FY21 JOHN DOE CONTRACTUAL DOCUMENTS SAMPLE 8 3 2020.pdf

Prepare and submit original contractual documents according to the following outline.

ALL signatures and dates must be in original ink

INCOMPLETE CONTRACTUAL DOCUMENTS WILL HOLD UP PROCESSING AND YOU MAY BE

CONTACTED BY OUR ACCOUNTING AND FINANCE DEPARTMENT

Commonwealth of Massachusetts Standard Contract Form

Request for Taxpayer Information Number and Certification (W9) Form

Contractor Authorized Signatory Listing (CASL)

Electronic Funds Transfer Payments (EFT)

Certificate of Good Standing from the Department of Revenue (DOR) - The fastest and easiest way to obtain a Certificate is online through MassTaxConnect https:// mtc.dor.state.ma.us/mtc and click on the tab (I Want To). A Certificate of Good Standing less than 6 months old must be provided at the time of submission.

A certificate of Unemployment Insurance Compliance from the Office of Unemployment Insurance. The fastest and easiest way to obtain a DUA Certificate is to apply online at https://uionline.detma.org/Employer/Core/ Login.ASPX. Self insured or reimbursable employers can get certificates of compliance from DUA via your UI Online account.

COMMBUYS Registration; since your business may have an active contract with our department, it is necessary for you to register your business with COMMBUYS. COMMBUYS is the Commonwealth’s state-of-the-art electronic Market Center supporting online commerce between government purchasers and businesses. Register with COMMBUYS online at https:// www.commbuys.com . If you have questions or need assistance with registration, please refer any questions you may have to the COMMBUYS Helpdesk at 1-888-627-8283. If you are already registered with COMMBUYS please skip this step.

ORIGINAL CONTRACTUAL DOCUMENTS MUST BE DOWNLOADED AND SUBMITTED VIA US

POST OR SIMILAR SERVICE TO:

Department of Industrial Accidents Office of Safety

Lafayette City Center 2 Avenue de Lafayette

Boston, MA 02111

If you have questions or need assistance with the contractual portion only, please refer all questions to Diane Lentini at 617-626-5913 or email diane.lentini@detma.org

CONTRACTUAL DOCUMENTS CHECK OFF SUMMARY

https://mtc.dor.state.ma.us/mtc https://mtc.dor.state.ma.us/mtc https://mtc.dor.state.ma.us/mtc https://www.commbuys.com/

COMMONWEALTH OF MASSACHUSETTS ~ STANDARD CONTRACT FORM

(Issued 6/27/2011) Page 1 of 5

This form is jointly issued and published by the Executive Office for Administration and Finance (ANF), the Office of the Comptroller (CTR) and the Operational Services Division (OSD) as the default contract for all Commonwealth Departments when another form is not prescribed by regulation or policy. Any changes to the official printed language of this form shall be void. Additional non-conflicting terms may be added by Attachment. Contractors may not require any additional agreements, engagement letters, contract forms or other additional terms as part of this Contract without prior Department approval. Click on hyperlinks for definitions, instructions and legal requirements that are incorporated by reference into this Contract. An electronic copy of this form is available at www.mass.gov/osc under Guidance For Vendors - Forms or www.mass.gov/osd under OSD Forms.

CONTRACTOR LEGAL NAME:

Brighton Asphalt & Cement Services

COMMONWEALTH DEPARTMENT NAME: Executive Office of Labor & workforce Development/Department of Industrial Accidents/Office of Safety

MMARS Department Code: EOL

Legal Address: (W-9, W-4,T&C): 1234 Industrial Road, Suite 100 Brighton, MA 02135 Business Mailing Address: 1 Congress Street, Ste.100 Boston, MA 02114

Contract Manager: Elizabeth Swann, Safety Manager Billing Address (if different): accountspayable@detma.org

E-Mail: Elizabethswann@brightonasphaulservices.org Contract Manager: Kathy Manson

Phone 877-555-1234 Fax: 617-555-1212 E-Mail: Kathy.Manson@dia.state.ma.us

Contractor Vendor Code: Phone: 617-727-4900 Fax: 617-727-8764

Vendor Code Address ID (e.g. “AD001 (Note: The Address Id Must be set up for EFT payments.)

