HomeMy WebLinkAboutCity of Tamarac Resolution R-2023-088Temp. Reso. # 13976
August 23, 2023
Page 1 of 5
CITY OF TAMARAC, FLORIDA
RESOLUTION NO. R-2023- OM
A RESOLUTION OF THE CITY COMMISSION OF THE CITY
OF TAMARAC, FLORIDA, AWARDING BID NO.23-1513 AND
APPROVING AN AGREEMENT WITH C&W PIPELINE, INC.,
FOR THE CONSTRUCTION OF THE WOODLAND GREENS
WATER MAIN REPLACEMENT PROJECT IN ACCORDANCE
WITH BID NO. 23-15B FOR A CONTRACT AMOUNT OF
$333,593.00; A CONTINGENCY IN THE AMOUNT OF
$33,359.30 WILL BE ADDED TO THE PROJECT ACCOUNT
FOR A TOTAL PROJECT BUDGET OF $366,952.30;
AUTHORIZING AN EXPENDITURE FROM THE
APPROPRIATE ACCOUNTS; PROVIDING FOR CONFLICTS;
PROVIDING FOR SEVERABILITY; AND PROVIDING FORAN
EFFECTIVE DATE.
WHEREAS, the City of Tamarac owns, operates and maintains the water supply,
treatment, and distribution systems; and
WHEREAS, the Woodland Greens Water Main Replacement project is an in-house
design project that includes the relocation of an existing 12" water main, located in the
landscape median between NW 58th Way and NW 57th Way, just north of Commercial Blvd
along NW 58th Place, within the Woodland Greens Community; and
WHEREAS, the water main relocation shall provide the necessary support to allow
for the future, proposed Buffer Wall system in the aforementioned landscape median; and
WHEREAS, the project will consist of the relocation of the existing 12" water main
with the furnishing and installation of a new 12" water main (C-900 PVC piping and
associated appurtenances), decommissioning of existing 4" water main servicing local
residences along NW 58th Place (Commercial Blvd frontage) and reconnecting customer
services off proposed service line laterals from new water main; installation of new concrete
curb (F-type) to mitigate existing water ponding concerns behind landscape median (along
Temp. Reso. # 13976
August 23, 2023
Page 2 of 5
NW 58'h Place), milling and resurfacing the Woodland Greens community, installing
temporary and new pavement markings; restoration of concrete sidewalks at service
connections, site restoration and other associated work required for the Woodland Greens
Water Main Replacement project; and
WHEREAS, the construction of this project will lead to improved water pressure
during peak hours resulting from proposed new water main and service lines; and
WHEREAS, on April 16, 2023, the City publicly advertised Bid No. 23-15B for the
Woodland Greens Water Main Replacement Project, incorporated herein by reference and
on file in the Office of the City Clerk; and
WHEREAS, on May 23, 2023, the City of Tamarac received and opened eight (8) bid
proposals, for the Woodland Greens Water Main Replacement Project, a copy of the bid
tabulation is attached hereto as "Exhibit 1 ", incorporated herein and made a specific part of
this resolution; and
WHEREAS, City staff reviewed the submitted bids and determined that the apparent
lowest bidder, TB Power, LLC., to be a non-responsive/responsible bidder; and upon City's
review of the next lowest bidder, determined that C&W Pipeline, Inc., to be the lowest
responsive and responsible bidder; and
WHEREAS, upon review of the C&W Pipeline, Inc.'s proposal and performed
background check, determined that C&W Pipeline, Inc., possesses the skills, experience,
and capacity to meet the requirements for the construction of the Woodland Greens Water
Main Replacement Project; and
WHEREAS, it is the recommendation of the Public Services Director, Director of
Financial Services, and the Purchasing and Contracts Manager that the appropriate City
Officials award Bid No. 23-15B and execute the agreement with C&W Pipeline, Inc. for the
Temp. Reso. # 13976
August 23, 2023
Page 3 of 5
Woodland Greens Water Main Replacement Project, a copy of the Agreement is attached
hereto as "Exhibit 2"; and
WHEREAS. the City Commission of the City of Tamarac, Florida, deems it to be in
the best interest of the citizens and residents of the City of Tamarac to award Bid No. 23-
15B and execute the Agreement with C&W Pipeline, Inc., for the Woodland Greens Water
Main Replacement project for a contract amount of $333,593.00; a contingency in the
amount of $33,359.30, for a total project budget of $366,952.30.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COMMISSION OF
THE CITY OF TAMARAC, FLORIDA, THAT:
SECTION 1: The foregoing "WHEREAS" clauses are hereby ratified and
confirmed as being true and correct and are hereby made a specific part of this Resolution
upon adoption hereof. All exhibits attached hereto are incorporated herein and made a
specific part hereof.
SECTION 2: The City Commission HEREBY awards Bid No. 23-15B to C&W
Pipeline, Inc. and approves an Agreement between the City of Tamarac and C&W Pipeline,
Inc., ("the Agreement") and the appropriate City Officials are hereby authorized to execute
the Agreement, attached hereto as "Exhibit 2", to provide for the construction of the
Woodlands Greens Water Replacement Project.
SECTION 3: Funding for Woodland Greens Water Main Replacement Project
in the amount not to exceed $333,593.00 is included in the FY 2023 Adopted Budget; and
there is a current available appropriation under Project Number UT23K, and in Account No.
441-6030-533.63-30.
SECTION 4: An expenditure in the amount not to exceed $333,593.00, a
contingency of $33,359.30 will be added to the account for a project total of $366,952.30,
for said purpose, is hereby approved.
Temp. Reso. # 13976
August 23, 2023
Page 4 of 5
SECTION 5: The City Manager, or his designee, are hereby authorized to
make changes, issue change orders not to exceed $65,000.00 per Section 6-147 of the
City Code, and close the contract award including, but not limited to making final payment
within the terms and conditions of the contract and within the contract price.
