraph listed below, B.2.d.

is being removed.

B.2 VEHICLE REQUIIREMENTS AND SPECIFICATIONS

d. Vehicle(s) cannot be more than five years old at the beginning of the contract term. A vehicle that becomes more than nine years old during the term, must be replaced at the expense of the supplier. For purposes of calculation, a vehicle will be considered as one year old on December 31 of its model year.

For Contract Delivery Service and Combination contracts, the paragraph listed below, B.7, last paragraph is being removed. This change does not affect the Terms and Conditions Clause 7-16: Insurance (Surface Transportation) (June 2020)

B.7 INSURANCE REQUIREMENTS

The supplier shall furnish to the contracting officer, prior to commencement of service under this contract, and thereafter as the contracting officer may require, proof that the supplier has all required insurance, plus a copy of the applicable policy or policies.

Contract Holder

SIGNATURE DATE

PRINTED NAME

UNITED STATES POSTAL SERVICE CONTRACTING OFFICER

SIGNATURE PRINTED NAME DATE

5-Digit HCR # Supplier Information

Please print the requested Information in the blank column and return to the Central Transportation Contracts Office.

Name of Individual or Company

Street Address (Physical) Location City, State, ZIP

Mailing Address (if different)

Mailing Address (if different) City, State, ZIP Primary Person Who Manages HCR(s)

Title of Person Who Manages HCR(s)

Primary Business Telephone Number

Primary Cell Phone Number

Primary Contact Residence Telephone

Primary Contact Email Address

In Case of Emergency, Person to Notify

Emergency Contact Telephone Number

Emergency Contact Telephone Email

Name of Alternate Person Who Manages HCR(s)

Alternate HCR Driver Phone Alternate HCR Driver Email Alternate HCR Driver Address

Tax Identification Number (Social Security Number or Employer Identification Number):

The United States Postal Service requires correct Tax Identification Number (TIN) Information from all existing and potential suppliers on all contract documents requiring a TIN. The Postal Service will require a copy of the Social Security Card as confirmation If a Social Security Administration Number (SSN) will be used as the TIN. If an Employer Identification Number will be used as a TIN, the Postal Service will require a copy of an official Internal Revenue Service (IRS) form as confirmation. Other-wise, the Postal Service may be fined by the IRS, and any related fines may be assessed to the supplier.

To confirm your TIN, please provide a copy of your Social Security Administration Card or a preprinted IRS form showing your Employer Identification Number and your name and/or company name on the same form.

Rev.

Contract Personnel Questionnaire Prepare in duplicate. Type or print all responses. If answer is No, state so. Attach sheets if more space is needed.

Privacy Act Statement: Your information will be used as a basis for an investigation to determine your fitness and suitability for contractual services to the U.S.

Postal Service® (USPS®). Collection is authorized by 39 U.S.C. 3061. Providing the information is voluntary, but if not provided you may be denied access to Postal Service premises, denied access to the mail, or denied participation under a USPS contract. We may disclose your information as follows: in relevant legal pro-ceedings; to law enforcement when the USPS or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel.

1. Print Your Full Name (Last, First, Middle Name) 2. Print Your Mailing Address (Include Apartment/Suite Number)

4a. Home Telephone Number (Include Area Code)

3. City, State and ZIP+4 Code™

5. List Other Names Used. (i.e., maiden name, names by former marriages, names changed legally or otherwise, aliases, nicknames. Specify which and dates used.)

10. Type of Screening (Check one)

13. Contractor’s Name and Mailing Address

14. Have You Had a Security Screening by USPS or Other Federal Agencies Within the Last Year?

11. Are You Presently a Highway Contract Driver?

(If Yes, include Contract Number and Termini.)

12. Highway Contract Number and Termini (If applicable)

7. Date of Birth (MM/DD/YYYY) 8. Place of Birth (City and State/Country) 9. Sex6. Social Security Number (SSN)

15. Dates and Places of Residence. (If actual places of residence differ from the mailing addresses, furnish and identify both. Begin with present residence and go back for the past five years.)

16. Employment. (List ALL periods of employment for the past five years starting with your present employment. Include dates when unemployed.

Give name under which employed if different from name now used.)

From

(MM/YYYY)

To

(MM/YYYY)

From

(MM/YYYY)

To

(MM/YYYY)

Number and Street City State ZIP+4 Code

Employer’s and Supervisor’s Names

Employer’s Address (City, State, Zip+4Code)

Occupation Reason for Leaving

Male Female

Sub-ContractorContractor’s Employee ADPContractor Yes No

Yes No

18b. Commercial Driver’s License

18a. Do You Have a Valid License? (Driver/Chauffeur) If “Yes”, include License Number, State, and Expiration Date. Yes No Yes No

PS Form 2025, March 2012, (Page 1 of 2) PSN 7530-01-000-9519

4b. Work Telephone Number (Include Area Code)

Other

Agency:

Your Name During Period of Employment

17a. Are You a United States Citizen?