MMARS Doc ID(s): CT EOL 0999 13Safety7003050000

RFR/Procurement or Other ID Number: DIA 2013 Safety

_X__ NEW CONTRACT

PROCUREMENT OR EXCEPTION TYPE: (Check one option only)

__ Statewide Contract (OSD or an OSD-designated Department) __ Collective Purchase (Attach OSD approval, scope, budget) _X_ Department Procurement (includes State or Federal grants 815 CMR 2.00) (Attach RFR and Response or other procurement supporting documentation) __ Emergency Contract (Attach justification for emergency, scope, budget) __ Contract Employee (Attach Employment Status Form, scope, budget) __ Legislative/Legal or Other: (Attach authorizing language/justification, scope and budget)

___ CONTRACT AMENDMENT

Enter Current Contract End Date Prior to Amendment: , 20 .

Enter Amendment Amount: $ . (or “no change”)

AMENDMENT TYPE: (Check one option only. Attach details of Amendment changes.)

__ Amendment to Scope or Budget (Attach updated scope and budget)

__ Interim Contract (Attach justification for Interim Contract and updated scope/budget)

__ Contract Employee (Attach any updates to scope or budget)

__ Legislative/Legal or Other: (Attach authorizing language/justification and updated scope and budget)

The following COMMONWEALTH TERMS AND CONDITIONS (T&C) has been executed, filed with CTR and is incorporated by reference into this Contract.

_X Commonwealth Terms and Conditions __ Commonwealth Terms and Conditions For Human and Social Services

COMPENSATION: (Check ONE option): The Department certifies that payments for authorized performance accepted in accordance with the terms of this Contract will be supported in the state accounting system by sufficient appropriations or other non-appropriated funds, subject to intercept for Commonwealth owed debts under 815 CMR 9.00.

_X_ Rate Contract (No Maximum Obligation. Attach details of all rates, units, calculations, conditions or terms and any changes if rates or terms are being amended.)

__ Maximum Obligation Contract Enter Total Maximum Obligation for total duration of this Contract (or new Total if Contract is being amended). $ .

PROMPT PAYMENT DISCOUNTS (PPD): Commonwealth payments are issued through EFT 45 days from invoice receipt. Contractors requesting accelerated payments must identify a PPD as follows: Payment issued within 10 days __% PPD; Payment issued within 15 days __ % PPD; Payment issued within 20 days __ % PPD; Payment issued within 30 days __% PPD. If PPD percentages are left blank, identify reason: X_agree to standard 45 day cycle __ statutory/legal or Ready Payments (G.L. c. 29, § 23A); __ only initial payment (subsequent payments scheduled to support standard EFT 45 day payment cycle. See Prompt Pay Discounts Policy.)

BRIEF DESCRIPTION OF CONTRACT PERFORMANCE or REASON FOR AMENDMENT: (Enter the Contract title, purpose, fiscal year(s) and a detailed description of the scope of performance or what is being amended for a Contract Amendment. Attach all supporting documentation and justifications.)

SAFETY GRANT

ANTICIPATED START DATE: (Complete ONE option only) The Department and Contractor certify for this Contract, or Contract Amendment, that Contract obligations:

_X 1. may be incurred as of the Effective Date (latest signature date below) and no obligations have been incurred prior to the Effective Date.

__ 2. may be incurred as of , 20 , a date LATER than the Effective Date below and no obligations have been incurred prior to the Effective Date.

__3. were incurred as of , 20 , a date PRIOR to the Effective Date below, and the parties agree that payments for any obligations incurred prior to the Effective Date are authorized to be made either as settlement payments or as authorized reimbursement payments, and that the details and circumstances of all obligations under this Contract are attached and incorporated into this Contract. Acceptance of payments forever releases the Commonwealth from further claims related to these obligations.

CONTRACT END DATE: Contract performance shall terminate as of June 30 , 2013 , with no new obligations being incurred after this date unless the Contract is properly amended, provided that the terms of this Contract and performance expectations and obligations shall survive its termination for the purpose of resolving any claim or dispute, for completing any negotiated terms and warranties, to allow any close out or transition performance, reporting, invoicing or final payments, or during any lapse between amendments.