SECTION 6: All resolutions or parts of resolutions in conflict herewith are
hereby repealed to the extent of such conflict.
SECTION 7: If any clause, section, other part or application of this Resolution
is held by any court of competent jurisdiction to be unconstitutional or invalid, in part or
application, it shall not affect the validity of the remaining portions or applications of this
Resolution.
"The remainder of this page is left blank intentionally."
SECTION 9:
passage and adoption.
Temp. Reso. # 13976
August 23, 2023
Page 5 of 5
This Resolution shall become effective immediately upon its
PASSED, ADOPTED AND APPROVED this a3#day of AtA67U ST ,2023.
ATTEST:
KIMBERLY DILLON, CMC
CITY CLERK
ICHELLE J.-GOMIL,
MAYOR
RECORD OF COMMISSION VOTE
MAYOR GOMEZ
DIST 1:
V/M BOLTON
DIST 2:
COMM. WRIGHT JR
DIST 3:
COMM. VILLALOBOS
DIST 4:
COMM. DANIEL
APPROVED AS TO FORM AND LEGAL SUFFICIENCY FOR THE USE AND RELIANCE
OF THE CITY OF T/AMARAC ONLY.
HA OTTINOT
CI ATTORNEY
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TAMARAC
The City For Your Life
City of Tamarac Purchasing and Contracts Division
CONSTRUCTION AGREEMENT
BETWEEN THE CITY OF TAMARAC
AND
C&W PIPELINE INCORPORATED
THIS AGREEMENT is made and entered into this 1ZS d day of _, 202Z by
and between the City of Tamarac, a municipal corporation with pri ipal offices located at
7525 N.W. 88th Ave., Tamarac, FL 33321 (the "CITY") and C&W Pipeline, Incorporated with
principal offices located at 13117 NW 42nd Avenue, Opa Locka, Florida 33054 (the
"Contractor") to provide for construction services for the Woodland Greens Watermain
Replacement Project.
Now therefore, in consideration of the mutual covenants hereinafter set forth, the City and
Contractor agree as follows:
1. THE CONTRACT DOCUMENTS
The Contract Documents consist of this Agreement, Bid Document No. 23-15B for
Woodland Greens Water Main Replacement Project, issued by the City of Tamarac on
April 16, 2023 including all conditions therein, (General Terms and Conditions, Special
Conditions and/or Special Provisions, Instructions to Bidder's), drawings and/or
schematic plans, Technical Specifications, all addenda, the Contractor's Bid response
dated May 23, 2023, and all modifications issued after execution of this Agreement.
These contract documents form the Agreement, and all are as fully a part of the
Agreement as if attached to this Agreement or repeated therein. In the event that there
is a conflict between Bid 23-15B for Woodland Greens Water Main Replacement
Project as issued by City, and the contractor's bid response; Bid 23-15B for Woodland
Greens as issued by City shall take precedence over the contractor's bid response.
Furthermore, in the event of a conflict between this document and any other Contract
Documents, this Agreement shall prevail.
2. THE WORK
2.1. The Contractor shall perform all work for the City required by the contract
documents as set forth below:
2.1.1 Contractor shall furnish all labor, materials, and equipment necessary to
complete the scope of work, as outlined in the contract documents
including all Addendums, Exhibits, Attachments and Appendices.
2.1.2 Contractor shall supervise the work force to ensure that all workers
conduct themselves and perform their work in a safe and professional
manner. Contractor shall comply with all OSHA safety rules and
regulations in the operation of equipment and in the performance of the
work. Contractor shall always have a competent, English speaking field
supervisor on the job site to enforce these policies and procedures at the
Contractor's expense.
2.1.3 Contractor shall provide the City with seventy-two (72) hours written
TAB M✓RAC
The City For Your Life
City of Tamarac Purchasir•7 and Contracts Division
notice prior to the beginning of work under this Agreement and prior to
any schedule change with the exception of changes caused by inclement
weather.
2.1.4 Contractor shall comply with any and all Federal, State, and local laws
and regulations now in effect, or hereinafter enacted during the term of
this Agreement, which are applicable to the Contractor, its employees,
agents or subcontractors, if any, with respect to the work and services
described herein.
3. INSURANCE
3.1. Contractor shall obtain at Contractor's expense all necessary insurance in such
form and amount as specified in the original bid document or as required by the
City's Risk and Safety Manager before beginning work under this Agreement
including, but not limited to, Workers' Compensation, Commercial General
Liability, Builder's Risk and all other insurance as required by the City, including
Professional Liability when appropriate. Contractor shall maintain such
insurance in full force and effect during the life of this Agreement. Contractor
shall provide to the City's Risk and Safety Manager certificates of all insurances
required under this section prior to beginning any work under this Agreement.
The Contractor will ensure that all subcontractors comply with the above
guidelines and will retain all necessary insurance in force throughout the term
of this agreement.
3.2. Contractor shall indemnify and hold the City harmless for any damages resulting
from failure of the Contractor to take out and maintain such insurance.
Contractor's Liability Insurance policies shall be endorsed to add the City as an
additional insured. Contractor shall be responsible for payment of all
deductibles and self-insurance retentions on Contractor's Liability Insurance
policies. The following are required types and minimum limits of insurance
coverage, which the Bidder agrees to maintain during the term of this contract:
• General Liability - $1 M/$2M
• Automobile — $1 M/$1 M
• Workers Comp — Statutory
4. PERFORMANCE, PAYMENT AND WARRANTY BONDS
4.1 Within fifteen (15) calendar days after contract award, but in any event prior to
commencing work, the Successful Bidder shall execute and furnish the CITY a
Performance Bond and Payment Bond, each written by a corporate surety,
having a resident agent in the State of Florida and having been in business with
a record of successful continuous operation for at least five (5) years. The surety
shall hold a current certificate of authority from the Secretary of Treasury of the
United States as an acceptable surety on federal bonds in accordance with
United States Department of Treasury Circular No. 570.
