Vendor Packet FY27.pdf

Office of County Commissioners Finance Department

130 Jacob’s Way, Suite 302, Clarkesville, GA 30523

706-839-0200 Fax 706-839-0219 accountspayable@habershamga.com

Vendor Application Return Document Checklist (Please Initial)

Required by all vendors:

_____ Vendor Application

_____ W9 Form

Required by vendors providing services (rather than tangible goods):

_____ Copy of your company's most recent Insurance Certificate(s)

_____ Contractor Affidavit (E-Verify) **********or State Issued Photo ID for individuals with no employees

Optional for all vendors:

_____ACH Payment Approval Form

_____ Bidder List Application

If any required forms are returned incomplete, Active Vendor status will not be granted, and subsequent payments may be delayed. Please remember that documents requesting notary verification must be notarized to be considered complete.

Company / Individual Name:

Doing Business As:

Physical Address:

City: State: Zip Code:

Remittance Address:

City: State: Zip Code:

Contact / Representative:

Phone Number:

Email Address:

Primary Industry of Business:

Brief Description of Goods / Services:

Vendor Application purchasing@habershamga.com 706-839-0200

Clarkesville, GA 30523 130 Jacob's Way, Suite 302

Finance Department Habersham County BOC

Form W-9 (Rev. March 2024)

Request for Taxpayer Identification Number and Certification

Department of the Treasury Internal Revenue Service Go to www.irs.gov/FormW9 for instructions and the latest information.

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

Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.

P ri nt o r ty p e.

S ee S p ec if ic

In st ru ct io n s on p ag e 3.

1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner’s name on line 1, and enter the business/disregarded entity’s name on line 2.)

2 Business name/disregarded entity name, if different from above.

3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor C corporation S corporation Partnership Trust/estate

LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) Note: Check the “LLC” box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate box for the tax classification of its owner.

Other (see instructions)

3b If on line 3a you checked “Partnership” or “Trust/estate,” or checked “LLC” and entered “P” as its tax classification, and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check this box if you have any foreign partners, owners, or beneficiaries. See instructions

4 Exemptions (codes apply only to certain entities, not individuals;

see instructions on page 3):

Exempt payee code (if any)

Exemption from Foreign Account Tax Compliance Act (FATCA) reporting code (if any)

(Applies to accounts maintained outside the United States.)

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. See also 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.

What’s New Line 3a has been modified to clarify how a disregarded entity completes this line. An LLC that is a disregarded entity should check the appropriate box for the tax classification of its owner. Otherwise, it should check the “LLC” box and enter its appropriate tax classification.

New line 3b has been added to this form. A flow-through entity is required to complete this line to indicate that it has direct or indirect foreign partners, owners, or beneficiaries when it provides the Form W-9 to another flow-through entity in which it has an ownership interest. This change is intended to provide a flow-through entity with information regarding the status of its indirect foreign partners, owners, or beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign partners may be required to complete Schedules K-2 and K-3. See the Partnership Instructions for Schedules K-2 and K-3 (Form 1065).

Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS is giving you this form because they

Cat. No. 10231X Form W-9 (Rev. 3-2024)

Habersham County Insurance Requirements

Companies conducting services on Habersham County property or on behalf of Habersham County must provide the following:

General Liability Coverage:

A valid General Liability Certificate of Insurance with a minimum limit of $1,000,000 per occurrence for bodily injury and property damage.*Habersham County must be shown as an additional insured*

Workers' Compensation:

A valid Worker's Compensation Certificate of Insurance with at minimum:

Employer's Liability:

Bodily Injury by Accident - $100,000 each accident

Bodily Injury by Disease - $500,000 policy limit Bodily Injury by Disease - $100,000 each employee

Auto Liability Certificate of Insurance:

Minimum $1,000,000 limit per occurrence for bodily injury and property damage. Comprehensive form covering all owned and non-owned and hired vehicles. (If autos are used in the performance of work)

Professional Services Insurance:

Minimum $1,000,000 limit

Habersham County E-Verify Requirements

Per O.C.G.A. §13-10-91 (b) – A public employer shall not enter into a contract for the physical performance of services unless the contractor registers for and participates in the federal work authorization program. Before a bid for any such service is considered by a public employer, the bid shall include a signed, notarized affidavit from the contractor attesting to the following:

A) The affiant has registered with, is authorized to use, and uses the federal work authorization program;

B) The user identification number and date of authorization for the affiant;

C) The affiant will continue to use the federal work authorization program throughout the contract period; and D) The affiant will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the same information required by subparagraphs (A), (B), and (C) of this paragraph.

Contractors that have no employees are not eligible to obtain an E-Verify Number. Instead of obtaining an affidavit from the contractor, the public employer is required to still document they are eligible to be in the United States by ensuring they have a state issued driver’s license from a state that verifies immigration through the licensing/renewal process.

Public employers can use other forms of ID such as a passport or military ID.