CERTIFICATIONS: Notwithstanding verbal or other representations by the parties, the “Effective Date” of this Contract or Amendment shall be the latest date that this Contract or Amendment has been executed by an authorized signatory of the Contractor, the Department, or a later Contract or Amendment Start Date specified above, subject to any required approvals. The Contractor makes all certifications required under the attached Contractor Certifications (incorporated by reference if not attached hereto) under the pains and penalties of perjury, agrees to provide any required documentation upon request to support compliance, and agrees that all terms governing performance of this Contract and doing business in Massachusetts are attached or incorporated by reference herein according to the following hierarchy of document precedence, the applicable Commonwealth Terms and Conditions, this Standard Contract Form including the Instructions and Contractor Certifications, the Request for Response (RFR) or other solicitation, the Contractor’s Response, and additional negotiated terms, provided that additional negotiated terms will take precedence over the relevant terms in the RFR and the Contractor’s Response only if made using the process outlined in 801 CMR 21.07, incorporated herein, provided that any amended RFR or Response terms result in best value, lower costs, or a more cost effective Contract.

AUTHORIZING SIGNATURE FOR THE CONTRACTOR:

X: . Date: HANDWRITTEN .

(Signature and Date Must Be Handwritten At Time of Signature)

Print Name: JOHN DOE Print Title: PRESIDENT

AUTHORIZING SIGNATURE FOR THE COMMONWEALTH:

X: . Date: .

(Signature and Date Must Be Handwritten At Time of Signature)

Print Name: Brian Boyd . Print Title Director of Contracts & Procurement http://www.mass.gov/eoaf http://www.mass.gov/osc http://www.mass.gov/osd http://www.mass.gov/osd http://www.mass.gov/osc http://www.mass.gov/?pageID=osctopic&L=2&L0=Home&L1=Guidance+for+Vendors&sid=Aosc http://www.mass.gov/osd http://www.mass.gov/?pageID=afmodulechunk&L=4&L0=Home&L1=Budget%2c+Taxes+%26+Procurement&L2=Oversight+Agencies&L3=Operational+Services+Division&sid=Eoaf&b=terminalcontent&f=osd_all_forms&csid=Eoaf http://www.mass.gov/?pageID=afmodulechunk&L=4&L0=Home&L1=Budget%2c+Taxes+%26+Procurement&L2=Oversight+Agencies&L3=Operational+Services+Division&sid=Eoaf&b=terminalcontent&f=osd_all_forms&csid=Eoaf mailto:accountspayable@detma.org https://massfinance.state.ma.us/VendorWeb/eftRegisterfrm.asp http://www.mass.gov/?pageID=oscterminal&L=2&L0=Home&L1=Publications+and+Reports&sid=Aosc&b=terminalcontent&f=regulations&csid=Aosc http://www.mass.gov/Aosc/docs/Forms/Payroll_LCM/Employment_Status_Form.doc https://massfinance.state.ma.us/VendorWeb/vendor.asp http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleIII/Chapter29/Section23A http://www.mass.gov/Aosc/docs/policies_procedures/accounts_payable/po_ap_prompt_%20payment_discounts_final.doc http://www.mass.gov/Aosc/docs/Forms/Contracts/standard_contract_frm.doc#Certifications http://www.mass.gov/Eoaf/docs/osd/policy/801cmr21.doc

.. SSeennssiittiivviittyy lleevveell –– hhiigghh ((wwhheenn ffiilllleedd iinn)) llooww ((wwhheenn bbllaannkk)) Form MA- W-9 (Rev. April 2009)

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 Services (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 an U.S. person (including an U.S. resident alien).

4. I am currently a Commonwealth of Massachusetts’s state employee: (check one): No____ Yes _____ If yes, in compliance with the State Ethics Commission requirements.

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.

Authorized Signature ► Date HANDWRITTEN DATE ONLY►

Purpose of Form A person who is required to file an information return with the IRS must get your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or debt, or contributions you made to an IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), to give your correct TIN to the person requesting it (the requester) and , when applicable, to:

1. Certify the TIN you are giving is correct (or you are waiting for a number to be issued).

2. Certify you are not subject to backup withholding

If you are a foreign person, use the appropriate Form W-8. See Pub 515, Withholding of Tax on Nonresident Aliens and Foreign Corporations.