4.2 The Contractor shall be required to provide acceptable, separate Performance
and Payment Bonds in the amount of one hundred 100% of the bid award
TAMARAC
The City For Your Life
City of Tomoror p,.,-:-hc- ;? n r! Contracts Division
amount as security for the faithful project performance and payment of all the
Contractor's obligations under the contract documents, per City Code Section
10-156. The Performance Bond shall be conditioned that the Successful Bidder
performs the contract in the time and manner prescribed in the contract. The
Payment Bond shall be conditioned that the Successful Bidder promptly make
payments to all persons who supply the Successful Bidder in the prosecution of
the work provided for in the contract and shall provide that the surety shall pay
the same in the amount not exceeding the sum provided in such bonds, together
with interest at the maximum rate allowed by law and that they shall indemnify
and hold harmless the CITY to the extent of any and all payments in connection
with the carrying out of said contract which the CITY may be required to make
under the law. Payment and Performance Bonds must be submitted on City
forms, included herein. At the completion and formal approval and acceptance
of all work associated with the project, a one-year warranty period will begin. If
the surety on any bond furnished by the Contractor is declared bankrupt or
becomes insolvent, or its right to do business is terminated in Florida, the
Contractor shall, within seven (7) days thereafter, substitute another bond
meeting the requirements outlined above, which must also be acceptable to the
City.
4.3 Such bonds shall continue in effect for one (1) year after final payment becomes
due except as otherwise provided by law or regulation or by the Contract
Documents with the final sum of said bonds reduced after final payment to an
amount equal to twenty five percent (25%) of the Contract price, or an additional
bond shall be conditioned that the Contractor correct any defective of faulty work
or material which appear within one (1) year after final completion of the
Contract, upon notification by CITY. The Warranty Bond shall cover the cost of
labor as welt as materials.
4.4 Pursuant to the requirements of Chapter 255.05 (1) (b), Florida Statutes, the
Contractor shall ensure that the Performance and Payment Bond or Bonds
referenced above shall be recorded in the Public records of Broward
County at the Bidder's expense. Proof of recording must be submitted to
the City prior to issuance of any purchase order or payment by the City.
One (1) set of original Performance and Payment Bond documents is required
to be provided to the City prior to the issuance of any Notice to Proceed by the
City.
5. TIME OF COMMENCEMENT AND SUBSTANTIAL COMPLETION
5.1 The work to be performed under this Agreement shall be commenced after City
execution of the Agreement and not later than ten (10) days after the date that
Contractor receives the City's Notice to Proceed. The work shall be completed
within One Hundred Fifty (150 ) Calendar days for Final Completion from
issuance of City's Notice to Proceed, subject to any permitted extensions of time
under the Contract Documents. The work under this agreement shall be
substantially complete (i.e. Substantial Completion) within One Hundred
Twenty (120 ) calendar days from issuance of City's Notice to Proceed.
5.2 During the pre -construction portion of the work hereunder, the parties agree to
work diligently and in good faith in performing their obligations hereunder, so
TAMARAC
The City For Your Life
Tamarac n ;;,; ? --1 Contracts Division
that all required permits for the construction portion of the work may be obtained
by the City in accordance with the Schedule included in the Contract
Documents. In the event that any delays in the pre -construction or construction
portion of the work occur, despite the diligent efforts of the parties hereto, and
such delays are the result of force majeure or are otherwise outside of the
control of either party hereto, then the parties shall agree on an equitable
extension of the time for substantial completion hereunder and any resulting
increase in general condition costs.
6. CONTRACT SUM
The Contract Sum for the above work is a "not to exceed" total of Three Hundred
Thirty Three Thousand Five Hundred Ninety -Three Dollars ($333,593.00).
7. PAYMENTS
Payment upon City approval will be made monthly for work that has been completed,
inspected and properly invoiced. A retainage of five percent (5%) will be deducted from
each monthly payment through project completion, upon City review and approval.
Retainage monies will be released upon satisfactory completion and final inspection of
the specific work order. Invoices must bear the bid number, project name, project
number, and purchase order number. The City has up to twenty-five (25) business days
to review, approve and pay all invoices after receipt of an approved application for
payment. The Contractor shall invoice the City and provide a written request to the City to
commence the one-year warranty period following the completion of all work, certificates of
approval, punch lists, etc., in connection with the contract documents. All necessary
Release of Liens and Affidavits shall be processed before the warranty period begins.
All payments shall be governed by the Florida Prompt Payment Act, F.S., Part VII,
Chapter 218.
8. REMEDIES
8.1 Damages: The City reserves the right to recover any ascertainable actual
damages incurred as a result of the failure of the Contractor to perform in
accordance with the requirements of this Agreement, or for losses sustained by
the City resultant from the Contractor's failure to perform in accordance with the
requirements of this Agreement.
8.2 Correction of Work: If, in the judgment of the City, work provided by the
Contractor does not conform to the requirements of this Agreement, or if the
work exhibits poor workmanship, the City reserves the right to require that the
Contractor correct all deficiencies in the work to bring the work into conformance
without additional cost to the City, and / or replace any personnel who fail to
perform in accordance with the requirements of this Agreement. The City shall
be the sole judge of non-conformance and the quality of workmanship.
9. CHANGE ORDERS
9.1 All Change Orders shall include a maximum Overhead and Profit, not to exceed
five percent (5%) and five percent (5%) respectively (not cumulative).
9.2 Without invalidating the contract, without any monetary compensation, and
without notice to any surety, the City reserves and shall have the right to make
increases, decreases or other changes to the work as may be considered
TAMARAC
The City For Your Life
Tamarac Purchasing and Contracts Division
necessary or desirable to complete the proposed construction in a satisfactory
manner. The Contractor shall not start work pursuant to a change order until the
change order setting forth the adjustments is approved by the City and executed
by the City and Contractor. Once the change order is so approved, the
Contractor shall promptly proceed with the work.
