BOA - SIGNED - Rubber_Grommet_Holder.pdf

State of Illinois Chief Procurement O�ce General Services 1

BOA under $50,000

V.23.2

Log

ORDERING INFORMATION

Item

Descrip.on (manufacturer, model, serial number, feature, etc.) Qty

One Time Charge Periodic Charge

Unit Extension Unit Extension

Rubber Grommet - Monadnock Tapered

Rubber Grommet Nightstick Holder

35 EA

Page Total: $

BOA Total (if mul.ple pages): $

STATE OF ILLINOIS

BASIC ORDERING AGREEMENT (BOA) < $50,000

The terms and condi.ons of this BOA, including those terms and condi.ons set forth in the addi.onal documents referenced below, and any con.nua.on sheets, cons.tute the en.re agreement between the par.es with respect to the subject ma:er of this BOA. State documents will prevail in the event of a con;ict between

State and Vendor documents. State Agency Name: Logan Correc.onal Center

Address: 1096 1350th St. Lincoln, Il. 62656

Contact: Chris. Withers Phone #: 217-735-5581

Email: Chris..withers@illinois.gov

Bill To:

Name: Logan Correc.onal Center

Address:

doc.loganaccountspayable@illinois.gov

Ship To:

Name: Logan Correc.onal Center

Address:

1096 1350th St. Lincoln, Il. 62656

CONTRACT INFORMATION

Contract #: 27-426DOC-LOGAN-R337634

Ac.on: New

Acquisi.on Type: Purchase

Payment Cycle: ONE TIME PURCHASE

Terms and Condi.ons: BOA Terms and Condi.ons

27LOG0183

Term:

Begin Date:

Upon Hnal signature

End Date: 6/30/27

CONTACT INFORMATION

Vendor Name:BOTACH INC Address: 4775 W HARMON AVE LAS VEGAS NV 89103 Contact:ACKAH SARBAH Phone #:7252107023 Email:ACKAH@BOTACH.COM. Fax #: Click here to enter text.

10 350

State of Illinois Chief Procurement O�ce General Services 2

V.23.2

ADDITIONAL INFORMATION / REFERENCES / ATTACHMENTS

1. Bids Due: by 8:30 am CST on 9/11/26

2. Bids must be submi:ed through BidBuy or email to the solicita.on contact on page one. Only electronic submission will be accepted.

3. VENDOR: All the requested items must be delivered within 60 days of contract execu.on unless another .meframe is agreed upon between the Vendor and Chief Engineer or designee.

4. Pricing for all commodi.es and/or equipment shall be in accordance with the unit of measure speciHed in the Pricing Sec.on and only one unit price shall be quoted per item unless otherwise stated. All extensions and totals requested shall be shown. Prices quoted must be net aJer deduc.ng all trade or quan.ty discounts.

5. Agency reserves the right to award bid in whole or in part.

6. Signed BOA with bid informa.on needs to be submi:ed through BidBuy or email to the solicita.on contact. Agency must have fully executed BOA, signed, and dated by both par.es, prior to product being sent to the Agency by Vendor.

The vendor will be responsible for shipping or delivery of the parts to the Agency. Prices must be F.O.B. DESTINATION with all transporta.on and handling included and paid by the Vendor. Deliveries are accepted Monday through Friday, 8:00 a.m. to 2:00 p.m., excluding state holidays. Delivery to be made to the facility’s warehouse receiving dock.

Click here to enter text.

STATE USE ONLY

Reference Number: R337634

Source Selec.on Method: Small Purchase

Is Financing Needed? No

Using Agency Funding Source:

Fiscal Year: 2027

Type: State

Approp. Account Code: 001-42677-1399-1300

Detailed Expenditure Object Code: 1399

Award Code: C

Original Procurement Method: Small Purchase

Subcontractors U.lized? No

Subcontractors Disclosed? No

State of Illinois Chief Procurement O�ce General Services 3

V.23.2

SIGNATURES The undersigned par.es agree to these terms and condi.ons.

Vendor State of Illinois

Signature: State Agency:

Signature agency representa.ve:

Printed Name:

Date: Title:

Date:

State of Illinois State of Illinois

Signature agency representa.ve: Signature agency representa.ve:

Printed Name: Printed Name:

Title: Title:

Date: Date:

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09/11/2026

Printed Name:ACKAH SARBAH

Title: MANAGER

9/11/26

STATE OF ILLINOIS

STANDARD TERMS AND CONDITIONS

State of Illinois Chief Procurement O�ce General Services 4

BOA under $50,000

V.23.2

1. PAYMENT TERMS AND CONDITIONS:

1.1. Late Payment: Payments, including late payment charges, will be paid in accordance with the State

Prompt Payment Act and rules when applicable. 30 ILCS 540; 74 III. Adm. Code 900. This shall be Vendor’s sole remedy for late payments by the State. Payment terms contained on Vendor’s invoices shall have no force and ePect.