What is backup withholding? Persons making certain payments to you must withhold a designated percentage, currently 28% and pay to the IRS of such payments under certain conditions. This is called “backup withholding.”

Payments that may be subject to backup withholding include interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

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 not be subject to backup withholding. Payments you receive will be subject to backup withholding if:

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

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

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

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

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

Certain payees and payments are exempt from backup withholding. See the Part II instructions on page 2.

Penalties

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

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

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

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

Form W-9

(Massachusetts Substitute W-9 Form) Rev. April 2009

Request for Taxpayer Identification Number and Certification

Completed form should be given to the requesting department or the department you are currently doing business with.

Name ( List legal name, if joint names, list first & circle the name of the person whose TIN you enter in Part I-See Specific Instruction on page 2)

Brighton Asphalt & Cement Services

Business name, if different from above. (See Specific Instruction on page 2)

Check the appropriate box: □ Individual/Sole proprietor x Corporation □ Partnership □ Other ►-----------------------------------------------

Legal Address: number, street, and apt. or suite no.

1234 Industrial Road, Suite 100 Brighton, MA 02135 Remittance Address: if different from legal address number, street, and apt. or suite no.

City, state and ZIP code

Brighton, MA 02135 City, state and ZIP code

Phone # ( ) 877-555-1234 Fax # ( ) 617-555-1213 Email address: Elizabethswann@brightonasphaulservices.org

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instruction on page 2. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 2.

Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter.

Vendors:

Dunn and Bradstreet Universal Numbering System (DUNS))

Social security number

OR

Employer identification number

05-1286943

OR

DUNS

f

Part II Certification f

P le a s e p ri n t o r ty p e

.. SSeennssiittiivviittyy lleevveell –– hhiigghh ((wwhheenn ffiilllleedd iinn)) llooww ((wwhheenn bbllaannkk)) Form MA- W-9 (Rev. April 2009)

Specific Instructions

Name. If you are an individual, you must generally enter the name shown on your social security card. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.

If the account is in joint names, list first and then circle the name of the person or entity whose number you enter in Part I of the form.

Sole proprietor. Enter your individual name as shown on your social security card on the “Name” line. You may enter your business, trade, or “doing business as (DBA)” name on the “Business name” line.

Limited liability company (LLC). If you are a single-member LLC (including a foreign LLC with a domestic owner) that is disregarded as an entity separate from its owner under Treasury regulations section 301.7701-3, enter the owner’s name on the “Name” line. Enter the LLC’s name on the “Business name” line.

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

Other entities. Enter your business name as shown on required Federal tax documents on the “Name” line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the “Business name” line.

Part I - Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box.

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

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN.

However, the IRS prefers that you use your

SSN.

If you are an LLC that is disregarded as an entity separate from its owner (see Limited liability company (LLC) above), and are owned by an individual, enter your SSN (or “pre-LLC” EIN, if desired). If the owner of a disregarded LLC is a corporation, partnership, etc., enter the owner’s EIN.

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

How to get a TIN. If you do not have a

TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office. Get Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can get Forms W-7 and SS-4 from the IRS by calling 1-800-TAX-FORM (1-800-829- 3676) or from the IRS’s Internet Web Site www.irs.gov.

If you do not have a TIN, write “Applied For” in the space for the 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 get a 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: Writing “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Part II - Certification

To establish to the paying agent that your TIN is correct or you are a U.S. person, or resident alien, sign Form W-9.

For a joint account, only the person whole TIN is shown in Part I should sign (when required).

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

Dunn and Bradstreet Universal Numbering System (DUNS) number requirement – The United States Office of Management and Budget (OMB) requires all vendors that receive federal grant funds have their DUNS number recorded with and subsequently reported to the granting agency. If a contractor has multiple DUNS numbers the contractor should provide the primary number listed with the Federal government’s Central Contractor Registration (CCR) at /www.ccr.gov . Any entity that does not have a DUNS number can apply for one on-line at www.DNB.com under the DNB D-U-N Number Tab.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to give your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA or MSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their tax laws

You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold a designated percentage, currently 28% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.