9.3 The Contract Price constitutes the total compensation (subject to authorized
adjustments, if applicable) payable to the Contractor for performing the work. All
duties, responsibilities and obligations assigned to or undertaken by the
Contractor shall be at Contractor's expense without change in the Contract Price
or Time except as approved in writing by the City.
9.4 The Contract Price and/or Time may only be changed by a Change Order. A
fully executed change order for any extra work must exist before such extra work
is begun. Any claim for an increase or decrease in the Contract Price shall be
based on written notice delivered by the party making the claim to the other party
promptly (but in no event later than 15 days) after the occurrence of the event
giving rise to the claim and stating the general nature of the claim. The amount
of the claim with supporting data shall be delivered (unless the City allows an
additional period of time to ascertain more accurate data in support of the claim)
and shall be accompanied by claimant's written statement that the amount
claimed covers all known amounts to which the claimant is entitled as a result
of the occurrence of said event. No claim for an adjustment in the Contract Price
will be valid if not submitted in accordance with this Paragraph.
9.5 The Contract Time may only be changed by a Change Order. A fully executed
change order must exist prior to extension of the contract time.
9.6 Any claim for an extension of the Contract Time shall be based on written notice
delivered by the party making the claim to the other party no later than fifteen
(15) days after the occurrence of the event giving rise to the claim. Notice of the
extent of the claim shall be delivered with supporting data and stating the
general nature of the claim. Contractor hereby agrees to waive rights to recover
any lost time or incurred costs from delays unless Contractor has given the
notice and the supporting data required by this Paragraph.
9.7 Extensions of time shall be considered and will be based solely upon the effect
of delays to the work as a whole. Extensions of time shall not be granted for
delays to the work, unless the Contractor can clearly demonstrate that such
delays did or will, in fact, delay the progress of work as a whole. Time extensions
shall not be allowed for delays to parts of the work that are not on the critical
path of the project schedule. Time extensions shall not be granted until all float
or contingency time, at the time of delay, available to absorb specific delays and
associated impacts is used.
9.8 In the event satisfactory adjustment cannot be reached by City and Contractor
for any item requiring a change in the contract, and a change order has not been
issued, City reserves the right at its sole option to terminate the contract as it
applies to these items in question and make such arrangements as City deems
necessary to complete the work. The cost borne by the City to complete the
work shall be levied against the Contractor including applicable mark-up of ten
(10%) for overhead and engineering costs. The cost of any work covered by a
TAMARAC
The City For Your Life
City of Tamar,-- " r rs Division
------------
change order for an increase or decrease in contract price shall be determined
by mutual acceptance of a Price by the City and Contractor. If notice of any
change in the contract or contract time is required to be given to a surety by the
provisions of the bond, the giving of such notice shall be the Contractor's
responsibility, and the amount of each applicable bond shall be adjusted
accordingly. The Contractor shall furnish proof of such adjustment to the City.
Failure of the Contractor to obtain such approval from the Surety may be a basis
for termination of this Contract by the City.
10. LIQUIDATED DAMAGES
Because of the importance of this project being finished on time, upon failure of the
Contractor to complete each individual requirement within the specified and mutually
agreed upon time frame (plus approved extensions, if any) the Contractor shall pay to
the City the sum of Five Hundred Dollars ($500.00) for each calendar day after the
time specified for Substantial Completion and the project is sufficiently complete for its
intended use in accordance with the Contract Documents, void of any safety concerns.
In the event of a delay in completion beyond the time frame set forth in the Contract
Documents for Final Completion, after Substantial completion has been obtained,
liquidated damages will be assessed against the Contractor in the amount of Two
Hundred Fifty Dollars and Zero Cents ($250.00) for each calendar day beyond the
time frame set in the Contract Documents until such work is completed and ready for
final payment. This amount is not a penalty but liquated damages to the City. Liquidated
damages are hereby fixed and agreed upon between the parties, recognizing the
impossibility of precisely ascertaining the amount of damages that will be sustained by
the City because of such delay, and both parties desiring to obviate any question of
dispute concerning the amount of said damages and the cost and effect of the failure
of the Contractor to complete the Contract on time. The City shall have the right to
deduct from and retain out moneys which may be due, or which may become due and
payable to Contractor. If the amount deducted and/or retained by the City is insufficient
to pay in full such liquidated damages, Contractor shall pay in full such liquidated
damages. Contractor shall also be responsible for reimbursing the City the total of all
monies paid by the City to the engineer for additional engineering, inspection and
administrative services until the work is complete.
