HomeMy WebLinkAboutC04-194 Colorado River Water Conservation District
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CG04008
GRANT CONTRACT
This Grant Contract is made and entered into by and between the COLORADO RIVER
WATER CONSERVATION DISTRICT (herein the "River District") and EAGLE COUNTY
GOVERNMENT (herein "Grantee") effective as of the date of the River District's execution hereof.
RECITALS
A. The River District is charged by its organic statute, C.R.S. ~3 7-46-101, et seq., with securing
and insuring adeqUate water supplies, both present and future, for beneficial uses within the
River District's boundaries.
B. The River District has adopted a policy and related criteria, most recently revised October
17,2001, for providing financial assistance to persons such as Grantee (the "Policy").
C. Grantee proposes to complete the project described in Exhibit A attached hereto (the
"Project") and has made application to the River District for financial assistance pursuant to
and in compliance with the River District's Policy.
D. The Project is consistent with the River District's statutory mission.
E. The River District has reviewed the Project pursuant to its Policy and desires to assist with
the funding of the Project subject to the terms and conditions of this Contract, and Grantee
desires to receive such financial assistance from the River District as provided herein.
AGREEMENTS
NOW, THEREFORE, in consideration of the foregoing recitals and the mutual promises
agreed to herein, the parties agree as set forth below.
I. River District's Financial Grant.
A. Within thirty (30) days after Grantee complies with subparagraph 4.D below by
providing the River District with the required certificates of insurance, the River
District will forward to Grantee $7,500.00, which constitutes fifty percent (50%) of
the grant amount of$15,OOO.00 approved by the River District Board of Directors.
B. Within sixty (60) days after Grantee complies with subparagraph 3.A below by
submitting a completed "Request for Final Payment" form, the River District will
forward to Grantee the remaining grant amount. The remaining grant amount may
be less than fifty percent (50%) of the total grant amount approved by the River
District Board of Directors if the documented final cost of the Project is less than the
original cost estimate (see subparagraph l.C below).
Grant Contract CG04008
Page 2
C. The total grant amount shall be equal to the amount allowed by the River District's
Grant Policy based on the documented final cost of the Project or the amount
originally approved by the River District Board of Directors, whichever is less.
D. If necessary, the River District will issue Grantee a 1099 form for each year in which
grant funds are distributed pursuant to this Contract. Grantee is and shall be solely
liable and responsible for any federal and state taxes applicable to this Contract and
any grant funds received hereunder. Grantee shall indemnify the River District for
any liability resulting from non-payment of such taxes.
2. Grantee's Proiect Plan and Use of Grant Money. The money granted by the River District
to Grantee shall be used only for the Project as described herein and in Exhibit A.
A. The total cost of the Project is estimated by Grantee at $90,425.00 as documented in
the Project budget supportive of Grantee's application.
B. The estimated date for commencement of construction of the Project is August I,
2004. The estimated date for the completion of the Project is December 31, 2004.
3. Final Payment and Re,payment of River District Grant.
A. Within sixty (60) days after completion of the Project, Grantee shall submit to the
River District a completed "Request for Final Payment" form, which is attached
hereto as Exhibit B. Timely submission shall be required for final payment pursuant
to subparagraph I.B above.
B. If completion of the Project is interrupted or delayed beyond the estimated
completion date stated in subparagraph 2.B above, Grantee shall notify the River
District on or before February 28, 2005 (i.e., within sixty (60) days after the
estimated completion date stated in subparagraph 2.B above) and request a Contract
Amendment to extend the estimated completion date.
C. Grantee shall not be eligible for final payment if the River District does not receive
on or before February 28,2005, either a completed Request for Final Payment form
or a request for a Contract Amendment to extend the estimated completion date.
D. Grantee shall repay the full amount of any grant funds received if construction of the
Project is not commenced on or before October 29,2004 (i. e., within ninety (90) days
after the estimated commencement date stated in subparagraph 2.B above).
4. Grantee's Additional Responsibilities and Liabilities.
Grant Contract CG04008
Page 3
A. Grantee shall be responsible for making all contracts and assuring the acquisition of
all interests in property or other rights and all permits or other governmental
approvals needed to complete the Project.