Yes No

17b. Are You a Citizen of American Samoa or Any Other Territory Owing Allegiance to the United States? Yes No

17c. Provide Alien Registration Number if not a United States Citizen

(Continued on Page 2)

Disposition

Action Taken

Action Taken

22. In the Past 5 years, Have You Been Convicted of any Traffic Violations (Other Than Parking) or Currently Have Charges Pending? (If Yes, complete information below.)

19b. Have you registered with the Selective Service System? If “Yes”, provide your registration number. If “No”, show the reason for your legal exemption.

19a. Are you a male born after December 31, 1959? If “No”, go to 20a. If Yes, go to 19b.

20a. Military Service (Past or Present). (If Yes, complete Items 20b, 20c, 20d, 20e, and 20f.)

20c. Branch of Service (Army, Navy, Air Force, Marines, etc.)

20b. Dates of Service (MM/YYYY)

To From

20d. Serial Number (If none, provide Grade or Rating at time of separation)

20e. Were You Discharged from the Military Service Under Honorable Conditions? (If your discharge was changed to “honorable” or “general” by a Discharge Review Board, answer “Yes”. If you received a clemency discharge, answer “No”.) If No, enter the date and type of discharge you received in the blocks below.

Yes

Yes No

No

Yes No

Yes No

Discharge Date (MM/YYYY) Type of Discharge

20f. While in Military Service, Were You Ever Convicted by Court Martial?

Yes No

21a. Have You Ever Been Convicted of, or Forfeited Collateral, for Any Felony/Misdemeanor Violation (Except Traffic Violations)?

(Generally, a felony is defined as any violation of law punishable by imprisonment of one year or longer.) Yes No

Yes No

Yes No

Yes No

21b. During the Last 10 Years Have You Forfeited Collateral, Been Convicted, Been Imprisoned, Been on Probation, or Been on Parole for any Violation of Law? (Do not include violations reported in question 21a.)

21c. Have You Ever Been Convicted of, or Forfeited Collateral for Any Assaults, Firearms or Explosives Violations?

21d. Are You Now Under Charges for Any Violation of Law?

21e. Are You Delinquent on any Federal Debt? (Include delinquencies arising from Federal taxes, overpayment of benefits, or other debts to the U.S. Government plus defaults on Federally guaranteed or insured loans such as student and home mortgage loans.) Yes No

Date (MM/YYYY) Place (City and State) Court Charge

Date (MM/YYYY) Place (City and State) Court Charge

If necessary, attach additional sheets.

If necessary, attach additional sheets.

Yes No

Warning

Check Here if Your Driver’s Abstract from Department of Motor Vehicles is Attached.

Certification

USPS Official Signature (Sign and print name) Date Signed (MM/DD/YYYY)

For Use of Postal Service Official Responsible for Reviewing for Completeness and Legibility. (See Administrative Support Manual 272.23, Contractor Clearance, for complete instructions.)

Review this form carefully to ensure you have answered all questions fully and correctly. Failure to answer all questions may result in your being denied access to mail and/or Postal Service premises. A fine not to exceed $250,000 or imprisonment of not more than five years or both is provided by law (18 U.S.C. 1001) for making a false statement or concealing any material fact on this Questionnaire.

I certify that the statements made by me on this questionnaire are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

I attest I have advised the Applicant to truthfully complete this Questionnaire, and the Applicant has passed the Drug Screening Test (If applicable, provide documentation).

Applicant’s Signature Date Signed (MM/DD/YYYY)

Date Signed (MM/DD/YYYY)Contractor’s Signature (Sign and print name)

PS Form 2025, March 2012 (Page 2 of 2)

If any answers to 21a - 21d are “Yes”, provide date, place, court location, charge, and disposition on an attached sheet.

Telephone Number (Include area code)

Organization, City, State, and ZIP+4 Code

Telephone Number (Include Area Code)

Court Martial Date (MM/DD/YYYY) Place (City and State/Country) Charge

19. Your Selective Service Record

19c. Registration Number 19d. Legal Exemption Explanation

Authorization and Release — Background Investigation

(USPS Contractors and Employees of Contractors)

Applicant: Carefully read the following information before you complete and sign this form.

Applicant’s Name (Last, First, Middle)

Date of Birth (Month, Day, Year)

Mailing Address

Email AddressHome Phone Number

Date Signed Signature

PS Form 2181-C, October 2015

Privacy Act Statement: Your information will be used as a basis for an investigation to determine your fitness and suitability for contractual service to the U.S. Postal Service (USPS). Collection is authorized by 39 U.S.C. 401 and 404; and 18 U.S.C.