11. NO DAMAGES FOR DELAYS
ALL TIME LIMITS STATED IN THE CONTRACT DOCUMENTS ARE OF THE
ESSENCE OF THE AGREEMENT. EXCEPT AS PROVIDED HEREIN, NO CLAIM FOR
DAMAGES OR ANY CLAIM OTHER THAN FOR AN EXTENSION OF TIME SHALL
BE MADE OR ASSERTED AGAINST CITY BY REASON OF ANY DELAYS. Contractor
shall not be entitled to an increase in the construction cost or payment or compensation
of any kind from City for direct, indirect, consequential, impact or other costs, expenses
or damages including but not limited to costs of acceleration or inefficiency, arising
because of delay, disruption, interference or hindrance from any cause whatsoever,
whether such delay, disruption, interference be reasonable or unreasonable, foreseeable
or unforeseeable, or avoidable or unavoidable; provided, however, that this provision
shall not preclude recovery of damages by Contractor for hindrances or delays due solely
to fraud, bad faith or active interference on the part of City or its agents. In addition, if
Contractor is delayed at any time in the progress of the Work by an act or neglect of the
The City For Your Life
CiN )fTramarac Purrn,,sing and Contracts Divisia
City's employees, or separate contractors employed by the City, or by changes ordered
in the Work, or by delay authorized by the City pending arbitration, then the Contract Time
shall be reasonably extended by Change Order. Furthermore, if Contractor is delayed at
any time in the progress of the Work by labor disputes, fire, unusual delay in deliveries,
adverse weather conditions not reasonably anticipated, unavoidable casualties or other
causes beyond the Contractor's control, or by other causes which the City and Contractor
agree may justify delay, then the Contract Time shall be reasonably extended by Change
Order. Otherwise, Contractor shall be entitled only to extensions of the Contract Time as
the sole and exclusive remedy for such resulting delay, in accordance with and to that
extent specifically provided above. No extension of time shall be granted for delays
resulting from normal weather conditions prevailing in the area. An extension of time will
be considered for "Excusable inclement Weather Delays" resulting in any weather
condition, the duration of which varies in excess of the average conditions expected,
which is unusual for the particular time and place where the Work is to be performed, or
which could not have been reasonably anticipated by the Contractor, as determined by
the U.S. Weather Bureau records for the preceding 3-year period. No extension of
Contract Time will be allowed for any inclement weather that could be reasonably have
been predicted from such weather records. Should the contractor prepare to begin work
at the regular starting time at the beginning of any regular work shift on any day on which
excusable inclement weather, or the conditions resulting from the weather, or the
condition of the Work prevents work from beginning at the usual starting time, and the
crew is dismissed as a result thereof, the Contractor will not be charged for a working
day, whether or not conditions change thereafter during said day, and the major portion
of the day could be considered to be suitable for such construction operations. The
Contractor shall base its construction schedule upon the inclusion of the number of days
of excusable inclement weather. No extension of the Contract Time due to excusable
inclement weather will be considered until after the said number of days of excusable
inclement weather has been reached. However, no reduction in Contract Time would be
made if said number of days of excusable inclement weather is not reached.
12. WAIVER OF LIENS
Prior to final payment of Contract Sum, a final waiver of lien shall be submitted to City
by Contractor from all suppliers, subcontractors, and/or Contractors who submitted a
"Notice to Owner" and a Consent of Surety on behalf of any and all other suppliers and
subcontractors who worked on the project that is the subject of this Agreement.
Payment of the invoice and acceptance of such payment by the Contractor shall
release City form all claims of liability by Contractor in connection with the agreement.
13. WARRANTY
Contractor warrants the work against defect for a period of One 1 year from the date
of City Final Acceptance of the project and approval of final payment. In the event that
defect occurs during this time, Contractor shall perform such steps as required to
remedy the defects. Contractor shall be responsible for any damages caused by defect
to affected area or to interior structure. The one (1) year warranty period does not
begin until approval of final payment for the entire project, and the subsequent release
of any Performance or Payment Bonds, which may be required by the original bid
document.
TAMARAC
The City For Your Life
City of Tamarac
14. INDEMNIFICATION
Purchasing and Contracts Division
14.1 The Contractor shall indemnify and hold harmless the City, its elected and
appointed officials, employees, and agents from any and all claims, suits,
actions, damages, liability, and expenses (including attorneys' fees) in
connection with loss of life, bodily or personal injury, or property damage,
including loss of use thereof, directly or indirectly caused by, resulting from,
arising out of or occurring in connection with the operations of the Contractor or
its officers, employees, agents, subcontractors, or independent Contractors,
excepting only such loss of life, bodily or personal injury, or property damage
solely attributable to the gross negligence or willful misconduct of the City or its
elected or appointed officials and employees. The above provisions shall
survive the termination of this Agreement and shall pertain to any occurrence
during the term of this Agreement, even though the claim may be made after
the termination hereof.
14.2 Nothing contained herein is intended nor shall be construed to waive City's
rights and immunities under the common law or Florida Statutes 768.28, as
amended from time to time.
15. NON-DISCRIMINATION & EQUAL OPPORTUNITY EMPLOYMENT
15.1 During the performance of the Contract, the Contractor and its subcontractors
shall not discriminate against any employee or applicant for employment
because of race, color, sex including pregnancy, religion, age, national origin,
marital status, political affiliation, familial status, sexual orientation, gender
identity and expression, genetic information or disability if qualified.
15.2 The Contractor will take affirmative action to ensure that employees and those
of its subcontractors are treated during employment, without regard to their race,
color, sex including pregnancy, religion, age, national origin, marital status,
political affiliation, familial status, sexual orientation, gender identity or
expression, or disability if qualified. Such actions must include, but not be
limited to, the following: employment, promotion; demotion or transfer;
recruitment or recruitment advertising, layoff or termination; rates of pay or other
forms of compensation; and selection for training, including apprenticeship.
15.3 The Contractor and its subcontractors shall agree to post in conspicuous places,
available to its employees and applicants for employment, notices to be
provided by the contracting officer setting forth the provisions of this
nondiscrimination clause. The Contractor further agrees that he/she will ensure
that all subcontractors, if any, will be made aware of and will comply with this
nondiscrimination clause.
16. INDEPENDENT CONTRACTOR
This Agreement does This Agreement does not create an employee/employer
relationship between the Parties. It is the intent of the Parties that the Contractor is an
independent contractor under this Agreement and not the City's employee for any
TAMARAC
The City For Your Life
City of rrrrornr P;-rControctS
purposes, including but not limited to, the application of the Fair Labor Standards Act
minimum wage and overtime payments, Federal Insurance Contribution Act, the Social
Security Act, the Federal Unemployment Tax Act, the provisions of the Internal
Revenue Code, the State Worker's Compensation Act, and the State Unemployment
Insurance law. The Contractor shall retain sole and absolute discretion in the judgment
of the manner and means of carrying out Contractor's activities and responsibilities
hereunder provided, further that administrative procedures applicable to services
rendered under this Agreement shall be those of Contractor, which policies of
Contractor shall not conflict with City, State, or United States policies, rules or
regulations relating to the use of Contractor's funds provided for herein. The Contractor
agrees that it is a separate and independent enterprise from the City, that it had full
opportunity to find other business, that it has made its own investment in its business,
and that it will utilize a high level of skill necessary to perform the work. This Agreement
shall not be construed as creating any joint employment relationship between the
Contractor and the City and the City will not be liable for any obligation incurred by
Contractor, including but not limited to unpaid minimum wages and/or overtime
premiums.
