ESBD_File_350860_South Texas Respite Packet 2024.docx

SOUTH TEXAS DEVELOPMENT COUNCIL AGING & DISABILITY RESOURCE CENTER

REQUEST FOR QUALIFICATIONS (RFQ) FOR RESPITE SERVICES

FEBRUARY 9,2024

SOUTH TEXAS DEVELOPMENT COUNCIL SOUTH TEXAS AGING & DISABILITY RESOURCE CENTER

Request for Qualifications for Respite Services

I. Background Information

In partnership with the Texas Health and Human Services Commission (HHSC) the South Texas Development Council's (STDC) South Texas Aging and Disability Resource Center (STARDC) is releasing this request for qualifications (RFQ) to utilize funding to provide respite services to individuals with disabilities of any age and /or individuals under the age of 60. The purpose of these services is to assist families within the four (4) county service area of the STADRC who have individuals with disabilities. The intention of the funding is to provide respite services which provide short-term, temporary relief to the informal, unpaid caregiver of eligible individuals. The STDC seeks to select one (1) potential service provider who is qualified to provide respite services.

Figure 1. South Texas ADRC Service Area

II. General Information

RFO/Project Schedule

All responses must be received by 5:00 PM on or before February 28,2024. Responses received after 5:00 PM on February 28,2024 will not be considered. For the respondent's packet to be considered One (1) original and two (2) copies (total of 3) must be submitted to be considered as the potential service provider.

Proposals must be delivered either:

By Mail to:

South Texas Development Council South Texas Aging and Disability Resource Center C/o Michelle Salinas, ADRC Supervisor P.O. Box 2187 Laredo, TX 78044

Or Hand Delivered or Courier Service to:

South Texas Development Council South Texas Aging and Disability Resource Center C/o Michelle Salinas, ADRC Supervisor 1002 Dicky Ln Laredo, TX 78043 Ill. Considerations This RFQ does not constitute an offer. Acceptance of proposals for review does not commit STDC to award or enter into agreement, nor is STDC liable for any costs incurred in the preparation of proposals. STDC reserves the right to award a service agreement to a single bidder, multiple bidders, or to reject any and all proposals or parts of proposals received. STDC reserves the right to negotiate services and costs on any and all proposals or to cancel this RFQ in part or its entirety. Final service agreement(s) will be subject to applicable rules and regulations under the funding requirements.

Proposals submitted in response to this RFQ must comply with the specifications stated herein. Failure to adhere to the formatting requirements may result in the proposals being determined non-responsive and may result in the elimination of the proposal for consideration. At the option of STDC, any or all aspects of the successful proposal(s) will become service agreement obligations if acquisition action ensues. Failure of the successful bidder to accept these obligations in the service agreement may result in cancellation of the award.

Final approval of a service agreement(s) for these services depends on the availability of funds and the continued authorization of funds.

An appeal of the selection process will be heard only if it is alleged that the STDC has violated a statutory or regulatory provision in awarding the service agreement. An appeal will not be heard based upon a challenge to the evaluation of a response. Applicants may appeal by submitting a written request to:

Juan E. Rodriguez, Executive Director South Texas Development Council P.0. Box 2187 Laredo, TX 78044

No later than five (5) calendar days following receipt of the notification or by the deadline posted in this announcement.

IV. Description of Service and Participant Eligibility

Caring for children with special needs presents additional challenges that go beyond the everyday stress of being a parent. As a result, parents and other primary caregivers may need longer rest periods or access to downtime. It may also be more difficult to find a qualified person to care for children. Respite seeks to help offset these challenges.

A respite break allows caregivers an opportunity to strengthen or foster relationships with their other children, spouses, partners, other family members and/or friends. Respite can also allow caregivers an opportunity to practice self-care, carry out household duties, complete errands, and even catch-up on their own sleep. As a result, respite services as can achieve several goas: 1) avoid "burnout"; 2) reduce stress; 3) prevent family disruption; and

4) enhance relationships.

Respite is not a substitute for childcare, school, or participation in other age-appropriate activities. Respite is also not a substitute for services provided by a home health aid for self care needs (bathing, dressing, feeding and toileting).

Project activities must be aimed at caregivers who are spouses and family members caring for individuals with a chronic serious health condition or disability who require assistance with one or more activities of daily living, as well as biological/adoptive/foster parents and grandparents caring for children with a chronic serious health condition or disability who require assistance with one or more activities of daily living. Individuals related under the first and second degrees of affinity may also eligible for respite services under the Texas lifespan Respite Care Program (TLRCP}.

Individuals Eligible to Receive nRCP Respite Services:

· Adult Child (caring for parent)

· Spouse

· Biological, Adoptive, or Foster Parents

· Grandparents (caring for children)

· Adult Grandchild

· Sibling (sister or brother)

· Mother-in-Law

· Father-in-Law

· Daughter-in-Law

· Son-in-Law

· Stepmother

· Stepfather

· Stepdaughter

· Stepson

· Stepsister

· Stepbrother

· Sister-in-Law

· Brother-in-Law

· Spouse's Grandparent

· Spouse's Grandchild

· Grandchild's Spouse

· Spouse of Grandparent

Other Eligibility Criteria:

· The caregiver must be caring for individuals (including children) with a chronic serious health condition or disability who require assistance with one or more activities of daily living.

· TLRCP is for caregivers who are unable to access respite care through other programs, are on a waitlist for respite services, or who have exhausted other sources of respite.

· Caregivers cannot be actively receiving respite assistance through Local Intellectual and Developmental Disability Authorities, Area Agencies on Aging, Medicaid waiver programs, or other resources.

V. Required Qualifications

· Applicants must be in good standing with all State and Federal agencies with which they may have an existing award or contractual relationship.

· If applicant is under a corrective action plan with STDC or any State of Texas or Federal agency/authority, the applicant may not submit a proposal for this RFQ. Responses shall not be reviewed and considered by STDC until all deficiencies listed in the corrective action plan have been eliminated to the satisfaction of the reviewing agency.

· Applicants may not be suspended, terminated, or barred for deficiencies in performance of any award, and if applicable, all past issues must be resolved as demonstrated by written documentation.

· Applicants that are presently under contract with STDC must be in compliance with the terms and conditions of their contract(s).

· Where required, all applicants must hold current State licenses, and provide evidence of licensure no later than the contract award date.

· All applicants must have a Data Universal Numbering System (DUNS) number. To acquire a DUNS number, contacted the dedicated toll-free DUNS number request line at 1-866-705-5711 or inquire online at www.dnb.com

· Applicants must be registered with the System for Award Management (SAM) and be publicly available for search. SAM registration must remain current throughout the duration of the performance period and must be free of any active exclusions. To register, or for more information please visit www.sam.gov.

VI. Responsibilities

Provider shall:

· Provide all services within the terms of the agreement.

· Provide uniform standards of care and conduct regardless of any participant's: age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex.

· Follow all rules and regulations governing the implementation of selected services.

· Provide invoices and reports according to the guidelines established by the STDC.

· Permit site visits by STDC and/or Texas Health and Human Services Commission staff in order to monitor files, financial records, and program implementation as it relates to the provision of services set forth under the service agreement.

· Ensure compliance with federal, state, and local guidelines.

· Collect data and provide programmatic and fiscal reports as required by STDC

· Maintain fiscal records in accordance with standard accounting practices and provide STDC with specified financial reports designed to verify and analyze expenditures.

· Cooperate with STDC with any reports due to the State of Texas

· Ensure that any certification or licensure requirements and personnel standards are met

· Ensure that all staff and/or volunteers providing respite services to individuals funded by this grant are adequately trained (or licensed as necessary) to carry out their assigned functions.

· Retain all invoices, records and other documents pertinent to this project until five (S) years following the expiration or termination of this contract, until any audits in progress at the end of the five (5) year period are completed, or until any litigation relating to this project are resolved, whichever date is later.

STDC shall:

· Monitor and review program performance in relationship to the stated program goals.

· Enroll participants and provide a roster of eligible participants to the provider, indicating who has been approved for services.

· Pay provider within 45 days of receipt of invoice for services rendered to eligible participants.

VII. Payment Process

Payment will be made for the authorized units of service provided, and not by cost reimbursement nor line-item reimbursement. All service agreement(s) will be based on negotiated units of service and the costs associated with the provision of service.

The provider must certify that claims made to STDC for payment of purchased services are for actual services rendered to eligible individuals as identified by STDC.

Invoices may be submitted only for services provided during the effective dates of the service agreement and must reflect the approved fixed unit cost for each unit of service.

Payment for services provided will be made upon submission of an invoice to ST0C within 30 days following the conclusion of services. All claims for payment must be made in a timely manner. Any invoice received by ST0C more than 30 days after the last date of the service agreement period is subject to nonpayment.

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VIII. Respondent Agency Information

AGENCY/CORPORATE CONTACT INFORMATION

Agency Name:

Physical Address:

Mailing Address (If different):

I DUNS#: I

Federal EIN #: I Required ID Numbers

Agency Contacts

Board President/Chief Principal

Name:

Title:

Phone:!

Fax:

Email:

CEO/Executive Director:

Name:1

Title:

Phone:!

Fax:

I Email:

For Notices Regarding this RFQ (i.e. Program Manager):

Name:

Title:

Phone:'

Fax:

Email: , For Fiscal/Billing Questions:

Name:;

Title:

Phone:

Fax:

Email: I l PROGRAM/PROJECT INFORMATION

Program/Project Name:

Site Address (if different):

Ages to be Served: I

1 Operational Information

Operation Days and Hours:

IX. Project Narrative

Please refer to the Section IV Description of Service and Participant Eligibility as a guide for preparing the proposal narrative, which must contain the following components:

Program Oesign-2 Page Maximum

1. Describe the service that is being proposed and how:

a. The service will be structured to allow for timely access and response to families in need of the service.

b. The provider of this service will work with others providing services to the family to ensure continuity of care

c. The services that are provided will be documented.

d. The services will be adapted to meet the needs of families having diverse backgrounds and needs.

2. Provide a description of the types of activities and/or curriculums that will be used as part of the service delivery.

3. Describe staff qualifications, training, and licensure requirements held to be able to provide the service being proposed.

4. Provide a list of agency accreditations and accrediting entity.

System of Evaluation-1 Page Maximum

Detail the process of supervising staff carrying out the proposed service. Explain how your agency will ensure quality services are provided to families and how supervision and training will be utilized for continuous quality improvement. If your organization is proposing to utilize volunteers, describe what training will be provided to volunteers and how their work will be supervised by your agency's staff.

History and Experience of Provider-1 Page Maximum

Describe how this program fits within your agency’s mission and describe your agency in terms of programs, services, and experience with the target population.

Include an Organization Chart for this project (does not count towards the page limit}.

Cost-1 Page Maximum

Provide the cost per unit of the service being provided in the RFQ response. If you have an established rate at your organization for similar services, please provide that published rate(s} for public or private consumers. If the rate being proposed in the RFQ response is greater than the cost listed in your current published rates, please provide justification of the rate. Explain the organization's capabilities and cost requirements in meeting the needs of Priority Individuals as defined in the following table.

Proposed Staffing Ratio (# of Individuals to Staff Members):

Priority1Individual Hourly Rate (Defined as individuals who may need specialty care or additional assistance due to chronic illness/disability.

e.g. feeding tube, limited mobility, etc.):

Non-Priority Individual Hourly Rate:

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SOUTH TEXAS DEVELOPMENT COUNCIL

Contractor Application/Renewal Update

Please type clearly print application information.

Contractor Name/Legal Entity

Doing Business As (if applicable)

Telephone:

Telephone: I

Fax:

Fax: I

Email:

Email:

local Office Contact {Print Name)

I Title:

Email:

Entity Type (Check all that apply)

Number of years entity has been in Business:

Years

Tax Identification Number {Federal Tax /Dor SSN):

Required Active DUNS ID Number:

Is yourentity registered in the System for Award Management (SAM.gov)? □Yes □No (If no, your application may cannor be considered. If assistance is required for DUNS and SAM.gov registration, please contact STDC).

Is your entity bonded?

(If yes, attach a copy of certificate of bonding insurance)

Does your entity have required liability insurance?

{If yes, attach certificate of all insurances)

***Please attach a coe of all applicable State and Federal licenses and for certifications for ourentitv***

If yes, please provide details:

llPage

Conflict of Interest Attach information of applicable names and relationships of any employee(s) officers of your entity that may have a conflict of interest with the South Texas Development Council Board Member, Employee, or Advisory Committee Member.

Service and Bidding Information Please provide the name of the proposed service from the Service Definitions individually below, and include the proposed Service Area City/ies and/or County (if County-Wide service would be available).

1. Proposed Service:

Service Area(s):

2. Proposed Service:

Service Area(s):

3. Proposed Service:

Service Area(s):

4. Proposed Service:

Service Area(s):

NOTE: Please see attached service definitions and unit definition(s) for specific service and unit information to specify the proposed service. Please indicate the service area(by city and/or county) and the cost per unit for both your entity’s standard cost, and the cost per unit being proposed to STDC.

21Page

(Rest of this page intentionally left blank)

CERTIFICATE OF SIGNATORY AUTHORITY

1. By Laws

2. Articles of Incorporation

3. Other(explain): _

Signature: Typed Name: Title: Date:

-Fo W-9 (Rev October 2018) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification a Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the requester. Do not send to the IRS.

1 Name (as shown on your income tax return). Name s required on this line. do not leave this I ne blank

2 Business name/d sregarded entity name, if different from above <"i 3 Check appropriate box for fooeral tax ctassificallonof the person whose name is enteroo on line 1. Check only one of the Ill [!llowing sevenboxes, O 4 Exemptions (codes apply only to certain entities. not individuals; see instructions on page 3):

C C CorporaUon S CorporaUon Partnership Trust/estate cii 5 .I5.I 'E lnd'vidualfsole proprietor or single-member LLC Exempt payee code (if any) O L1m1ted liability company. Enter the tax classification (C'-C corporation, s s corporation, P Partnership)n Note: Check the appropriate box m the I ne above for the tax class,fication of the single-member owner. Do not check LLC ,f the LLC s classlfioo as a smgle-member LLC that Is disregarded from the owner unless the owner of the LLC is 'u l-'=--'-s"""d"'"is""'"re-g"""'ac..rd,...e...,.d..,.r"'"om..c. ,t+h -'-'-ow""-' e""r"""s°"'ho-'-u"'"ld-,-",ch-e""'c,-k"'th'-e-a""'p-p"""'ro--p..;aria"'t"'e-,-bo-'-x'-"-,-fo'-r""'th'-e""t"-axc..,c,cl,.cac..css.c..fi ca.c..c,,tio-'-n--another LLC that ,snot d'sre ardoo from the owner for U.S. federal tax urposes Otherwise a sin le-member LLC that e n Exemption from FATCA reporting code (if any) o"'f,..c1t,-s""o...cw--n""ei-".-'--"'--C.C...-"-"-"-'=-'-------------r8n.

rn

- 1 Address (number streeL and apt. or suite no.) See instructions.

Other (see nstructIonsJ " (Applies to acccunts mamta/nod outSldo 1ho VS)

Requester's name and address (optional)

6 City, state. and ZIP code

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 genera ly 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 VI/hat Name and Number To Give the Requester for guidelines on whose number lo enter.

So.iJ.ffeutlty ill I I I I I or

Employer Identification number

Certification

Under penalties of pe ury, I certify that

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue SeNice (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 reportall 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

I 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/Fonni¥9.

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-lNT {interest earned or paid) Form 1099-DIV {dividends, including those from stocks or mutual funds)

· Form 1099-MISC (various types of income, prizes, awards, orgross proceeds}

· Form 1099-8 (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 Fonn W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, laier.

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

Form W-9 (Rev 10-2018) Page 2 Example. Article 20 of the U.S.-China income tax treaty allows an

By signing the filled-out form. you:

1. Certify that the TIN youare 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 exemptionfrom 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 VVhat is FA TCA reporting, later, for further information.

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 thelaws 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 with1 old'ng on its allocable share of net income from the partnership conduct ng 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 granter trust with a U.S. grantor or other U.S. owner. generally, the U.S. granter 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 granter 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 e ected 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 Pub. 515, Withho d ng of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally. only a nonresident alien ind v1dua1may 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 lncomeeven 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 af'en.

2. The treaty article addressing the income.

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

4. The type and amount of Income that quahfies for the exemption from tax.

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

exemption from tax for scholarship income received by a Chinese studenttemporarily 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 calendaryears. However, paragraph 2 of thefirstProtocolto theU.S.-Chinatreaty (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 forthis exception (under paragraph 2 of the first protocol) and is relying on this exception lo 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 24% 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 instructions for Part II 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 withholdlng under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt frombacl<up withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information.

Also see Special rules for partnerships, earlier.

What is FATCAReporting?

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, later, 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 TlN changes for the account; for exampie, 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 fallure 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.

Form W-9 (Rev 10-2018) Page3IF the entity/person on line 1 is a(n) ...

THEN check the box for ...

· Corporation Corporation

· Individual

· Sole proprietorship, or

· Single-member lim led hab lity company (LLC) owned by an individual and disregarded for U.S federal tax purposes.

Ind vidual/sole proprietor or single- memberLLC

· LLC treated as a partnership for U.S. federal tax purposes.

· LLC that has filed Form 8832 or 2553 to be taxed as a corporation, or

· LLC that is disregarded as an entity separate from its owner but the owner is another LLC that is not d sregarded for U.S. federal tax purposes.

Limited !,ability company and ente the appropriate tax classificabon (P= Partnership; C= C corporation or S= S corporation)

· Partnership Partnership

· Trust/estate Trust/estate

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties inc udlng fines and/or imprisonment Misuse of TINs. If the requester discloses or uses TINs in violation of federal 1aw. the requester may be subject to civil and criminal penalties.

Specific Instructions Line 1 You must enter one of thefollowing 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 (other than an account maintained by a foreign financial institution (FFI)). list first. and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a jointaccount, each holder of the account that is a U.S. person must provide a 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. lme 1a. This should also be the same as the name you entered on the Form 1040/1040Af1040EZ you filed with your application.

b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040Af1040EZ on line 1. You may enter your business, trade, or "doing business as• (DBA) name on lme 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 OBA name on line 2.

d. Other entitles. 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 OBA 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.

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

Line 3 Check the appropriate box on line 3 for the U.S. federal tax classificationof the person whose name is entered on line1. Check only one box on line 3.

Line 4, Exemptions If you are exempt from backup withholding and/or FATCA reporting. enter in the appropriate space on I ne 4 any code(s) that may app y to you.

Exempt payee code.

· Generally, indivldua s (induding sole proprietors) are not exemp from backup withholding.

· Except as provided below, corpora ·ons are exempt from backup withholding for certain payments. including Interest and dividends.

· Corporations are not exempt from backup withhold ng 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(bX7) if the account satisfies the requirements of section 401(f)(2) 2- The United States orany of its agencies orinstrumentalities 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

Form W-9 (Rev. 10-2018) Page4 M A tax exempt trust under a section 403(b) plan orsection 457{g)

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.

for ...

Payments over $600 required to be reported and direct sales over $5,0001 Generally. exempt payees 1 through 52

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 acoount 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 providingyou with a Fann 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 Xi) 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 1940 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) plan Note: You may wish to consult with the financial institution requesting this fonn 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. If this address differs from the one the requester already has on file, write NEW at the top. If a new address is provided, there is still a chance the old address will be used until the payer changes your address in their records.