B. Grantee shall be responsible for the acts, errors and omissions of itself and its
employees, consultants, agents, and any other persons employed or retained on behalf
of Grantee in connection with the Project and for the acts, errors and omissions of the
Project's facility owners and users. Grantee agrees to indemnify, hold harmless, and
defend the River District and its directors, officers, employees, agents, and attorneys
for the actions, errors and omissions of Grantee and Grantee's employees,
consultants, agents, and any other persons employed or retained on behalf of Grantee
in the performance of this Contract and for the acts, errors and omissions of the
Project's facility owners and users. The parties recognize that the River District is a
governmental entity subject to the provisions of the Colorado Governmental
Immunity Act, C.R.S. ~~ 24-10-101, et seq.
C. At its sole cost Grantee or its contractor(s) shall purchase and maintain in effect
through Project completion insurance which will protect it and the River District
from claims which may arise out of, result from or be related to Grantee's
performance of the work on the Project, whether such performance be by itself or by
anyone directly or indirectly retained or employed by any of Grantee or by anyone for
whose acts, errors, or omissions any of them may be liable. Such insurances required
herein shall be written for limits of liability as follows:
i. Commercial General Liability:
(1) Bodily Injury and Property Damage:
$1,000,000 each occurrence/$I,OOO,OOO aggregate
(2) Personal Injury:
$1,000,000 each occurrence/$I,OOO,OOO aggregate
ii. Commercial Automobile Liability:
(I) Bodily Injury & Property Damage:
$1,000,000 anyone accident or loss
Hi. Workers' Compensation and Employer's Liability:
(1) Workers' Compensation: Statutory
(2) Employer's Liability:
$100,000 each accident
$100,000 disease - each employee
$500,000 disease - policy limit
D. The Commercial General Liability and Commercial Automobile Liability policies
required hereunder shall include the River District named as additional insured.
" .
Grant Contract
Page 4
CG04008
Grantee shall supply the River District a certificate of each form of insurance
required herein at least thirty (30) days prior to the estimated commencement date
stated in subparagraph 2.B above. The certificates of insurance shall evidence that
the premium has been paid and contain a valid provision or endorsement that the
policies may not be canceled, terminated, changed or modified without thirty (30)
days written notice to the River District. Each certificate of insurance must reference
the contract number assigned to this Agreement (CG04008).
E. Grantee warrants performance of this Contract and the completion of all work
required for the Project. Grantee and any persons work4tg on its behalf shall at all
times comply with all applicable local, state, and federa1laws and regulations. Not
by way oflimitation of the foregoing, it is specifically agreed that neither Grantee nor
any persons working on its behalf on the Project shall discriminate against any person
because of age, race, sex, national origin, ancestry, disability, or religion.
5. Authorized Representatives.
A. The River District designates Lorra L. Nichols, Legal Assistant/Paralegal, and Kirstin
E. McMillan, Staff Attorney, whose address, telephone number and fax number for
notices and communications are: P. O. Box 1120, Olenwood Springs, Colorado
81602, (970) 945-8522, Fax (970) 945-8799, as its representatives to act for the River
District in connection with this Contract.
B. Grantee designates Phillip M. Bowman, P .E., whose address, telephone number and
fax number for notices and communications are: P. O. Box 850, Eagle, CO 81631-
0850; Phone: (970) 328-3560, as its representative to act for Grantee in connection
with this Contract.
6. Miscellaneous.
A. Assignment. The Contract involves the grant of public money for public purposes.
Consequently, this Contract shall not be assigned by Grantee without the River
District's prior written approval, which may be withheld in the River District's sole .
discretion.
B. Binding Effect. This Contract shall be immediately binding upon both parties and
their respective successors, if any.
C. No Partnership. Joint Venture or Third Party Beneficiaries. This Contract is not
intended to and does not create any partnership, joint venture or similar relationship
between the River District and Grantee or any other persons or entities. The
enforcement of the terms and conditions of this Contract and all rights of action
relating to such enforcement shall be strictly reserved to the River District and
Grantee, and nothing contained in this Contract shall give or allow any claim or right
Grant Contract
Page 5
CG04008
of action whatsoever by any other or third person or entity. It is the express intent of
the parties to this Contract that any person or entity receiving services or benefits
under this Contract shall be deemed an incidental beneficiary only.
D. Additional Limitations on the River District's Res,ponsibilities. The River District's
involvement with the Project's construction and operation shall be limited to payment
of the above sum in the form of a grant to Grantee. The River District shall not be
responsible for or in control of the Project's feasibility, implementation, operation,
maintenance, repair, or replacement.