17. ASSIGNMENT AND SUBCONTRACTING
Contractor shall not transfer or assign the performance required by this Agreement
without the prior consent of the City. This Agreement, or any portion thereof, shall not
be subcontracted without the prior written consent of the city.
18. NOTICE
Whenever either party desires or is required under this Agreement to give notice to any
other party, it must be given by written notice either delivered in person, sent by U.S.
Certified Mail, U.S. Express Mail, air or ground courier services, or by messenger
service, as follows:
CITY
City Manager
City of Tamarac
7525 N.W. 88th Avenue
Tamarac, FL 33321
With a copy to the City Attorney at the following address:
Hans Ottinot, PA
7525 N.W. 881h Ave.
Tamarac, FL 33321
CONTRACTOR
Name: ,&, uo Q %' 1iZrG
Address: NW Lj1 -r`d PPZ 0P0)-10ckC-, A ?3Y)5v
FIN/EIN:S"1-UI-131
Contract Licensee:COC j22 S 321 I CC-NG V50 FD q-1
Contact: VJA ( 4-e Y `1 Z od f v-� �
Email:(�WVt�l1" � H0 11 Ccrr-)
TAMARAC
The City For Your Life
C=tu of Tamarac _ Purchasing and Contracts Division
Phone: a>OS - (a51 - aa'LCv - —
Fax: `�o3 - ton 1 - c>o ?-I
19. TERMINATION
19.1 Termination for Convenience: This Agreement may be terminated by City for
convenience, upon seven (7) days of written notice by terminating party to the
other party for such termination in which event Contractor shall be paid its
compensation for services performed to termination date, including services
reasonably related to termination. In the event that Contractor abandons this
Agreement or causes it to be terminated, Contractor shall indemnify city against
loss pertaining to this termination.
19.2 Default by Contractor: In addition to all other remedies available to the City, this
Agreement shall be subject to cancellation by the City for cause, should the
Contractor neglect or fail to perform or observe any of the terms, provisions,
conditions, or requirements herein contained, if such neglect or failure shall
continue for a period of thirty (30) days after receipt by Contractor of written
notice of such neglect or failure. Written notice of cancellation of this agreement
shall state the date upon which the Contractor shall cease all Work under this
Contract and vacate the Project(s) site(s). The Contractor shall, upon receipt of
such notice, unless otherwise directed by the City: Stop all Work on the
Project(s) on the date specified in the notice (the effective date); Take such
action as may be necessary for the protection and preservation of the City's
materials and property; Cancel all cancelable orders for materials and
equipment; Assign to the City and deliver to the site, or any other location
specified by the City, any non -cancelable orders for materials and equipment
that can not otherwise be used except for Work under the Contract and have
been specifically fabricated for the sole purpose of the Work and not
incorporated in the Work; Take no action that shall increase the amounts
payable by the City under the Contract Documents and take reasonable
measures to mitigate the City's liability under the Contract Documents. All
charts, drawings, reports, as-builts and other documents, including electronic
documents, related to Work authorized under the Contract, whether finished or
not, must be turned over to the City. Failure to timely deliver the documentation
shall cause to withhold any payments due without recourse by the Contractor
until all documentation is delivered to the City.
20. AGREEMENT SUBJECT TO FUNDING
This agreement shall remain in full force and effect only as long as the expenditures
provided for in the Agreement have been appropriated by the City Commission of the
City of Tamarac in the annual budget for each fiscal year of this Agreement and is
subject to termination based on lack of funding.
21. VENUE
This Agreement shall be governed by the laws of the State of Florida as now and
hereafter in force. The venue for actions arising out of this agreement is fixed in
Broward County, Florida.
TAMARAC
The City For Your life
City of Tamarac
22. SIGNATORY AUTHORITY
Purchasing and C7, - , rt,
The Contractor shall provide the City with copies of requisite documentation evidencing
that the signatory for Contractor has the authority to enter into this Agreement.
23. SEVERABILITY; WAIVER OF PROVISIONS
Any provision in this Agreement that is prohibited or unenforceable in any jurisdiction
shall, as to such jurisdiction, be ineffective to the extent of such prohibition or
unenforceability without invalidating the remaining provisions hereof or affecting
validity or enforceability of such provisions in any other jurisdiction. The non-
enforcement of any provision by either party shall not constitute a waiver of that
provision nor shall it affect enforceability of that provision or of the remainder of this
Agreement.
24. UNCONTROLLABLE CIRCUMSTANCES
24A Neither the City nor Contractor shall be considered to be in default of this
Agreement if delays in or failure of performance shall be due to Uncontrollable
Forces, the effect of which, by the exercise of reasonable diligence, the non-
performing party could not avoid. The term "Uncontrollable Forces" shall mean
any event which results in the prevention or delay of performance by a party of its
obligations under this Agreement and which is beyond the reasonable control of
the nonperforming party. It includes, but is not limited to fire, flood, earthquakes,
storms, lightning, epidemic, war, riot, civil disturbance, sabotage, and
governmental actions, such as delays in permitting due to outside agencies,
which are beyond the Contractor's control.
24.2 Neither party shall, however, be excused from performance if nonperformance is
due to forces, which are preventable, removable, or remediable, and which the
nonperforming party could have, with the exercise of reasonable diligence,
prevented, removed, or remedied with reasonable dispatch. The nonperforming
party shall, within a reasonable time of being prevented or delayed from
performance by an uncontrollable force, give written notice to the other party
describing the circumstances and uncontrollable forces preventing continued
performance of the obligations of this Agreement.
25. MERGER; AMENDMENT
This Agreement constitutes the entire Agreement between the Contractor and the City,
and negotiations and oral understandings between the parties are merged herein. This
Agreement can be supplemented and/or amended only by a written document
executed by both the Contractor and the City.