What Name and Number to Give the Requester

For this type of account: Give name and SSN of:

1. Individual

2. Two or more individuals (joint account)

3. Custodian account of a minor (Uniform Gift to Minors Act)

4. a. The usual revocable savings trust (grantor is also trustee)

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

5. Sole proprietorship

The individual The actual owner of the account or, if combined funds, the first individual on the account 1

The minor 2

The grantor-trustee 1

The actual owner 1

The owner 3

For this type of account: Give name and EIN of:

6. Sole proprietorship

7. A valid trust, estate, or pension trust

8. Corporate

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

10. Partnership

11. A broker or registered nominee

12. Account with the

Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments

The owner 3

Legal entity 4

The corporation The organization

The partnership The broker or nominee

The public entity

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, but you may also enter your business or “DBA” name. You may use either your SSN or EIN (if you have one).

. List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.)

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.

If you have questions on completing this form, please contact the Office of the State Comptroller.

(617) 973-2468.

Upon completion of this form, please send it to the Commonwealth of Massachusetts Department you are doing business with.

http://www.irs.gov/ http://www.ccr.gov/ http://www.mass.gov/Eoaf/docs/osd/xuanl/Local%20Settings/Temporary%20Internet%20Files/OLK6E/www.DNB.com

CONTRACTOR AUTHORIZED SIGNATORY LISTING (CASL)

Executive Office of Labor and Workforce Development

PLEASE USE BLUE INK ONLY

CONTRACTOR LEGAL NAME: Brighton Asphalt & Cement Services

COMMONWEALTH’S ASSIGNED VENDOR CODE

CONTRACTOR VENDOR/CUSTOMERCODE: LEAVE BLANK IF YOU HAVE NOT PREVIOUSLY DONE BUSINESS WITH THE

COMMONWEALTH.

DBA (if applicable): Brighton Asphalt & Cement Services

INSTRUCTIONS: All Contractors (other than a sole-proprietor or an individual contractor) must provide a listing of individuals who are authorized as legal representatives of the Contractor who are authorized to sign contracts and other legally binding documents on the Contractor’s behalf. In addition to this listing, additional proof of authority to sign contracts on behalf of the Contractor, and/or proof of authenticity of signature is required by Contractor’s submission of a completed Contractor Authorized Signature Verification Form (CASV).

NOTICE: Acceptance of any payment under a Contract or Grant shall operate as a waiver of any defense by the

Contractor challenging the existence of a valid Contract due to an alleged lack of authority to execute the document by the signatory.

For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized signatories of contractors.

PRINT AUTHORIZED SIGNATORY’S NAME TITLE

(NAME OF LEAD AUTHORIZED SIGNATORY)

Hector Barbosa

(ACCEPTABLE TITLES ONLY FOR LEAD

SIGNATORY)

PRESIDENT, CEO, CFO, CORPORATE CLERK, LEGAL COUSEL

(NAME OF ALTERNATE AUTHORIZED SIGNATORY TO

ABOVE)

Elizabeth Swann

(EXACT TITLE OF ALTERNATE)

Safety Manager

I certify that I am the President, Chief Executive Officer, Chief Fiscal Officer, Corporate Clerk or Legal Counsel for the Contractor and as an authorized officer of the Contractor I certify that the names of the individuals identified on this listing are current as of the date of execution below and that these individuals are authorized to sign contracts and other legally binding documents related to contracts with the Commonwealth of Massachusetts on behalf of the

Contractor. I understand and agree that the Contractor has a duty to ensure that this listing is immediately updated and communicated to any state department with which the Contractor does business whenever the authorized signatories above retire, are otherwise terminated from the Contractor’s employ, have their responsibilities changed resulting in their no longer being authorized to sign contracts with the Commonwealth or whenever new signatories are designated.

Signature: Date: HANDWRITTEN DATE ONLY

PRESIDENT, CEO, CFO, CORPORATE

Print Name: Hector Barbosa Title: CLERK, LEGAL COUSEL___________

Telephone: Fax: Email:

Mariap Text Box

COUNSEL

Mariap Text Box

COUNSEL

CONTRACTOR AUTHORIZED SIGNATORY LISTING (CASL)

Executive Office of Labor and Workforce Development

CONTRACTOR LEGAL NAME:

CONTRACTOR VENDOR/CUSTOMER CODE:

DBA (if applicable):

EOLWD CASL revised 07-11 Page 1 of 1

Issued May 2004

[Listing cannot be accepted unless all of the information is completed. The Contractor must also complete and submit a Contractor Authorized Signature Verification Form (CASV), as appropriate.]

Request type must be checked: Initial Request Changing Existing Account Closing Account

I____________________, hereby certify that the account/s indicated on this form is under my direct control and access; therefore, I authorize the State Treasurer as fiscal agent for the State of Massachusetts to initiate, change or cancel credit entries to that account/s as indicated on this form. For ACH debits consistent with the International ACH Transaction (IAT) rules check one:

I affirm that payments authorized hereunder are not to an account that is subject to being transferred to a foreign bank account.

I affirm that payments authorized hereunder are to an account that is subject to being transferred to a foreign bank account.

This authority is to remain in full force and effect until the Office of Comptroller has received written notification, from either me or an authorized officer of organization of the account's termination in such time and in such a manner as to afford CTR a reasonable opportunity to act upon it.

VENDOR BANK INFORMATION

Vendor Bank Name: _________________________ Vendor Bank Transit Number (ABA): _________________________ Vendor Bank Account Number: _________________________ Account Type: _________________________

Filling out this field is a requirement for changing account number Vendor Bank Old Account Number: _________________________ Account Type: _________________________

VENDOR INFORMATION

Vendor Tax Identification Number (TIN):________________________ Vendor/Business Name: _________________________ Vendor Contact Name: _________________________ E-mail: _________________________ Telephone: _________________________ Address: _________________________ City: _______________State: _____Zip:___________

This authorization will remain in effect until either canceled in writing or an updated form changing information is sent to the Department you currently do business with.

AUTHORIZED SIGNATURE: ____________________________________________________

Print Name: ______________________ Title:______________________ Date: ________

Form forwarded to Commonwealth Department:_________________________________ Attached voided check here:

COMMONWEALTH OF MASSACHUSETTS

OFFICE OF THE COMPTROLLER

Electronic Funds Transfer Sign Up Form mariap Highlight mariap Highlight mariap Highlight mariap Highlight mariap Highlight mariap Highlight mariap Highlight mariap Highlight

MASSACHUSETTS DEPT. OF REVENUE

P.O. BOX 7066

BOSTON, MA 02204

MARK E. NUNNELLY, COMMISSIONER

CHARLENE HANNAFORD, ACTING DEPUTY COMMISSIONER

CERTIFICATE OF GOOD STANDING AND/OR TAX COMPLIANCE

The Commissioner of Revenue certifies as of the above date, that the above named individual or entity is in compliance with its tax obligations payable under M.G.L. c. 62C, including corporation excise, sales and use taxes, sales tax on meals, withholding taxes, room occupancy excise and personal income taxes, with the following exceptions.

This Certificate certifies that individual taxpayers are in compliance with income tax obligations and any sales and use taxes, sales tax on meals, withholding taxes, and/or room occupancy taxes related to a sole proprietorship. Persons deemed responsible for the payment of these taxes on behalf of a corporation, partnership or other business entity may not use our automated process to obtain a Certificate.

This Certificate does not certify that the entity's standing as to taxes such as unemployment insurance administered by agencies other than the Department of Revenue, or taxes under any other provisions of law. Taxpayers required to collect or remit the following taxes must submit a separate request to certify compliance: Alcoholic Beverage Excise, Cigarette Excise, Sales Tax on Boats, International Fuels Tax Agreement, Smokeless Tobacco or Ferry Embarkation.

THIS IS NOT A WAIVER OF LIEN ISSUED UNDER GENERAL LAWS, CHAPTER 62C,

SECTION 52.

Very truly yours

Charlene Hannaford, Acting Deputy Commissioner mariap Highlight

Pages from FY19 JOHN DOE GRANT SAMPLE.pdf

Pages from 20 CASL.pdf