E. Remedies. If Grantee is in breach or default of any obligation under this Contract,
the River District may give Grantee written notice of such breach or default. Upon
receipt of such notice, within thirty (30) days Grantee shall both cure such breach or
default and provide the River District evidence of such cure. If Grantee fails to cure
any such breach or default within thirty (30) days, the River District may terminate
this Contract and Grantee shall be required to promptly repay to the River District the
full amount of any grant funds received. In any action for breach or for enforcement
of this Contract, the River District shall be entitled to recover its attorneys fees and
litigation costs.
F. Notices. All notices required or appropriate pursuant to this Contract shall be given
in writing to the parties' designated representatives at the addresses stated in
paragraph 5. Notices shall be deemed received upon hand delivery or three (3) days
after first class mailing thereof with return receipt requested
G. Entire Aereement/Amendments. This Contract is the complete integrated
understanding between the parties. No prior or contemporaneous addition, deletion,
or other amendment to this Contract shall have any force or effect unless stated in
writing approved and executed by both parties.
IN WITNESS WHEREOF, the Parties hereto have accepted, made and executed this Contract
upon the terms, conditions and provisions stated herein.
COLORADO RIVER WATER CONSERVATION
DISTRICT
I/IA.~
DATE:
~p1/o'f
I
By:
ATTEST:
J2 CLD C~
Richard E. Kuhn, Secretary/General Manager
APlrO,?-D AS TO FORM:
JYWt ~~r.------
Kirstin E. Mc Illan, taff Attorney
Grant Contract
Page 6
CG04008
EAGLE COUNTY GOVERNMENT
By:
Name:
Title:
. .
COLORADO RIVER WATER CONSERVATION DISTRICT
2004 Water Project Grant Program Application
Project Title: NeUson Pump Line Ditch Intake Structure Improvements
Project Sponsor: Eagle County Government
Contact I Name: Phillip M. Bowman, PE I Address: PO Box 850, Eagle, CO 81631-0850
Information I Ea2le Counb Eneineerine
Phone: (970) 328-3560 Fax: (970) 328-8789 I Email: phillip.bowman@eaglecounty.us
Is this a completed project? NO
If YES: State Completion Date:
If NO: Estimated Start Date: August 2004 I Estimated Completion Date: I December 2004
Proposed Grant Amount: $ 15,000 I Match Amount (AD Sources): 1$ 75,425
Total Project Cost: $ 90,425 (See Attached Estimates)
Basin: Colorado (Eagle River)
Project Category: See Attached
Project Summary:
See Attached Project Narrative and Summary
FOR CRWCD Use Only: Grant Contract No: CG04 DC) i'
Date Received:
EXHIBIT B
COLORADO RIVER WATER CONSERVATION DISTRICT
2004 Water Project Grant Program
REQUEST FOR FINAL PAYMENT
Grant Contract Number: CG04008
Grant Sponsor: EAGLE COUNTY GOVERNMENT
Address:
Phone: ( ) Fax: ( ) I Email:
Est. Original Project Cost: $ I Total Grant Award Amount: 1$
Final Project Cost: $
Actual Completion Date:
Description of Final Project: (please include a narrative description of the project, an accounting of the final
costs of the project, relevant photos, and any public relations information which may have been generated by the
project).
I certify that the above listed costs are true and accurate and that the project has been completed as
described above.
Signature: Date:
Mail completed form within 60 days of project completion to:
Lorra Nichols, CRWCD, P.O. Box 1120, Glenwood Springs, CO 81602
FOR CRWCD Use Only: Approved by: Date:
Date Check Issued: Check Amount:
.-
I Form w.g
, (Rev. Dec:emb8r 1996)
. DePIf!/NIIIl of tile TNUUIY
, Im.naI Rwenua Sennce
Name (If a joint account or you changed your nama, _ SpecIfIc InaIructIona on page 2.)
Eagle County Government
Business name, if different from above. (See SpecIftc InsIructicms on page 2.)
Request for Taxpayer
Identification Number and Certification
.J
'6
,{
'.
II
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A.
Give farm to the
requester. Do NOT
send to the IRS.
Checl< appropriate box: 0 IndlviduallSole proprietor
Addr8a (number, street. and apt. or 8UIte no.)
PO Box 850
o Corporation
o Partnership xg Other. Gnv.enunent.....................
Requester'1S name and addrllsll (optJonal)
City, state, and ZIP code
Eagle. Colorado 81631
Tax a er Identification Number
Enter your TIN in the appropriate box. For .
individuals, this Is your social security number
(SSN). However, if you are a resident alien OR a
sole proprietor. see the instructions on page 2.
For other entities, j6 Is your employer .
identification nurn~r (Elr....'). If tOO do r.ct t'.ave a
number. see How To Get a nN 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.
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 waItI!'lg 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 IntemaJ
Revenue SerVice (IRS) that I am subject to backup withholding as a result of a failure to report aJllnterest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding.
CertIfIcation Instructlona.-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 dMdends, you are not required to sign the CertIfIcation, but you must
provide your correct TIN. (See the I ctionS on page 2.)
Sign
Here
~
OR
~
8 4 6 0 0 7 6 2
Signature ~
..
Purpose of Fonn.--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, ~ncome paid to you, real estate
transactions, mortgage interest you paid,
acquisition or abandonment of secured
property, canC!'llation of debt, or
contributions you made to an IRA.
Use Form W-9 to give your correct ltIN
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, or
3. Claim exemption frorn backup
, withholding if you are an exempt payee.
Note: If a requester gives you a form other '
, than a W-9 to request your TIN, you must
, use the requester's form if It is substantially
similar to this Form W-9.
What Is Backup Wlthholding?-Persons
making certain payments to you must
withhold and pay to the IRS 31 % of such
payments under certain conditions. This is
, called "backup withholding. II Payments
that may be subject to backup withholding
Include interest, lvidends, 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, meke the p:-:per certfficatlons, 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 fumlsh your TIN to the
requester, or
2. The IRS tells the requester that you
furnished an Incorrect TIN, or
3. 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
4. You do not certify to the requester
that you are not subject to backup
withholding under 3 above (for reportable
interest and dividend accounts opened
after 1983 only), or
Ust account number(lS) here (optional)
For Payees Exampt From Backup
VmhhokI1ng (See tml inst:'.lctlons
on page 2.)
.
Date ~ -
pO
5. You do not certify your TIN when
required. See the Part III Instructions on
page 2 for details.
CertaIn payees and payments are
exempt from backup withholding. See the
Part II instructions and the separate
. Instructions for the Requester of Fonn
W-t.
Penalties
FaIlure To Furnish nN.-1f you fall to
fumish 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 Wlthholding.-Jf 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
Infonnation.- Willfully falsifying
certifications or affirmations may subject
you to criminal penaJtles including fines
and/or imprisonment.
Misuse of nNs.-1f the requester
discloses or uses TINs in violation of
Federal law , the requester may be subject
to civil and criminal penalties.
Cat. No. 10231X
Form W-9 (Rev. 12-96)
Form W-9 (Rev. 1-2003)
Example. Article 20 of the U.S.-China income tax treaty
allows an exemption from tax for scholarship income
received by a Chinese student temporarily 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 calendar years. However. paragraph 2 of
the first Protocol to the U.S.-China treaty (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 UnitecJ States. A Chinese student who qualifies for this
exception (under paragraph 2 of the first protocoO and is
relying on this exception to 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 not
suQject to backup withholding, give the requester the
appropriate completed Form W-8.
What is backup withholding? Persons making certain
payments to you must under certain conditions withhold and
pay to the IRS 30% of such payments (29% after December
31, 2003; 28% after December 31, 2005). 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.
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. or
2. You do not certify your TIN when required (see the Part
II instructions on page 4 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 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 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 instructions below and the separate
Instructions for the Requester of Form W-9.
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.
Page 2
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 entered
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.
Umited liability company (LLC). If you are a single-member
LLC Qncluding 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 liC's name on the
"Business name" line.
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.
Note: You are requested to check the appropriate box for
your status (individuaVsole proprietor; corporation. etc.).
Exempt From Backup Withholding
If you are exempt. enter your name as described above and
check the appropriate box for your status, then check the
"Exempt from backup withholding" box In the line following
the business name. sign and date the form.
Generally, individuals Qncluding sole proprietors) are not
exempt from backup withholding. Corporations are exempt
from backup withholding for certain payments. such as
interest and dividends.
Note: If you are exempt from backup withholding. you should
still complete this form to avoid possible erroneous backup
withholding.
Exempt payees. Backup withholding is not required on any
payments made to the following payees:
1. An organization exempt from tax under section 501(a),
any IRA. or a custodial account under section 403(b)(7) if the
account satisfies the requirements of section 401 (f)(2);
2. The United States or any of its agencies or
instrumentalities;
3. A state. the District of Columbia. a possession of the
UnitecJ States. or any of their political subdivisions or
instrumentalities;
4. A foreign government or any of its political subdMsions.
agencies, or instrumentalities; or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup
withholding include:
6. A corporation;
7. A foreign central bank of issue;
8. A dealer in securities or commodities required to register
in the United States. the District of Columbia, or a
possession of the United States;
Form W-9 (Rev. 1-2(03)
Page 3
9. A futures commission merchant registered with the
Commodity Futures Trading Commission;
10. A real estate investment trust;
11. An entity registered at all times during the tax year
under the Investment Company Act of 1940;
12. A common trust fund operated by a bank under
section 584(a);
13. A financial institution;
14. A middleman known in the investment community as a
nominee or custodian; or
15. A trust exempt from tax under section 664 or
described in section 4947.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt recipients listed above, 1 through 15.
If the payment is for . . . THEN the payment is exempt
for . ..
Interest and dMdend payments
All exempt recipients except
for 9
Broker transactions
Exempt recipients 1 through 13.
Also, a person registered under
the Investment AdvIsers Act of
1940 who regularly acts as a
broker
Barter exchange transactions
and patronage dMdends
Payments over $600 required
to be reported and direct
sales over $5,000 1
1 See Form l098-M1SC, Miscellaneous Income, and Its instructions.
· However, the following payments made to a corporation (Including gross
proceeds paid to an attorney under section 6045(f), even If the attorney Is a
corporation) and reportable on Form l099-MISC are not eJlempt from backup
withholding: medical and health care payments, attorneys' fees; and payments
for 5eIVlces paid by a Federal executive agency.
Exempt recipients 1 through 5
Generally, exempt recipients
1 through 7 Z
Part I. Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate box. If you are a resident
anen and you do not have and are not eligible to get an
SSN. your TIN is your IRS indMdual taxpayer idenliflcation
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 a single-owner liC that is disregarded as an
entity separate from its owner (see Umited liabirJty
company (LLC) on page 2), enter your SSN (or EIN, if you
have one). If the LLC is a corporation, partnership, etc., enter
the entity's EIN.
Note: See the chart on page 4 for further darification 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 55-5,
Application for a Social Security Card, from your local Social
Security Administration office or get this form on-line at
www.ssa.gov/onfme/sSS.htmJ. You may also get this form
by calling 1-800-772-1213. Use Form W-7, Application for
IRS Individual Taxpayer Identification Number, to apply for an
ITIN, or Form 55-4, 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 Web Site at www.irs.gov.
If you are asked to complete Form W-9 but do not have a
TIN, write "Applied Forn 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 50-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 Forn means that you have already
applied for a nN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign
owner must use the appropriate Form W-8.
."
.
Form W.g (Rev. 1-20(3)
Page 4
Part II. Certification
To establish to the withholding agent that you are aU,S,
person, or resident alien, sign Form W-9. You may be
requested to sign by the withholding agent even if items 1, 3,
and 5 below indicate otherwise.
For aJoint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt recipients, see
Exempt from backup withholding on page 2.
Signature requirements. Complete the certification as
indicated in 1 through 5 below.
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 withholding will apply. If you are
subject to 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 Qncluding payments to corporations), payments to a
nonemployee for services, payments to certain fishing boat
crew members and fishermen. and gross proceeds paid to
attorneys Qncluding 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),
IRA or Archer MSA 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
Requester
For this lYDe of account:
1.lndMdual
2. Two or more IndMduals Ooint
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 vaUd
trust under state law
5. Sole Proprietorship or
sino/e-owner LlC
For this type of account:
6. Sole proPrietorship or
single-owner LlC
7. A vaUd trust. estate, or
pension trust
8. Corporate or LLC electing
corporate status on Form
8832
9. Association, club, religious,
charitable, educational. or
other tax-exempt organization
10. Partnership or multi-member
LLC
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 .
GIve name and SSN of:
The indMdual
The actual owner of the account
or, if combined funds, the first
indMdual on the account 1
The minor 2
The grantor-trustee 1
The actual owner 1
The owner 3
GIve name and ElN of:
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 eccount has an SSN. that person's number must be
fumfshed.
· Circle the mInor's name and furnish the minor's SSN.
3 You must show your IndIvIduaJ 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 bUSt. (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
fisted, the number will be considered to be that of the first
name listed.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide 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 Archer 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. We may also disclose this information to other countries under a tax treaty. or to Federal and state agencies to enforce
Federal nontax criminal laws and to combat terrorism.
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% 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.
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