26. NO CONSTRUCTION AGAINST DRAFTING PARTY
Each party to this Agreement expressly recognizes that this Agreement results from
the negotiation process in which each party was represented by counsel and
contributed to the drafting of this Agreement. Given this fact, no legal or other
presumptions against the party drafting this Agreement concerning its construction,
TAMARAC
The City For Your Life
City o`7-,^m.o— Purr.,",;, a and Contracts Division
_.._. __—---- _------------ ._.--------------
interpretation or otherwise accrue to the benefit of any parry to the Agreement, and
each party expressly waives the right to assert such a presumption in any proceedings
or disputes connected with, arising out of, or involving this Agreement.
27. CONTINGENT FEES
The Contractor warrants that it has not employed or retained any company or person,
other than a bona fide employee working solely for the Contractor to solicit or secure
this Agreement and that it has not paid or agreed to pay any person, company,
corporation, individual or firm, other than a bona fide employee working solely for the
Contractor, any fee, commission, percentage, gift or any other consideration contingent
upon or resulting from the award or making of this Agreement.
28. SCRUTINIZED COMPANIES - 287.135 AND 215.473
28.1 By execution of this Agreement, Contractor certifies that Contractor is not
participating in a boycott of Israel. Contractor further certifies that Contractor is
not on the Scrutinized Companies that Boycott Israel list, not on the Scrutinized
Companies with Activities in Sudan List, and not on the Scrutinized Companies
with Activities in the Iran Petroleum Energy Sector List, or has Contractor been
engaged in business operations in Syria. Subject to limited exceptions provided
in state law, the City will not contract for the provision of goods or services with
any scrutinized company referred to above.
28.2 Submitting a false certification shall be deemed a material breach of contract.
The City shall provide notice, in writing, to Contractor of the City's determination
concerning the false certification. Contractor shall have five (5) days from receipt
of notice to refute the false certification allegation. If such false certification is
discovered during the active contract term, Contractor shall have ninety (90)
days following receipt of the notice to respond in writing and demonstrate that
the determination of false certification was made in error. If Contractor does not
demonstrate that the City's determination of false certification was made in error
then the City shall have the right to terminate the contract and seek civil
remedies pursuant to Section 287.135, Florida Statutes, as amended from time
to time.
29. PUBLIC RECORDS
29.1 The CITY is a public agency subject to Chapter 119, Florida Statutes. The
CONTRACTOR shall comply with Florida's Public Records Law. Specifically,
CONTRACTOR shall:
29.1.1 Keep and maintain public records required by the CITY in order to perform
the service.
29.1.2 Upon request from the CITY, provide the public agency with a copy of the
requested records or allow the records to be inspected or copied within a
reasonable time at no cost to the CITY.
29.1.3 Ensure that public records that are exempt or confidential and exempt from
public records disclosure requirements are not disclosed except as
authorized by law for the duration of the contract term and following
TAMARAC
The City For Your Life
Tamarac ,r.-t,.,—in, r: 4 Contracts Division
completion of the Agreement and any renewals thereof if CONTRACTOR
does not transfer the records to the CITY.
29.1.4 Upon completion of the Agreement, transfer, at no cost to the CITY, all
public records in possession of CONTRACTOR, or keep and maintain
public records required by the CITY to perform the service. If
CONTRACTOR transfers all public records to the CITY upon completion
of the Agreement, CONTRACTOR shall destroy any duplicate public
records that are exempt or confidential and exempt from public records
disclosure requirements. If CONTRACTOR keeps and maintains public
records upon completion of the Agreement, CONTRACTOR shall meet all
applicable requirements for retaining public records. All records stored
electronically must be provided to the CITY, upon request from the CITY's
custodian of public records in a format that is compatible with the
information technology systems of the CITY.
29.2 During the term of this Agreement and any renewals, CONTRACTOR shall
maintain all books, reports and records in accordance with generally accepted
accounting practices and standards for records directly related to this contract.
30. E-VERIFY
Definitions:
"Agency" or "Public Employer" for purposes of this section shall mean the City of
Tamarac, a Municipal Corporation which is a political subdivision of the State of Florida.
"Contractor" means a person or entity that has entered or is attempting to enter into a
contract with a public employer to provide labor, supplies, or services to such employer
in exchange for salary, wages, or other remuneration. "Contractor" includes, but is not
limited to, a vendor or consultant.
"Subcontractor" means a person or entity that provides labor, supplies, or services to
or for a contractor or another subcontractor in exchange for salary, wages, or other
remuneration.
"E-Verify system" means an Internet -based system operated by the United States
Department of Homeland Security that allows participating employers to electronically
verify the employment eligibility of newly hired employees.
Effective January 1, 2021, public and private employers, contractors and
subcontractors will begin required registration with, and use of, the E-verify system in
order to verify the work authorization status of all newly hired employees. Contractor
acknowledges and agrees to utilize the U.S. Department of Homeland Security's E-
Verify System to verify the employment eligibility of:
a) All persons employed by Contractor to perform employment duties within
Florida during the term of the contract; and
The City For Your Life
City of TarYt(-c- P-Jr rc-jr',-- and Contracts Divisi±"
b) All persons (including sub-vendors/subconsultants/subcontractors)
assigned by Contractor to perform work pursuant to the contract with the City.
The Contractor acknowledges and agrees that use of the U.S. Department of
Homeland Security's E-Verify System during the term of the contract is a
condition of the contract with the City of Tamarac.
Should Vendor become the successful Contractor awarded for the above -named
project, by entering into this Agreement, the Contractor becomes obligated to comply
with the provisions of § 448.095, FL. Statutes, as amended from time to time. This
includes but is not limited to utilization of the E-Verify System to verify the work
authorization status of all newly hired employees; and requiring all Subcontractors to
provide an affidavit attesting that the Subcontractor does not employ, contract with, or
subcontract with, an unauthorized alien. The Contractor shall maintain a copy of such
affidavit for the duration of the contract. Failure to comply will lead to termination of
this Contract, or if a Subcontractor knowingly violates the statute, the Subcontract must
be terminated immediately. Any challenge to termination under this provision must be
filed in the Circuit Court no later than 20 calendar days after the date of termination. If
this contract is terminated for a violation of the statute by the Contractor, the Contractor
may not be awarded a public contract by the City for a period of 1 year after the date
of termination. By signing below, the Vendor acknowledges these terms shall be an
integral part of its bid and the Contract.