3061. Providing the information is voluntary, but if not provided, it may have an adverse effect on your opportunities to perform services under contract with the USPS. We may disclose your information as follows: in relevant legal proceedings; to law enforcement when the USPS or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS (service providers); to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel. For additional information regarding our privacy policies, visit www.usps.com/privacypolicy.

This constitutes my consent and authorization to the disclosure or furnishing of any relevant and necessary information or records to any duly authorized official of the USPS by any person, corporation, agency, or association concerning my character, personal history, credit standing, educational claims, current or prior employment, military service, and other information which may be relevant and necessary to determine my fitness and suitability to perform services under contract with the USPS.

This authorization is executed with full knowledge and understanding that the USPS will take measures to protect the aforementioned information against unauthorized disclosure to any parties not having a legitimate need for it in the discharge of official business of the United States, or its agencies and instrumentalities.

I hereby RELEASE the aforementioned persons, corporators, agencies, associations and their employees, agents and representatives from any and all liability for damages resulting from a decision by the USPS not to contract for my services on account of compliance with this authorization, except for any damages resulting from knowingly providing false or misleading information or records about me.

A copy of this authorization shall be as effective and valid as the original. This authorization shall be valid from the date it is signed until any contract employment with the USPS is completed or terminated.

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)

Form W-9 (Rev. 12-2014) Page 2

Note. If you are a U.S. person and 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.

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

• 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 under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a 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 section 1446 withholding on your share of partnership income.

In the cases below, the following person must give 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:

• In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;

• In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and

• In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:

1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2. The treaty article addressing the income.

3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions.

4. The type and amount of income that qualifies for the exemption from tax.

5. Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years.

However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.

Backup Withholding

What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1. You do not furnish your TIN to the requester,

2. You do not certify your TIN when required (see the Part II instructions on page 3 for details),

3. The IRS tells the requester that you furnished an incorrect TIN,

4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See Exempt payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information.

Also see Special rules for partnerships above.

What is FATCA reporting?

The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information.

Updating Your Information

You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions

Line 1

You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.

If this Form W-9 is for a joint account, list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9.

a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

Note. ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.

b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2.

c. Partnership, LLC that is not a single-member LLC, C Corporation, or S Corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.

d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.

e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.

Form W-9 (Rev. 12-2014) Page 3

Line 2

If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.

Line 3

Check the appropriate box in line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box in line 3.

Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a partnership for U.S. federal tax purposes, check the “Limited Liability Company” box and enter “P” in the space provided. If the LLC has filed Form 8832 or 2553 to be taxed as a corporation, check the “Limited Liability Company” box and in the space provided enter “C” for C corporation or “S” for S corporation. If it is a single-member LLC that is a disregarded entity, do not check the “Limited Liability Company” box; instead check the first box in line 3 “Individual/sole proprietor or single-member LLC.”

Line 4, Exemptions

If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space in line 4 any code(s) that may apply to you.

Exempt payee code.

• Generally, individuals (including sole proprietors) are not exempt from backup withholding.

• Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.

• Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.

• Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form

1099-MISC.

The following codes identify payees that are exempt from backup withholding.

Enter the appropriate code in the space in line 4.

1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)

2—The United States or any of its agencies or instrumentalities

3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

4—A foreign government or any of its political subdivisions, agencies, or instrumentalities

5—A corporation

6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession

7—A futures commission merchant registered with the Commodity Futures Trading Commission

8—A real estate investment trust

9—An entity registered at all times during the tax year under the Investment Company Act of 1940

10—A common trust fund operated by a bank under section 584(a)

11—A financial institution

12—A middleman known in the investment community as a nominee or custodian

13—A trust exempt from tax under section 664 or described in section 4947

The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.

IF the payment is for . . . THEN the payment is exempt for . . .

Interest and dividend payments All exempt payees except for 7

Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012.

Barter exchange transactions and patronage dividends

Exempt payees 1 through 4

Payments over $600 required to be reported and direct sales over $5,0001

Generally, exempt payees 1 through 52

Payments made in settlement of payment card or third party network transactions

Exempt payees 1 through 4

1 See Form 1099-MISC, Miscellaneous Income, and its instructions.

2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.

Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank.

Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code.

A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)

B—The United States or any of its agencies or instrumentalities

C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)

E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i)

F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state

G—A real estate investment trust

H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of

I—A common trust fund as defined in section 584(a)

J—A bank as defined in section 581

K—A broker

L—A trust exempt from tax under section 664 or described in section 4947(a)(1)

M—A tax exempt trust under a section 403(b) plan or section 457(g) plan

Note. You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.

Line 5

Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns.

Line 6

Enter your city, state, and ZIP code.

Part I. Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on this page), enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Note. See the chart on page 4 for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.ssa.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN.