DIV_0_-_Formal_non-CWA.pdf

MT. SAN ANTONIO COMMUNITY COLLEGE DISTRICT

Non-Collusion Declaration - 00320

NON-COLLUSION DECLARATION

STATE OF CALIFORNIA

COUNTY OF _________________________)

BID NO.:

PROJECT:

I, _____________________________________, being first duly sworn, deposes and says that I am the (Typed or Printed Name)

____________________________ of __________________________________________, the party submitting (Title) (Bidder Name) the foregoing Bid Proposal ("the Bidder"). In connection with the foregoing Bid Proposal, the undersigned declares, states and certifies that:

1. The Bid Proposal is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization or corporation.

2. The Bid Proposal is genuine and not collusive or sham.

3. The bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham bid, and has not directly or indirectly colluded, conspired, connived, or agreed with any other bidder or anyone else to put in sham bid, or to refrain from bidding.

4. The bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price, or that of any other bidder, or to fix any overhead, profit or cost element of the bid price or that of any other bidder, or to secure any advantage against the public body awarding the contract or of anyone interested in the proposed contract.

5. All statements contained in the Bid Proposal and related documents are true.

6. The bidder has not, directly or indirectly, submitted the bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any person, corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid.

Executed this _____ day of _________________, 20___ at __________________________________.

(City, County and State)

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

Signature (Address)

Name Printed or Typed (City, County and State)

(Area Code and Telephone Number)

MT. SAN ANTONIO COLLEGE

BID BOND – 00350

BID BOND

KNOW ALL MEN BY THESE PRESENTS that we, ________________________________, as Surety and ___________________________________, as Principal, are jointly and severally, along with their respective heirs, executors, administrators, successors and assigns, held and firmly bound unto MT. SAN ANTONIO COMMUNITY COLLEGE DISTRICT, hereinafter "the Obligee,” for payment of the penal sum hereof in lawful money of the United States, as more particularly set forth herein.

THE CONDITION OF THIS OBLIGATION IS SUCH THAT:

WHEREAS, the Principal has submitted the accompanying Bid Proposal to the Obligee for the Work commonly described as the

Project Name ______________________ Bid No. ____

WHEREAS, subject to the terms of this Bond, the Surety is firmly bound unto the Obligee in the penal sum of ten percent (10%) of the maximum amount of the Bid Proposal submitted by the Principal to the Obligee, as set forth above.

NOW THEREFORE, if the Principal shall not withdraw said Bid Proposal within the period specified therein after the opening of the same, or, if no period be specified, for sixty (60) days after opening of said Bid Proposal; and if the Principal is awarded the Contract, and shall within the period specified therefor, or if no period be specified, within five (5) days after the prescribed forms are presented to him for signature, enter into a written contract with the Obligee, in accordance with the Bid Proposal as accepted and give such bond(s) with good and sufficient surety or sureties, as may be required, for the faithful performance and proper fulfillment of such Contract and for the payment for labor and materials used for the performance of the Contract, or in the event of the withdrawal of said Bid Proposal within the period specified for the holding open of the Bid Proposal or the failure of the Principal to enter into such Contract and give such bonds within the time specified, if the Principal shall pay the Obligee the difference between the amount specified in said Bid Proposal and the amount for which the Obligee may procure the required Work and/or supplies, if the latter amount be in excess of the former, together with all costs incurred by the Obligee in again calling for Bids, then the above obligation shall be void and of no effect, otherwise to remain in full force and effect.

Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Contract or the Call for Bids, the Work to be performed thereunder, the Drawings or the Specifications accompanying the same, or any other portion of the Contract Documents shall in no way affect its obligations under this Bond, and it does hereby waive notice of any such change, extension of time, alteration or addition to the terms of said Contract, the Call for Bids, the Work, the Drawings or the Specifications, or any other portion of the Contract Documents.

In the event suit or other proceeding is brought upon this Bond by the Obligee, the Surety shall pay to the Obligee all costs, expenses and fees incurred by the Obligee in connection therewith, including without limitation, attorneys fees.

BID BOND – 00350

IN WITNESS WHEREOF, THE Principal and Surety have executed this instrument by their duly authorized agents or representatives on this ________ day of __________________, 20_____ .

(Principal’s Corporate Seal) (Principal Name)

By:______________________________________

(Typed or Printed Name)

Title: ____________________________________

(Surety’s Corporate Seal) (Surety Name)

(Area Code and Telephone Number of Surety)

By:______________________________________ (Signature of Attorney-in-Fact for Surety)

(Attach Attorney-in-Fact Certificate) (Typed or Printed Name)

(Attorney-in-Fact Telephone)

(Attorney-in-Fact Street Address)

(Attorney-in-Fact City, State and Zip Code)

AGREEMENT – 00400

AGREEMENT

THIS AGREEMENT is made this ___ day of ________, ____, in the City of Walnut, County of Los Angeles, State of California, by and between MT. SAN ANTONIO COMMUNITY COLLEGE DISTRICT, a California Community College District ("District") and _____________________, ("Contractor").

WITNESSETH, that the District and the Contractor in consideration of the mutual covenants contained herein agree as follows:

1. The Work. Within the Contract Time and for the Contract Price, subject to adjustments thereto pursuant to the Contract Documents, the Contractor shall perform and provide all necessary labor, materials, tools, equipment, utilities, services and transportation to complete in a workmanlike manner all of the Work required in connection with the work of improvement commonly referred to as

Bid No. __________

Contractor shall complete all Work covered by the Contract Documents, including without limitation, the Drawings and Specifications prepared by the Architect, and other Contract Documents enumerated in Article 5 below, along with all modifications and addenda thereto issued in accordance with the Contract Documents.

2. Contract Time. The Work shall be commenced on the date stated in the District's Notice to Proceed; the Contractor shall achieve Final Completion of the Work within the Contract Time set forth in the Contract Documents.

3. Contract Price. The District shall pay the Contractor as full consideration for the Contractor's full, complete and faithful performance of the Contractor's obligations under the Contract Documents, subject to adjustments of the Contract Price in accordance with the Contract Documents, the Contract Price of _________________________________________Dollars (_______________).

The Contract Price is based upon the Contractor's Base Bid Proposal and Allowance amount.

The District's payment of the Contract Price shall be in accordance with the Contract Documents.

4. Liquidated Damages. If the Contractor fails to achieve Final Completion of the Work within the Contract Time, including adjustments thereto authorized by the Contract Documents, the Contractor shall be subject to assessment of Liquidated Damages in accordance with the Contract Documents. Failure of the Contractor to complete Major Milestones or to submit Submittals within the time(s) established to do so will result in the District’s assessment of Liquidated Damages in accordance with the Contract Documents.

5. The Contract Documents. The documents forming a part of the Contract Documents consist of the following, all of which are component parts of the Contract Documents.

Notice to Contractors Calling For Bids Instructions for Bidders Bid Proposal Subcontractors List Non-Collusion Affidavit Iran Contracting Certification Bid Bond Bid Addenda, if any Agreement Change Orders/Amendments, if any Performance Bond Labor and Materials Payment Bond Drug-Free Workplace Certification Certification of Workers Compensation Insurance Certificates of Insurance General Conditions Supplemental Conditions Specifications Guarantee

6. Notices. Any notice relevant to this Agreement shall conform to the requirements of Section 16.9 of the General Conditions, and shall be addressed to the signatories listed below. The District shall timely notify Contractor of any third-party claim related to this Agreement as set forth in Section 16.9 of the General Conditions.

7. Authority to Execute. The individual(s) executing this Agreement on behalf of the Contractor is/are duly and fully authorized to execute this Agreement on behalf of Contractor and to bind the Contractor to each and every term, condition and covenant of the Contract Documents.

CONTRACTORS ARE REQUIRED BY LAW TO BE LICENSED

AND REGULATED BY THE CONTRACTORS' STATE LICENSE

BOARD. ANY QUESTIONS CONCERNING A CONTRACTOR

MAY BE REFERRED TO THE REGISTRAR, CONTRACTORS'

STATE LICENSE BOARD, P.O. BOX 2600, SACRAMENTO,

CALIFORNIA 95826

IN WITNESS WHEREOF, this Agreement has been duly executed by the District and the Contractor as of the date set forth above.

DISTRICT CONTRACTOR

Mt. San Antonio Community College District _____________________________ 1100 North Grand Avenue _____________________________ Walnut, CA 91789 _____________________________

(909) 594-5611; fax (909) 468-4025 _____________________________

By: ________________________________ By: __________________________

Morris Rodrigue Name: _______________________ Vice President, Administrative Services

Title: _________________________

MT. SAN ANTONIO COLLEGE PERFORMANCE BOND

DOCUMENT 00 61 13.13-1

DOCUMENT 00 61 13.13

PERFORMANCE BOND

(100% of Contract Price)

(Note: Bidders must use this form, NOT a surety company form.)

KNOW ALL PERSONS BY THESE PRESENTS:

WHEREAS, the governing board (“Board”) of the Mt. San Antonio College, (“Owner”) and , (“Principal)” have entered into a contract for the furnishing of all materials and labor, services and transportation, necessary, convenient, and proper to perform the following project:

(Project Name)

(“Contract”) which Contract dated , 20___, and all of the Contract Documents attached to or forming a part of the Contract, are hereby referred to and made a part hereof; and

WHEREAS, said Principal is required under the terms of the Contract to furnish a bond for the faithful performance of the Contract.

NOW, THEREFORE, the Principal and (“Surety”) are held and firmly bound unto the Board of the Owner in the penal sum of DOLLARS ($ ), lawful money of the United States, for the payment of which sum well and truly to be made we bind ourselves, our heirs, executors, administrators, successors, and assigns jointly and severally, firmly by these presents, to:

- Perform all the work required to complete the Project; and

- Pay to the Owner all damages the Owner incurs as a result of the Principal’s failure to perform all the Work required to complete the Project.

The condition of the obligation is such that, if the above bounden Principal, his or its heirs, executors, administrators, successors, or assigns, shall in all things stand to and abide by, and well and truly keep and perform the covenants, conditions, and agreements in the Contract and any alteration thereof made as therein provided, on his or its part to be kept and performed at the time and in the intent and meaning, including all contractual guarantees and warrantees of materials and workmanship, and shall indemnify and save harmless the Owner, its trustees, officers and agents, as therein stipulated, then this obligation shall become null and void, otherwise it shall be and remain in full force and virtue.

As a condition precedent to the satisfactory completion of the Contract, the above obligation shall hold good for a period equal to the warranty and/or guarantee period of the Contract, during which time Surety’s obligation shall continue if Contractor shall fail to make full, complete, and satisfactory repair and replacements and totally protect the Owner from loss or damage resulting from or caused by defective materials or faulty workmanship. The obligations of Surety hereunder shall continue so long as any obligation of Contractor remains.

Nothing herein shall limit the Owner’s rights or the Contractor or Surety’s obligations under the Contract, law or equity, including, but not limited to, California Code of Civil Procedure section 337.15.

MT. SAN ANTONIO COLLEGE PERFORMANCE BOND

DOCUMENT 00 61 13.13-2

The Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration, or addition to the terms of the contract or to the work to be performed thereunder or the specifications accompanying the same shall in any way affect its obligation on this bond, and it does hereby waive notice of any such change, extension of time, alteration, or addition to the terms of the Contract or to the work or to the specifications.

IN WITNESS WHEREOF, two (2) identical counterparts of this instrument, each of which shall for all purposes be deemed an original thereof, have been duly executed by the Principal and Surety above named, on the day of , 20___.

(Affix Corporate Seal)

Principal

By

Surety

Name of California Agent of Surety

Address of California Agent of Surety

Telephone Number of California Agent of Surety

Bidder must attach a Notarial Acknowledgment for all Surety's signatures and a Power of Attorney and Certificate of Authority for Surety. The California Department of Insurance must authorize the Surety to be an admitted surety insurer.

END OF DOCUMENT

MT. SAN ANTONIO COLLEGE PAYMENT BOND

DOCUMENT 00 61 13.16-1

DOCUMENT 00 61 13.16

PAYMENT BOND

Contractor's Labor & Material Bond

(100% of Contract Price)

(Note: Bidders must use this form, NOT a surety company form.)

KNOW ALL PERSONS BY THESE PRESENTS:

WHEREAS, the governing board (“Board”) of the Mt. San Antonio College, (“Owner”) and , (“Principal”) have entered into a contract for the furnishing of all materials and labor, services and transportation, necessary, convenient, and proper to perform the following project:

(Project Name)

(“Contract”) which Contract dated , 20___, and all of the Contract Documents attached to or forming a part of the Contract, are hereby referred to and made a part hereof; and

WHEREAS, pursuant to law and the Contract, the Principal is required, before entering upon the performance of the work, to file a good and sufficient bond with the body by which the Contract is awarded in an amount equal to one hundred percent (100%) of the Contract price, to secure the claims to which reference is made in sections 9000 through 9510 and 9550 through 9566 of the Civil Code, and division 2, part 7, of the Labor Code.

NOW, THEREFORE, the Principal and , (“Surety”) are held and firmly bound unto all laborers, material men, and other persons referred to in said statutes in the sum of Dollars ($ ), lawful money of the United States, being a sum not less than the total amount payable by the terms of Contract, for the payment of which sum well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors, or assigns, jointly and severally, by these presents.

The condition of this obligation is that if the Principal or any of his or its subcontractors, of the heirs, executors, administrators, successors, or assigns of any, all, or either of them shall fail to pay for any labor, materials, provisions, provender, or other supplies, used in, upon, for or about the performance of the work contracted to be done, or for any work or labor thereon of any kind, or for amounts required to be deducted, withheld, and paid over to the Employment Development Department from the wages of employees of the Principal or any of his or its subcontractors of any tier under Section 13020 of the Unemployment Insurance Code with respect to such work or labor, that the Surety will pay the same in an amount not exceeding the amount herein above set forth, and also in case suit is brought upon this bond, will pay a reasonable attorney’s fee to be awarded and fixed by the Court, and to be taxed as costs and to be included in the judgment therein rendered.

It is hereby expressly stipulated and agreed that this bond shall inure to the benefit of any and all persons, companies, and corporations entitled to file claims under section 9100 of the Civil Code, so as to give a right of action to them or their assigns in any suit brought upon this bond.

Should the condition of this bond be fully performed, then this obligation shall become null and void; otherwise it shall be and remain in full force and affect.

MT. SAN ANTONIO COLLEGE PAYMENT BOND

DOCUMENT 00 61 13.16-2

And the Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration, or addition to the terms of Contract or the specifications accompanying the same shall in any manner affect its obligations on this bond, and it does hereby waive notice of any such change, extension, alteration, or addition.

IN WITNESS WHEREOF, two (2) identical counterparts of this instrument, each of which shall for all purposes be deemed an original thereof, have been duly executed by the Principal and Surety above named, on the day of , 20___.

(Affix Corporate Seal)

Principal

Surety

Name of California Agent of Surety

Address of California Agent of Surety

Telephone Number of California Agent of Surety

Bidder must attach a Notarial Acknowledgment for all Surety's signatures and a Power of Attorney and Certificate of Authority for Surety. The California Department of Insurance must authorize the Surety to be an admitted surety insurer.

WORKERS' COMP CERTIFICATE - 00440

CERTIFICATE OF WORKERS' COMPENSATION INSURANCE

I, the ______________________________ (Name) (Title) of ,declare, state and certify that:

(Contractor Name)

1. I am aware that California Labor Code §3700(a) and (b) provides:

"Every employer except the state shall secure the payment of compensation in one or more of the following ways:

(a) By being insured against liability to pay compensation in one or more insurers duly authorized to write compensation insurance in this state.

(b) By securing from the Director of Industrial Relations a certificate of consent to self-insure either as an individual employer, or one employer in a group of employers, which may be given upon furnishing proof satisfactory to the Director of Industrial Relations of ability to self-insure and to pay any compensation that may become due to his or her employees."

2. I am aware that the provisions of California Labor Code §3700 require every employer to be insured against liability for workers' compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of this Contract.

(Contractor Name)

By:______________________________________

(Signature)

(Typed or printed name)

DRUG FREE CERTIFICATION - 00450

DRUG-FREE WORKPLACE CERTIFICATION

I, __________________________________, am the __________________________ of (Print Name) (Title)

_________________________________________, I declare, state and certify to all of the following:

(Contractor Name)

1. I am aware of the provisions and requirements of California Government Code §§8350 et seq., the Drug Free Workplace Act of 1990.

2. I am authorized to certify, and do certify, on behalf of Contractor that a drug free workplace will be provided by Contractor by doing all of the following:

A. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance is prohibited in Contractor's workplace and specifying actions which will be taken against employees for violation of the prohibition;

B. Establishing a drug-free awareness program to inform employees about all of the following:

i. The dangers of drug abuse in the workplace;

ii. Contractor's policy of maintaining a drug-free workplace;

iii. The availability of drug counseling, rehabilitation and employee-assistance programs; and

iv. The penalties that may be imposed upon employees for drug abuse violations;

C. Requiring that each employee engaged in the performance of the Contract be given a copy of the statement required by subdivision (A), above, and that as a condition of employment by Contractor in connection with the Work of the Contract, the employee agrees to abide by the terms of the statement.

D. Contractor agrees to fulfill and discharge all of Contractor's obligations under the terms and requirements of California Government Code §8355 by, inter alia, publishing a statement notifying employees concerning: (a) the prohibition of any controlled substance in the workplace, (b) establishing a drug-free awareness program, and (c) requiring that each employee engaged in the performance of the Work of the Contract be given a copy of the statement required by California Government Code §8355(a) and requiring that the employee agree to abide by the terms of that statement.

DRUG FREE CERTIFICATION - 00450

3. Contractor and I understand that if the District determines that Contractor has either: (a) made a false certification herein, or (b) violated this certification by failing to carry out and to implement the requirements of California Government Code §§8355, the Contract awarded herein is subject to termination, suspension of payments, or both. Contractor and I further understand that, should Contractor violate the terms of the Drug-Free Workplace Act of 1990, Contractor may be subject to debarment in accordance with the provisions of California Government Code §§8350, et seq.

4. Contractor and I acknowledge that Contractor and I are aware of the provisions of California Government Code §§8350, et seq. and hereby certify that Contractor and I will adhere to, fulfill, satisfy and discharge all provisions of and obligations under the Drug- Free Workplace Act of 1990.

I declare under penalty of perjury under the laws of the State of California that all of the foregoing is true and correct.

Executed at this ____day of

(City and State)

________________, 20____.

(Signature)

(Handwritten or Typed Name)

Mt. San Antonio College 00454

IRAN CONTRACTING ACT CERTIFICATION (Public Contract Code § 2204)

Pursuant to Public Contract Code (PCC) section 2204, an Iran Contracting Act certification is required for solicitations of goods or services of one million dollars ($1,000,000) or more.

Bidder shall complete ONLY ONE of the following paragraphs.

1. Bidder’s Proposal is less than one million dollars ($1,000,000).

OR

2. Bidder’s Proposal is one million dollars ($1,000,000) or more, but Bidder is not on the current list of persons engaged in investment activities in Iran created by the California Department of General Services (“DGS”) pursuant to Public Contract Code § 2203(b), and Bidder is not a financial institution extending twenty million dollars ($20,000,000) or more in credit to another person, for 45 days or more, if that other person will use the credit to provide goods or services in the energy sector in Iran and is identified on the current list of persons engaged in investment activities in Iran created by DGS.

OR

3. Bidder’s Proposal is one million dollars ($1,000,000) or more, but the District has given prior written permission to Bidder to submit a proposal pursuant to PCC 2203(c) or (d). A copy of the written permission from the District is included with this Contract.

I certify that I am duly authorized to legally bind the Vendor/Contractor to this certification, that the contents of this certification are true, and that this certification is made under the laws of the State of California.

Date:

Proper Name of Designer/Builder: _______________________

Signature:

Print Name: _________

Title: ________________

VERIFICATION OF CONTRACTOR AND

SUBCONTRACTORS' D IR REGISTRATION

I am the ___________________ of ("Bidder")

(Title/Position) (Bidder Name) submitting the accompanying Bid Proposal for the Work described as

1. The Bidder is currently registered as a contractor with the Department of Industrial Relations ("DIR").

2. The Bidder's DIR Registration Number is________________ The expiration date of the Bidder's DIR Registration is______________, 20__

3. If the Bidder is awarded the Contract for the Work and the expiration date of the Bidder's DIR Registration will occur: (i) prior to expiration of the Contract Time for the Work; or (ii) prior to the Bidder completing all obligations under the Contract for the Work, the Bidder will take all measures necessary to renew the Bidder's DIR Registration so that there is no lapse in the Bidder's DIR Registration while performing Work under the Contract.

4. The Bidder, if awarded the Contract for the Work will remain a DIR registered contractor for the entire duration of the Work.

5. The Bidder has independently verified that each Subcontractor identified in the Subcontractors List submitted with the Bid Proposal of the Bidder is currently a DIR registered contractor.

6. The Bidder has provided the DIR Registration Number for each subcontractor identified in the Bidder's Subcontractors' List or within twenty-four (24) hours of the opening of Bid Proposals for the Work, the Bidder will provide the District with the DIR Registration Number for each subcontractor identified in the Bidder's Subcontractors List.

7. The Bidder's solicitation of subcontractor bids included notice to prospective subcontractors that: (i) all sub-tier subcontractors must be DIR registered contractors at all times during performance of the Work; and (ii) prospective subcontractors may only solicit sub-bids from and contract with lower-tier subcontractors who are DIR registered contractors.

8. If any of the statements herein are false or omit material facts rendering a statement to be false or misleading, the Bidder's Bid Proposal is subject to rejection for non-responsiveness.

9. I have personal first hand-knowledge of all of the foregoing

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

Executed this day of , 20 at

(City and State)

(Signature)

(Name, typed or printed)

DVBE Participation Goal

Per California Education Code §17076.11 - Any school district using funds allocated pursuant to this chapter for the construction or modernization of a school building, shall have a participation goal of at least 3 percent, per year, of the overall dollar amount expended each year by the school district, for disabled veteran business enterprises.

Please select the appropriate box below:

The Bidder acknowledges that the District has established a three percent (3%) Participation Goal for

Disabled Veteran Business Enterprises. The undersigned Bidder certifies to the District the following:

The three percent (3%) DVBE Participation Goal has been achieved

The three percent (3%) DVBE Participation Goal has not been achieved, the Bidder has made Good

Faith Efforts to achieve the DVBE Participation Goal.

Company Name: _____________________________________

By: ______________________________________

(Contractor Signature)

(Typed or Printed Name)

Title: _____________________________________

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 nt o r ty p e.

S ee S p ec ifi c

In st ru ct io ns 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)

Mt. San Antonio College Purchasing Department 1100 N. Grand Ave.

Walnut, CA 91789

Phone (909) 274-4245 Fax (909) 274-2025

VENDOR INFORMATION

1. GENERAL INFORMATION

Company Name

Contact Name dba (if applicable)

Mailing Address

City, State & Zip Code

Phone Number Fax Number

E-Mail Address

Website Address

2. Remittance Address (If different from Item 1):

Company Name

Contact Name dba (if applicable)

Mailing Address

City, State & Zip Code

Phone Number Fax Number

E-Mail Address

Alternate E-Mail Address

3. Affirmative Action (Check One):

□ Minority-Owned/Disadvantaged Business

□ Woman-Owned Business

□ Small Business Concern

□ Disabled Veteran Enterprise

□ Other___________________________________

□ None of the Above

4. ACH Info:

Bank Name: __________________________________

Routing # : ___________________________________

Account Name: ________________________________

Account # : ___________________________________

Account Type: ____Checking ____Savings

Does an employee or officer of Mt. San Antonio College own, partly own, operate, or have a financial interest in this business? □ Yes □ No If yes, please provide the name of the Mt. San Antonio College employee or officer who is affiliated with this business. _________________________________________________

DISTRICT USE ONLY

VENDOR I.D. NO:

DATE ENTERED:

By:

BANK VERIFICATION:

DATE VERIFIED:

PRE-NOTE:

DATE COMPLETED:

Dear Prospective Vendor, If your address is outside California our college may need one of the additional forms below.

To assist you in determining which form to submit, below are brief form descriptions:

Form 590 withholding exemption certificate: to be used if a company is claiming an exemption from withholding i.e. they have a presence in California

Form 588 Nonresident Withholding Waiver Request: to be used if a company is requesting a withholding waiver i.e. they are filing a California Tax Return for reason(s) listed on the form

Form 587 Nonresident Withholding allocation Worksheet: to be filled out by a company if the other two forms are not applicable i.e. the company does not have a presence (address) in California and are not filing California tax returns

Attached are additional forms that your company will need to review.

Please choose one and send back with W9 and company information. Thank you.

Form 588 2021 Side 1

Part I Withholding Agent Information

Part II Requester Information

Part III Type of Income Subject to Withholding

Business name

Business name

SSN or ITIN

SSN or ITIN

FEIN

FEIN

CA Corp no.

CA Corp no.

CA SOS file no.

CA SOS file no.

First name

First name

Check one box only.

Check one type only.

Withholding Agent Payee Authorized Representative for Withholding Agent Authorized Representative for Payee

Initial

Initial

Last name

Last name

Telephone

Telephone

Telephone

Date

Fax

Fax

State

State

ZIP code

ZIP code

Address (apt./ste., room, PO box, or PMB no.)

Address (apt./ste., room, PO box, or PMB no.)

City (If you have a foreign address, see instructions.)

City (If you have a foreign address, see instructions.)

A □ Payments to Independent Contractors

B □ Trust Distributions

I □ Other

C □ Rents or Royalties

D □ Distributions to Domestic Nonresident Partners/Members/Beneficiaries/S Corporation Shareholders

E □ Estate Distributions

Complete Side 2, Part IV Schedule of Payees, before signing below.

Our privacy notice can be found in annual tax booklets or online. Go to ftb.ca.gov/privacy to learn about our privacy policy statement, or go to ftb.ca.gov/forms and search for 1131 to locate FTB 1131 EN-SP, Franchise Tax Board Privacy Notice on Collection. To request this notice by mail, call 800.338.0505 and enter form code 948 when instructed.

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than withholding agent) is based on all information of which preparer has any knowledge.

Type or print requester’s name and title

Requester’s signature

7051223

TAXABLE YEAR

2022 Nonresident Withholding Waiver Request

CALIFORNIA FORM

Sign Here

Side 2 Form 588 2021

Requester Name: Requester TIN:

Part IV Schedule of Payees Do not use your own version of the Schedule of Payees to report additional payees. We can only accept and process additional payees reported on this form. See instructions.

Business name

Business name

Business name

SSN or ITIN FEIN CA Corp no.

CA Corp no.

CA Corp no.

CA SOS file no.

First name

First name

First name

Initial

Initial

Initial

Last name

Last name

Last name

Address (apt./ste., room, PO box, or PMB no.)

Address (apt./ste., room, PO box, or PMB no.)

Address (apt./ste., room, PO box, or PMB no.)

City (If you have a foreign address, see instructions.)

City (If you have a foreign address, see instructions.)

City (If you have a foreign address, see instructions.)

Reason for Waiver Request (Check box next to one Reason Code.)

Reason for Waiver Request (Check box next to one Reason Code.)

Reason for Waiver Request (Check box next to one Reason Code.)

Newly Admitted Date (mm/dd/yyyy) (Must be included when selecting Reason Code “D.”)

Newly Admitted Date (mm/dd/yyyy) (Must be included when selecting Reason Code “D.”)

Newly Admitted Date (mm/dd/yyyy) (Must be included when selecting Reason Code “D.”)

□ A □ B □ C □ D □ E

□ A □ B □ C □ D □ E

□ A □ B □ C □ D □ E

State

State

State

ZIP code

ZIP code

ZIP code

SSN or ITIN

SSN or ITIN

FEIN

FEIN

CA SOS file no.

CA SOS file no.

Waiver Request Reason Codes

A Payee has California state tax returns on file for the two most current taxable years in which the payee has a filing requirement. Payee is considered current on any tax obligations with the Franchise Tax Board (FTB).

B Payee is making timely estimated tax payments for the current taxable year. Payee is considered current on any tax obligations with the FTB.

C Payee is a corporation that is not qualified to do business and does not have a permanent place of business in California but is filing a tax return based on a combined report with a corporation that does have a permanent place of business in California. Attach a copy of Schedule R-7, Election to File a Unitary Taxpayers’ Group Return, from the combined report.

D Payee is a newly admitted S corporation shareholder, partner of a partnership, or member of a limited liability company. In the “Newly Admitted Date” box, provide the date this shareholder, partner, or member was admitted. The waiver will expire at the end of the calendar year succeeding the date the payee was newly admitted. Once expired, the payee must have the most current California tax return due on file or estimated tax payments for the current taxable year in order to have a new waiver granted.

E Other – Attach a specific reason and include substantiation that would justify a waiver from withholding. If payee is a group return participant, attach a copy of Schedule 1067A, Nonresident Group Return Schedule, from the group return.

7052223

Form 587 2021

TAXABLE YEAR

Nonresident Withholding Allocation Worksheet

CALIFORNIA FORM

Part I Withholding Agent Information

Part II Nonresident Payee Information

Part III Payment Type

Part IV Income Allocation

Certification of Nonresident Payee

Nonresident payee’s entity type: (Check one)

The payee completes this form and returns it to the withholding agent. The withholding agent keeps this form with their records.

Nonresident payee: (Check one)

Gross payments expected from the withholding agent during the calendar year for:

If the nonresident payee performs all the services within California, withholding is required on the entire payment for services unless the payee is granted a withholding waiver from the Franchise Tax Board (FTB). For more information, get FTB Pub. 1017, Resident and Nonresident Withholding Guidelines.

(a) Within California (b) Outside California (c) Total payments 1 Goods and services:

Goods/materials (no withholding required)

5 Other payments . . . . . . . . . . . . . . . . . . . . . . . . . . ___________________________ ___________________________ ___________________________ 6 Total payments subject to withholding.

Add column (a), line 1 through line 5 . . . . . . . . ___________________________ ___________________________ ___________________________

Nonresident withholding threshold amount: $1,500.00

Backup withholding threshold amount: $0.00

• Estate or trust• Limited liability company (LLC)• Partnership• Corporation• Individual/sole proprietor

□ Performs services totally outside California (no withholding required, skip to Certification of Nonresident Payee)

□ Provides goods and services in California (see Part IV, Income Allocation)

□ Provides services within and outside California (see Part IV, Income Allocation)

□ Other (Describe)___________________________________________

Withholding agent’s name

Address (apt./ste., room, PO box, or PMB no.)

City (If you have a foreign address, see instructions.) State ZIP code

Payee’s name □ SSN or ITIN □ FEIN □ CA Corp no. □ CA SOS file no.

Address (apt./ste., room, PO box, or PMB no.)

City (If you have a foreign address, see instructions.) State ZIP code

Our privacy notice can be found in annual tax booklets or online. Go to ftb .ca .gov/privacy to learn about our privacy policy statement, or go to ftb .ca .gov/forms and search for 1131 to locate FTB 1131 EN-SP, Franchise Tax Board Privacy Notice on Collection. To request this notice by mail, call 800.338.0505 and enter form code 948 when instructed.

Under penalties of perjury, I declare that I have examined the information on this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I further declare under penalties of perjury that if the facts upon which this form are based change, I will promptly notify the withholding agent.

Sign Here

Print or type payee’s name Telephone

Payee’s signature

X Date

Print or type representative’s name and title Telephone

Authorized representative’s signature

X Date

7041223

□ Provides only goods or materials (no withholding required, skip to Certification of Nonresident Payee)

Form 590 20217061223

TAXABLE YEAR

2022 Withholding Exemption Certificate

CALIFORNIA FORM

The payee completes this form and submits it to the withholding agent. The withholding agent keeps this form with their records.

Withholding Agent Information Name

Name □ SSN or ITIN □ FEIN □ CA Corp no. □ CA SOS file no.

Address (apt./ste., room, PO box, or PMB no.)

City (If you have a foreign address, see instructions.) State ZIP code

Exemption Reason Check only one box.

By checking the appropriate box below, the payee certifies the reason for the exemption from the California income tax withholding requirements on payment(s) made to the entity or individual.

CERTIFICATE OF PAYEE: Payee must complete and sign below.

Our privacy notice can be found in annual tax booklets or online. Go to ftb.ca.gov/privacy to learn about our privacy policy statement, or go to ftb.ca.gov/forms and search for 1131 to locate FTB 1131 EN-SP, Franchise Tax Board Privacy Notice on Collection. To request this notice by mail, call 800.338.0505 and enter form code 948 when instructed.

Under penalties of perjury, I declare that I have examined the information on this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. I further declare under penalties of perjury that if the facts upon which this form are based change, I will promptly notify the withholding agent.

Type or print payee’s name and title ___________________________________________________ Telephone _________________

Payee Information

□ Individuals — Certification of Residency:

I am a resident of California and I reside at the address shown above. If I become a nonresident at any time, I will promptly notify the withholding agent. See instructions for General Information D, Definitions.

Payee’s signature ▶ Date ______________________

□ Corporations:

The corporation has a permanent place of business in California at the address shown above or is qualified through the

California Secretary of State (SOS) to do business in California. The corporation will file a California tax return. If this corporation ceases to have a permanent place of business in California or ceases to do any of the above, I will promptly notify the withholding agent. See instructions for General Information D, Definitions.

□ Partnerships or Limited Liability Companies (LLCs):

The partnership or LLC has a permanent place of business in California at the address shown above or is registered with the

California SOS, and is subject to the laws of California. The partnership or LLC will file a California tax return. If the partnership or LLC ceases to do any of the above, I will promptly inform the withholding agent. For withholding purposes, a limited liability partnership (LLP) is treated like any other partnership.

□ Insurance Companies, Individual Retirement Arrangements (IRAs), or Qualified Pension/Profit-Sharing Plans:

The entity is an insurance company, IRA, or a federally qualified pension or profit-sharing plan.

□ California Trusts:

At least one trustee and one noncontingent beneficiary of the above-named trust is a California resident. The trust will file a

California fiduciary tax return. If the trustee or noncontingent beneficiary becomes a nonresident at any time, I will promptly notify the withholding agent.

□ Estates — Certification of Residency of Deceased Person:

I am the executor of the above-named person’s estate or trust. The decedent was a California resident at the time of death.

The estate will file a California fiduciary tax return.

□ Nonmilitary Spouse of a Military Servicemember:

I am a nonmilitary spouse of a military servicemember and I meet the Military Spouse Residency Relief Act (MSRRA) requirements. See instructions for General Information E, MSRRA.

□ Tax-Exempt Entities:

The entity is exempt from tax under California Revenue and Taxation Code (R&TC) Section 23701 ______

Internal Revenue Code Section 501(c) _____ the withholding agent. Individuals cannot be tax-exempt entities.

(insert letter) or (insert number). If this entity ceases to be exempt from tax, I will promptly notify