Contractor Affidavit under O.C.G.A. § 13-10-91(b)(l)

The undersigned contractor ("Contractor") executes this Affidavit to comply with O.C.G.A § 13-10-91 related to any contract to which Contractor is a party that is subject to O.C.G.A. § 13-10-91 and hereby verifies its compliance with O.C.G.A. § 13-10-91, attesting as follows:

a) The Contractor has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program;

b) The Contractor will continue to use the federal work authorization program throughout the contract period, including any renewal or extension thereof;

c) The Contractor will notify the public employer in the event the Contractor ceases to utilize the federal work authorization program during the contract period, including renewals or extensions thereof;

d) The Contractor understands that ceasing to utilize the federal work authorization program constitutes a material breach of Contract;

e) The Contractor will contract for the performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the Contractor with the information required by O.C.G.A. § 13-10-91(a), (b), and (c);

f) The Contractor acknowledges and agrees that this Affidavit shall be incorporated into any contract(s) subject to the provisions of O.C.G.A. § 13-10- 91 for the project listed below to which Contractor is a party after the date hereof without further action or consent by Contractor; and

g) Contractor acknowledges its responsibility to submit copies of any affidavits, drivers' licenses, and identification cards required pursuant to O.C.G.A. § 13-10-91 to the public employer within five business days of receipt.

Federal Work Authorization User Identification Number Date of Authorization

Name of Contractor Name of Project

Name of Public Employer

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

Executed on _________, _____, 20_____ in _______________ (city), __________ (state).

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE _______ DAY OF _____________, 20______.

NOTARY PUBLIC

My Commission Expires: _____________________________

Vendor ACH/Direct Deposit Authorization Form Habersham County Board of Commissioners

1. Please Check One:

NEW Direct Deposit CHANGE Direct Deposit CANCEL Direct Deposit

2. Vendor/Payee Information

Name:

Address:

Contact Person’s Name (if other than payee):

Telephone Number:

Email Address:

3. Financial Institution Information

Bank Name:

Name on Bank Account:

Bank Account Number:

Nine-Digit Bank Routing/Transit Number (ABA):

Type of Account:

Email Address for Remittance Notification:

Checking Savings

4. Approvals/Authorizations - I certify that the information provided on this form is correct, and I hereby authorize Habersham County Accounts Payable to electronically deposit payments to the bank account designated above. It is my responsibility to notify AP (accountspayable@habershamga.com or 706-839-0200) immediately if I believe there is a discrepancy between the amount deposited to my bank account and the amount of the invoice(s) paid. I understand that I must notify Habersham County AP in writing immediately of any changes in status or banking information. I understand that this authorization will remain in full force and effect until AP has received written notification requesting a change or cancellation and has had reasonable opportunity to act on it, which should take no longer than seven (7) to ten (10) business days.

Print Name: Signature: Date: _

Important Information

Please return completed form via email: accountspayable@habershamga.com

For Office of Accounts Payable Use Only Date Stamp - Received

Entered by:____________

Reviewed by:__________

I

HABERSHAM COUNTY

BOARD OF COMMISSIONERS

130 JACOB'S WAY, SUITE 302

CLARKESVILLE, GEORGIA 30523

706-832-0206 purchasing@habcrshamga.com

HAIIERSHAM COUNTY

t:EOR<;!A I f.11. 1818 BIDDER'S LIST APPLICATION

General Business Information DATE: _______________ _

COMPANY NAME

STREET ADDRESS

CITY STATE

MAILING ADDRESS (if different than above)

CITY STATE

PHONE NUMBER FAX NUMBER

PRINCIPAL LINE OF BUSINESS

ZIPCODE

ZIPCODE

EMAIL ADDRESS

ORGANIZED AS: 0 Individual O Partnership O Corporation Date: ------- State: -----

Business Representatives

Click on any field to fill-out.

When completed you may email to purchasing@habershamga.com or print-out for mailing .

PLEASE TYPE OR PRINT IN INK

FEDERAL TAX 1.0. NUMBER (If Company)

[IJ-11111111

SOCIAL SECURITY NUMBER (If Individual)

I I I I-ITH I I I I

PRIMARY BUSINESS (Check One)

D Construction Firm D Jobber

0 Aulhorized Dislribulor O Service Firm

0 Surplus Dealer O Retaij Deale, 0 Faclory Representative O Manufacturer

BUSINESS VOLUME (Check One)

D Large Business Concern (S1M sa!es +)

0 Small Business Concern (under S1M sales)

SPECIAL STATUS

□ Minority 0.•med (51% +)

0 Woman 0.sTied (51% •)

0 Olher: _________ _

PLEASE TYPE OR PRINT IN INK

(Additional Official Representatives may be submitted on a separate sheet)

NAME OF OFFICIAL REPRESENTATIVE T ITLE BUSINESS PHONE CELL PHONE EMAIL

NAME OF OFFICIAL REPRESENTATIVE TITLE BUSINESS PHONE CELL PHONE EMAIL

NAME OF OFFICIAL REPRESENTATIVE TITLE BUSINESS PHONE CELL PHONE EMAIL

Names and Signatures of Persons Authorized to Sign Bids and Contracts. This M!.!.fil be kept current. (Additional Official Signatories may be submitted on a separate sheet)

Actual Signature (Manually Signed) TITLE BUSINESS PHONE PRINTED NAME

Actual Signature (Manually Signed) TITLE BUSINESS PHONE PRINTED NAME

Actual Signature (Manually Signed) TITLE BUSINESS PHONE PRINTED NAME

Dun & Bradstreet Commercial Rating: as of Standard Selling Terms for your Business:

Bank Reference: Normal Discounts extended to the County:

City Business License # Expires Return & Refund Policy:

County Business License II Expires Misc.:

What type of standard business insurance do you carry and it's maximum benefits?

Commodity Codes

Please fill-out left lo right first, then top to bottom. A complete list of current codes can be obtained from the NIGP Website (,WIW.nigp.org).

I I I I I I I I I I I I I I I I I I

I I I I I I I I I I I I I I I I I I Rev. Nov 2025 • Habersham County Government