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.

If you are a single-member LLC that is disregarded as an entity separate from its owner. 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 What Name and Number To Give the Requester, later, 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 applyforan SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this fonn online at www.SSA.gov. You may also get this fonn 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 ElN. You can apply for an EIN onlineby accessing the IRS website at www.irs.gov/Businesses and clicking on Employer Identification Number (EIN) under Starting a Business. Goto www.irs.gov/Formsto view, download, or print Form W-7 and/or Form SS-4. Or, youcan go to www.irs.gov/OrderForms to place an order and have Form W-7and/or SS-4 mailed lo you within 10 business days.

If you are asked to complete Form W-9 but do not have a TIN. apply for a TIN and write "Applied For·in lhespace for !he TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to geta TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note: Entering "Applied For" means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.

Part II. Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even If item 1, 4, or 5 below indicates otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees. see Exempt payee code, earlier.

Signature requirements. Complete the certification as indicated in items 1 through 5 below.

Form W-9 (Rev 10-2018) F'age5For this type of account:

Give name and EIN of:

14 Account with lhe Department ot Agnculture in the name of a public entity (such as a state or local government, school district, or prison) thal receives agricultu,al program payments

15. Grantor trust filing under the Fann 1041 Filing Method or the Optional Fonn 1099 Filing Method 2 (see Regulalio<ls secioo 1 671-4[bM2 Ki XS)) The pubic entity

The trust

1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.

2_ Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup v,ithholding ...,;11 apply. If you are subjectto backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.

3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

4. Other payments. You must give your correct TIN. but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. "Other payments" include payments made in the course of the requester's trade or business for rents. royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments lo a nonemptoyee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), ABLE accounts (under section 529A), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the RequesterFor this type of account:

Give name and SSN of:

1. Individual

2. Two or more individuals (joint account) other than an account maintained by an FFI 3 Two or m0<e U S persons (joint account maintained by an FFI)

4. Custodial l!lCCount ol a minor (Uniform Gift to Minors Act)

5. a. The usua revocable savings trust (grentor is also trustee)

b. So-<:alled trust account that is not a legal or valid trust under state law

6. Sole proprietorship or d1Stegarded entlly owned by an individual

7. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i) {A)) The individual The actual owner of the account or, if combined funds, the first individual on Iha account' Each hol<Jer of the account

The minor"

The grantor-trustee' The actual owner' The owner'

The grantor' For this type of account:

Give name and EIN of:

8. Disregarood entity not owne<I by an individual

9. A valid trust. estate, or pension trust

10. Corporalion or LLC electing corporate status on Form 8832 or Form 2553

11. Association, club. religious. charitable, educational, or other tax exempt organization

12. Partnership or multi-member LLC

13. A broker or registered nominee The owner

Legal entity' The corporation

The organization

The partnership The broker or nominee

1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person's number must be furnished.

2 Circle the minor's name and furnish the minor's SSN.

3 You must show your individual name and you may also enter your business or OBA name on the "Business name/disregarded entity" name line. You may use either your SSN or EIN (if you have one), bu! the IRS encourages you to use your SSN.

4 List first and circle the name of the trust, estate. or pension trust. {Do not furnish the TIN of thepersonal representative or trustee unless the legal entity itself is not designated in the account tit e.) Also see Special rules for partnerships, earlier.

*Note: The grantor also must prov de a Form W-9 to trustee of trust.

Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Secure Your Tax Records From Identity Theft Identity theft occurs when someone uses your personal information such as your name. SSN, or other identifying mformation, v,ithout your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk:

· Protect your SSN.

· Ensure your employer is protecting your SSN, and

· Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a noticefrom the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a IOst or stolen purse or wallet. questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Pub. 5027, Identity Theft Information for Taxpayers.

Victims of identity theft who are experiencing economic harm or a systemic problem, or are seeking help in resolving tax problems that have not been resolved through normal channels.