1.2. Minority Contractor Ini.a.ve: Any Vendor awarded a contract under Sec.on 20-10, 20-15, 20-25 or 20-

30 of the Illinois Procurement Code (30 ILCS 500) of $1,000 or more is required to pay a fee of $15. The

Comptroller shall deduct the fee from the Hrst check issued to the Vendor under the contract and deposit the fee in the Comptroller’s Administra.ve Fund. 15 ILCS 405/23.9.

1.3. Expenses: The State will not pay for supplies provided or services rendered, including related expenses, incurred prior to the execu.on of this contract by the Par.es even if the ePec.ve date of the contract is prior to execu.on.

1.4. Prevailing Wage: As a condi.on of receiving payment Vendor must (i) be in compliance with the contract,

(ii) pay its employees prevailing wages when required by law, (iii) pay its suppliers and subcontractors according to the terms of their respec.ve contracts, and (iv) provide lien waivers to the State upon request. Examples of prevailing wage categories include public works, prin.ng, janitorial, window washing, building and grounds services, site technician services, natural resource services, security guard and food services. The prevailing wages are revised by the Department of Labor and are available on the

Department’s o�cial website, which shall be deemed proper no.Hca.on of any rate changes under this subsec.on. Vendor is responsible for contac.ng the Illinois Department of Labor to ensure understanding of prevailing wage requirements at 217-782-6206 or (h:ps://labor.illinois.gov/).

1.5. Federal Funding: This contract may be par.ally or totally funded with Federal funds. If federal funds are expected to be used, then the percentage of the good/service paid using Federal funds and the total

Federal funds expected to be used will be provided in the award no.ce.

1.6. Invoicing: By submiQng an invoice, Vendor cer.Hes that the supplies or services provided meet all requirements of the contract, and the amount billed and expenses incurred are as allowed in the contract.

Invoices for supplies purchased, services performed, and expenses incurred through June 30 of any year must be submi:ed to the State no later than July 31 of that year; otherwise Vendor may have to seek payment through the Illinois Court of Claims. 30 ILCS 105/25. All invoices are subject to statutory oPset.

30 ILCS 210.

1.6.1. Vendor shall not bill for any taxes unless accompanied by proof that the State is subject to the tax. If necessary, Vendor may request the applicable Agency/University state tax exemp.on number and federal tax exemp.on informa.on.

1.6.2. Vendor shall invoice at the comple.on of the contract unless invoicing is .ed in the contract to milestones, deliverables, or other invoicing requirements agreed to in the contract.

2. ASSIGNMENT: This contract may not be assigned, transferred in whole or in part by Vendor without the prior wri:en consent of the State.

https://labor.illinois.gov/

State of Illinois Chief Procurement O�ce General Services 5

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3. SUBCONTRACTING: For purposes of this sec.on, subcontractors are those with contracts with an annual value exceeding $100,000 and who are speciHcally hired to perform all or part of the work covered by the contract.

Vendor must receive prior wri:en approval before use of any subcontractors in the performance of this contract.

Vendor shall describe, in an a:achment if not already provided, the names and addresses of all authorized subcontractors to be u.lized by Vendor in the performance of this contract, together with a descrip.on of the work to be performed by the subcontractor and the an.cipated amount of money that each subcontractor is expected to receive pursuant to this contract. If required, Vendor shall provide a copy of any subcontracts within

HJeen (15) days aJer execu.on of this contract. All subcontracts must include the same cer.Hca.ons that Vendor must make as a condi.on of this contract. Vendor shall include in each subcontract the Standard Illinois

Cer.Hca.on form available from the State. If at any .me during the term of the Contract, Vendor adds or changes any subcontractors, then Vendor must promptly no.fy, by wri:en amendment to the Contract, the State

Purchasing O�cer or the Chief Procurement O�cer of the names and addresses, the expected amount of money that each new or replaced subcontractor will receive pursuant to the Contract , and the general type of work to be performed. 30 ILCS 500/20-120.

4. AUDIT/RETENTION OF RECORDS: Vendor and its subcontractors shall maintain books and records rela.ng to the performance of the contract or subcontract and necessary to support amounts charged to the State pursuant the contract or subcontract. Books and records, including informa.on stored in databases or other computer systems, shall be maintained by the Vendor for a period of three (3) years from the later of the date of Hnal payment under the contract or comple.on of the contract, and by the subcontractor for a period of three (3) years from the later of Hnal payment under the term or comple.on of the subcontract. If Federal funds are used to pay contract costs, the Vendor and its subcontractors must retain their respec.ve records for Hve (5) years. Books and records required to be maintained under this sec.on shall be available for review or audit by representa.ves of: the procuring Agency, the Auditor General, the Execu.ve Inspector General, the Chief Procurement O�cer, State of

Illinois internal auditors or other governmental en..es with monitoring authority, upon reasonable no.ce and during normal business hours. Vendor and its subcontractors shall cooperate fully with any such audit and with any inves.ga.on conducted by any of these en..es. Failure to maintain books and records required by this sec.on shall establish a presump.on in favor of the State for the recovery of any funds paid by the State under this contract or any subcontract for which adequate books and records are not available to support the purported disbursement. The Vendor or subcontractors shall not impose a charge for audit or examina.on of the Vendor’s or subcontractor’s books and records. 30 ILCS 500/20-65.

5. TIME IS OF THE ESSENCE: Time is of the essence with respect to Vendor’s performance of this contract. Vendor shall con.nue to perform its obliga.ons while any dispute concerning the contract is being resolved unless otherwise directed by the State.

6. NO WAIVER OF RIGHTS: Except as speciHcally waived in wri.ng, failure by a Party to exercise or enforce a right does not waive that Party’s right to exercise or enforce that or other rights in the future.

7. FORCE MAJEURE: Failure by either Party to perform its du.es and obliga.ons will be excused by unforeseeable circumstances beyond its reasonable control and not due to its negligence, including acts of nature, acts of terrorism, riots, labor disputes, Hre, ;ood, explosion, and governmental prohibi.on. The non-declaring Party may cancel the contract without penalty if performance does not resume within thirty (30) days of the declara.on.

8. CONFIDENTIAL INFORMATION: Each Party, including its agents and subcontractors, to this contract may have or gain access to conHden.al data or informa.on owned or maintained by the other Party in the course of carrying out its responsibili.es under this contract. Vendor shall presume all informa.on received from the State or to

State of Illinois Chief Procurement O�ce General Services 6

BOA under $50,000

V.23.2 which it gains access pursuant to this contract is conHden.al. Vendor informa.on, unless clearly marked as conHden.al and exempt from disclosure under the Illinois Freedom of Informa.on Act, shall be considered public.

No conHden.al data collected, maintained, or used in the course of performance of the contract shall be disseminated except as authorized by law and with the wri:en consent of the disclosing Party, either during the period of the contract or thereaJer. The receiving Party must return any and all data collected, maintained, created or used in the course of the performance of the contract, in whatever form it is maintained, promptly at the end of the contract, or earlier at the request of the disclosing Party, or no.fy the disclosing Party in wri.ng of its destruc.on. The foregoing obliga.ons shall not apply to conHden.al data or informa.on lawfully in the receiving Party’s possession prior to its acquisi.on from the disclosing Party; received in good faith from a third

Party not subject to any conHden.ality obliga.on to the disclosing Party; now is or later becomes publicly known through no breach of conHden.ality obliga.on by the receiving Party; or is independently developed by the receiving Party without the use or beneHt of the disclosing Party’s conHden.al informa.on.

9. USE AND OWNERSHIP: All work performed or supplies created by Vendor under this contract, whether wri:en documents or data, goods or deliverables of any kind, shall be deemed work for hire under copyright law and all intellectual property and other laws, and the State of Illinois is granted sole and exclusive ownership to all such work, unless otherwise agreed in wri.ng. Vendor hereby assigns to the State all right, .tle, and interest in and to such work including any related intellectual property rights, and/or waives any and all claims that Vendor may have to such work including any so-called "moral rights" in connec.on with the work. Vendor acknowledges the

State may use the work product for any purpose. ConHden.al data or informa.on contained in such work shall be subject to conHden.ality provisions of this contract.

10. INDEMNIFICATION AND LIABILITY: The Vendor shall indemnify and hold harmless the State of Illinois, its agencies, o�cers, employees, agents and volunteers from any and all costs, demands, expenses, losses, claims, damages, liabili.es, se:lements and judgments, including in-house and contracted a:orneys’ fees and expenses, arising out of: (a) any breach or viola.on by Vendor of any of its cer.Hca.ons, representa.ons, warran.es, covenants or agreements; (b) any actual or alleged death or injury to any person, damage to any real or personal property, or any other damage or loss claimed to result in whole or in part from Vendor’s negligent performance; (c) any act, ac.vity or omission of Vendor or any of its employees, representa.ves, subcontractors or agents; or (d) any actual or alleged claim that the services or goods provided under this contract infringe, misappropriate, or otherwise violate any intellectual property (patent, copyright, trade secret, or trademark) rights of a third party. In accordance with Ar.cle VIII, Sec.on 1(a),(b) of the Cons.tu.on of the State of Illinois and 1973 Illinois A:orney

General Opinion 78, the State may not indemnify private par.es absent express statutory authority permiQng the indemniHca.on. Neither Party shall be liable for incidental, special, consequen.al, or puni.ve damages.

11. INSURANCE: Vendor shall, at all .mes during the term and any renewals maintain and provide a Cer.Hcate of

Insurance naming the State as addi.onally insured for all required bonds and insurance. Cer.Hcates may not be modiHed or canceled un.l at least thirty (30) days’ no.ce has been provided to the State. Vendor shall provide:

(a) General Commercial Liability occurrence form in amount of $1,000,000 per occurrence (Combined Single Limit

Bodily Injury and Property Damage) and $2,000,000 Annual Aggregate; (b) Auto Liability, including Hired Auto and

Non-owned Auto, (Combined Single Limit Bodily Injury and Property Damage) in amount of $1,000,000 per occurrence; and (c) Worker’s Compensa.on Insurance in amount required by law. Insurance shall not limit

Vendor’s obliga.on to indemnify, defend, or se:le any claims.

12. INDEPENDENT CONTRACTOR: Vendor shall act as an independent contractor and not an agent or employee of, or joint venture with the State. All payments by the State shall be made on that basis.

State of Illinois Chief Procurement O�ce General Services 7

BOA under $50,000

V.23.2

13. SOLICITATION AND EMPLOYMENT: Vendor shall not employ any person employed by the State during the term of this contract to perform any work under this contract. Vendor shall give no.ce immediately to the Agency’s director if Vendor solicits or intends to solicit State employees to perform any work under this contract.

14. COMPLIANCE WITH THE LAW: The Vendor, its employees, agents, and subcontractors shall comply with all applicable federal, state, and local laws, rules, ordinances, regula.ons, orders, federal circulars and all license and permit requirements in the performance of this contract. Vendor shall be in compliance with applicable tax requirements and shall be current in payment of such taxes. Vendor shall obtain at its own expense, all licenses and permissions necessary for the performance of this contract.

15. BACKGROUND CHECK: Whenever the State deems it reasonably necessary for security reasons, the State may conduct, at its expense, criminal and driver history background checks of Vendor’s and subcontractor’s o�cers, employees or agents. Vendor or subcontractor shall reassign immediately any such individual who, in the opinion of the State, does not pass the background check.

16. APPLICABLE LAW:

16.1. PREVAILING LAW: This contract shall be construed in accordance with and is subject to the laws and rules of the State of Illinois.

16.2. EQUAL OPPORTUNITY: The Department of Human Rights’ Equal Opportunity requirements are incorporated by reference. 44 ILL. ADM. CODE 750.

16.3. COURT OF CLAIMS; ARBITRATION; SOVEREIGN IMMUNITY: Any claim against the State arising out of this contract must be Hled exclusively with the Illinois Court of Claims. 705 ILCS 505/1. The State shall not enter into binding arbitra.on to resolve any dispute arising out of this contract. The State of Illinois does not waive sovereign immunity by entering into this contract.

16.4. OFFICIAL TEXT: The o�cial text of the statutes cited herein is incorporated by reference. An uno�cial version can be viewed at (www.ilga.gov/legisla.on/ilcs/ilcs.asp).

17. ANTI-TRUST ASSIGNMENT: If Vendor does not pursue any claim or cause of ac.on it has arising under federal or state an.trust laws rela.ng to the subject ma:er of the contract, then upon request of the Illinois A:orney

General, Vendor shall assign to the State rights, .tle and interest in and to the claim or cause of ac.on.

18. CONTRACTUAL AUTHORITY: The Agency that signs for the State of Illinois shall be the only State en.ty responsible for performance and payment under the contract. When the Chief Procurement O�cer or authorized designee signs in addi.on to an Agency, they do so as approving o�cer and shall have no liability to Vendor. When the

Chief Procurement O�cer or authorized designee, or State Purchasing O�cer signs a master contract on behalf of State agencies, only the Agency that places an order with the Vendor shall have any liability to Vendor for that order.

19. EXPATRIATED ENTITIES: Except in limited circumstances, no business or member of a unitary business group, as deHned in the Illinois Income Tax Act, shall submit a bid for or enter into a contract with a State agency if that business or any member of the unitary business group is an expatriated en.ty.

http://www.ilga.gov/legislation/ilcs/ilcs.asp

State of Illinois Chief Procurement O�ce General Services 8

BOA under $50,000

V.23.2

20. NOTICES: No.ces and other communica.ons provided for herein shall be given in wri.ng via electronic mail whenever possible. If transmission via electronic mail is not possible, then no.ces and other communica.ons shall be given in wri.ng via registered or cer.Hed mail with return receipt requested, via receipted hand delivery, via courier (UPS, Federal Express or other similar and reliable carrier), or via facsimile showing the date and .me of successful receipt. No.ces shall be sent to the individuals who signed this contract using the contact informa.on following the signatures. Each such no.ce shall be deemed to have been provided at the .me it is actually received. By giving no.ce, either Party may change its contact informa.on.

21. MODIFICATIONS AND SURVIVAL: Amendments, modiHca.ons and waivers must be in wri.ng and signed by authorized representa.ves of the Par.es. Any provision of this contract o�cially declared void, unenforceable, or against public policy, shall be ignored and the remaining provisions shall be interpreted, as far as possible, to give ePect to the Par.es’ intent. All provisions that by their nature would be expected to survive, shall survive termina.on. In the event of a con;ict between the State’s and the Vendor’s terms, condi.ons and a:achments, the State’s terms, condi.ons and a:achments shall prevail.

22. PERFORMANCE RECORD / SUSPENSION: Upon request of the State, Vendor shall meet to discuss performance or provide contract performance updates to help ensure proper performance of the contract. The State may consider Vendor’s performance under this contract and compliance with law and rule to determine whether to con.nue the contract, suspend Vendor from doing future business with the State for a speciHed period of .me, or whether Vendor can be considered responsible on speciHc future contract opportuni.es.

23. FREEDOM OF INFORMATION ACT: This contract and all related public records maintained by, provided to or required to be provided to the State are subject to the Illinois Freedom of Informa.on Act (FOIA) (50 ILCS 140) notwithstanding any provision to the contrary that may be found in this contract.

24. SCHEDULE OF WORK: Any work performed on State premises shall be done during the hours designated by the

State and performed in a manner that does not interfere with the State and its personnel.

25. WARRANTIES FOR SUPPLIES AND SERVICES:

25.1. Vendor warrants that the supplies furnished under this contract will: (a) conform to the standards, speciHca.ons, drawing, samples or descrip.ons furnished by the State or furnished by the Vendor and agreed to by the State, including but not limited to all speciHca.ons a:ached as exhibits hereto; (b) be merchantable, of good quality and workmanship, and free from defects for a period of twelve months or longer if so speciHed in wri.ng, and Ht and su�cient for the intended use; (c) comply with all federal and state laws, regula.ons and ordinances pertaining to the manufacturing, packing, labeling, sale and delivery of the supplies; (d) be of good .tle and be free and clear of all liens and encumbrances and; (e) not infringe any patent, copyright or other intellectual property rights of any third party. Vendor agrees to reimburse the State for any losses, costs, damages or expenses, including without limita.ons, reasonable a:orney’s fees and expenses, arising from failure of the supplies to meet such warran.es.

25.2. Vendor shall insure that all manufacturers’ warran.es are transferred to the State and shall provide a copy of the warranty. These warran.es shall be in addi.on to all other warran.es, express, implied or statutory, and shall survive the State’s payment, acceptance, inspec.on or failure to inspect the supplies.

State of Illinois Chief Procurement O�ce General Services 9

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V.23.2

25.3. Vendor warrants that all services will be performed to meet the requirements of the contract in an e�cient and ePec.ve manner by trained and competent personnel. Vendor shall monitor performances of each individual and shall reassign immediately any individual who is not performing in accordance with the contract, who is disrup.ve or not respecVul of others in the workplace, or who in any way violates the contract or State policies.

26. REPORTING, STATUS AND MONITORING SPECIFICATIONS: Vendor shall immediately no.fy the State of any event that may have a material impact on Vendor’s ability to perform the contract.

27. EMPLOYMENT TAX CREDIT: Vendors who hire qualiHed veterans and certain ex-oPenders may be eligible for tax credits. 35 ILCS 5/216, 5/217. Please contact the Illinois Department of Revenue (telephone #: 217-524-4772) for informa.on about tax credits.

28. TERMINATION FOR CAUSE: The State may terminate this contract, in whole or in part, immediately upon no.ce to the Vendor if: (a) the State determines that the ac.ons or inac.ons of the Vendor, its agents, employees or subcontractors have caused, or reasonably could cause, jeopardy to health, safety, or property, or (b) the Vendor has no.Hed the State that it is unable or unwilling to perform the contract.

28.1. If Vendor fails to perform to the State’s sa.sfac.on any material requirement of this contract, is in viola.on of a material provision of this contract, or the State determines that the Vendor lacks the

Hnancial resources to perform the contract, the State shall provide wri:en no.ce to the Vendor to cure the problem iden.Hed within the period of .me speciHed in the State’s wri:en no.ce. If not cured by that date the State may either: (a) immediately terminate the contract without addi.onal wri:en no.ce or (b) enforce the terms and condi.ons of the contract.

28.2. For termina.on due to any of the causes contained in this Sec.on, the State retains its rights to seek any available legal or equitable remedies and damages.

29. TERMINATION FOR CONVENIENCE: The State may, for its convenience and with thirty (30) days prior wri:en no.ce to Vendor, terminate this contract in whole or in part and without payment of any penalty or incurring any further obliga.on to the Vendor.

29.1. The Vendor shall be en.tled to compensa.on upon submission of invoices and proof of claim for supplies and services provided in compliance with this contract up to and including the date of termina.on.

30. AVAILABILITY OF APPROPRIATION: This contract is con.ngent upon and subject to the availability of funds. The

State, at its sole op.on, may terminate or suspend this contract, in whole or in part, without penalty or further payment being required, if (1) the Illinois General Assembly or the federal funding source fails to make an appropria.on su�cient to pay such obliga.on, or if funds needed are insu�cient for any reason (30 ILCS 500/20-

60), (2) the Governor decreases the Department’s funding by reserving some or all of the Department’s appropria.on(s) pursuant to power delegated to the Governor by the Illinois General Assembly, or (3) the

Department determines, in its sole discre.on or as directed by the O�ce of the Governor, that a reduc.on is necessary or advisable based upon actual or projected budgetary considera.ons. Contractor will be no.Hed in wri.ng of the failure of appropria.on or of a reduc.on or decrease.

TAXPAYER IDENTIFICATION NUMBER

State of Illinois Chief Procurement O�ce General Services 10

Taxpayer Iden.Hca.on Number

V.23.2

I cer.fy that:

The number shown on this form is my correct taxpayer iden.Hca.on number (or I am wai.ng for a number to be issued to me), and

I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been no.Hed 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 no.Hed me that I am no longer subject to backup withholding, and

I am a U.S. person (including a U.S. resident alien).

If you are an individual, enter your name and SSN as it appears on your Social Security Card.

If you are a sole proprietor, enter the owner’s name on the name line followed by the name of the business and the owner’s SSN or EIN.

If you are a single-member LLC that is disregarded as an en.ty separate from its owner, enter the owner’s name on the name line and the D/B/A on the business name line and enter the owner’s SSN or EIN.

If the LLC is a corpora.on or partnership, enter the en.ty’s business name and EIN and for corpora.ons, a:ach IRS acceptance le:er (CP261 or CP277).

For all other en..es, enter the name of the en.ty as used to apply for the en.ty’s EIN and the EIN.

or

Individual Governmental

Sole Proprietor Nonresident alien

Partnership Estate or trust

Legal Services Corpora.on Pharmacy (Non-Corp.)

Tax-exempt Pharmacy/Funeral Home/Cemetery (Corp.)

Corpora.on providing or billing Limited Liability Company medical and/or health care services (select applicable tax classiHca.on)

Corpora.on NOT providing or billing C = corpora.on medical and/or health care services P = partnership

Signature of Authorized Representa.ve:

Date: Click here to enter a date.

Name: ACKAH SARBAH

Business Name: BOTACH INC

Taxpayer Iden.Hca.on Number:

Social Security Number: Click here to enter text.

Employer Iden.Hca.on Number: 45-4102112.

Legal Status (check one):

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9/11/26

CONTACT INFORMATION