31. CUSTODIAN OF RECORDS
IF THE CONTRACTOR HAS QUESTIONS REGARDING THE
APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE
CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING
TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC
RECORDS AT:
CITY CLERK
7525 NW 88TH AVENUE
ROOM 101
TAMARAC, FL 33321
(954) 597-3505
CITYCLERK@TAMARAC.ORG
TAMARAC
The City For Your Life
City of Tamarac
Purchosinq and Contracts Division
IN WITNESS WHEREOF, the parties have made and executed this Agreement on the
respective dates under each signature. CITY OF TAMARAC, signing by and through its Mayor
and City Manager, and CONTRACTOR, signing by and through its President / Owner duly
authorized to execute same.
It
A`
EST PBL�s : �
PL • O
ATTEST �O SE ••�v:`
GL,
Kimberly gillon, CMC
City Clerk
U 2ea 2023
Date
ATTEST:
CITY OF TAMARAC
9WIJ6�5�0m�'
Mich Ile J. Go m-ez,'U&yor6
81 a31-�oa.3
Date
Levert Sucuoglu, City /Manager '
Date 7
2
Date
and legal sufficiency:
Company Name CAW �" Pe I ► W , -in
Company Name
.4? 421
Signatu f Corporate Secretary Signatur President / Owner
o - Wc1k� Jcf%%)e�—
Type/Print Name of Corp to ecy. Type/Print Name of President / Owner
9-3
(CORPORATE SEAL) Date
Tamarac
TAMARAC
The City For Your Life
CORPORATE ACKNOWLEDGEMENT
STATE OF L
:SS
COUNTY OF DO,4 :
Purchasing and Contracts Division
I HEREBY CERTIFY that on this day, before me, an Officer duly authorized in the State
aforesaid and in the County aforesaid to take acknowledgments, personally appeared
Wca tte & 42 , President of CW Pipeline, Inc., a Florida Corporation, to me known
to be the person(sed in and who executed the foregoing instrument and acknowledged
before me that he/she executed the same.
WITNESS my hand and official seal this day of Av j,4 % // , 20 41,3
-�m
Si nature of Notary Public
zo•"` °:; GISELL a at Large
MY COMMISSION # HH 105742
o EXPIRES: Marc
For n4c• i3ondM Thru Noh-.ft PI
h 17, 2025
"`c' Stamp
Name of Notary Public
E] Personally, known to me
or
❑ Produced Identification
Type of I.D. Produced
Q DID take an oath, or
❑ DID NOT take an oath.
AFRO® CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/2023 Y)
OSI09I023
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT. If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT Amanda Nogues
NAME:
Eastern Insurance Group, Inc.
PHONE (305) 595-3323 FAX (305) 595-7135
A/C No Ext : A/C, No
7400 SW 50th Terrace
E-MAIL amanda.nogues@eigrisk.com
ADDRESS:
Suite 100
INSURER(S) AFFORDING COVERAGE
NAIC #
Miami FL 33155
INSURER A : p HDI Global Specialty SE
41343
INSURED
INSURER 8Clear Blue Insurance Co.
C & W Pipeline, Inc.
INSURER C: Florida, Citrus, Business & Industries Fund
13117 NW 42 Ave
INSURER D : p Capitol Specialty Ins. Corp.
INSURER E :
Opa Locka FL 33054
INSURER F
COVERAGES CERTIFICATE NUMBER: Master 23-24 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
INSD
WVD
POLICY NUMBER
POLICY EFF
MMIDD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑X OCCURut
EACH OCCURRENCE
1 ,000,000
$
RENTED
PREMISES Ea occurrence
50,000
$
MILD EXP (Any one person)
$ Excluded
PERSONAL & ADV INJURY
$ 1,000,000
A
CAS000759/2300
02/22/2023
02/22/2024
GEN'L
X
AGGREGATE LIMIT APPLIES PER
POLICY ❑ PRO ❑
JECT LOC
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS-COMP/OP AGG
2,000,000
$
$
OTHER
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$ 1,000,000
BODILY INJURY (Per person)
$
ANY AUTO
B
OWNED SCHEDULED
AUTOS ONLY X AUTOS
AQIYFL000827-04
02/03/2023
02/03/2024
IX
BODILY INJURY (Per accident)
$
HIRED NON -OWNED
AUTOS ONLY X AUTOS ONLY
PROPTY D
Per accDAMAGE
$
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAR
CLAIMS -MADE
DED I I RETENTION $
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N
OFFICER/MEMBER EXCLUDED? �
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
10660179-2023
05/17/2023
05/17/2024
/� STATUTE EORH
E.L. EACH ACCIDENT
1,000,000
$
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
E.L. DISEASE - POLICY LIMIT
1,000,000
$
D
Pollution Liability
EV20230516-01
08/07/2023
08/07/2024
Each Pollution Incident
Policy Aggregate
$1,000,000
$1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Water & Sewer Main Contractor
CITY OF TAMARAC
7525 NW 88TH AVENUE
TAMARAC
FL 33321
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Request for Taxpayer
Give Form
Form
(Rev. October2018)
Identification Number and Certification
to the
requester. Do not
Department of the Treasury
Internal Revenue Service
► Go to wwwJrs.gov/FormW9 for instructions and the latest information.
send to the IRS.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
C&W PIPELINE, INC.
CQ
44)
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
4 Exemptions (codes apply only to
following seven boxes.
certain entities, not individuals; see
a
p
❑ Individual/sole proprietor or ❑ C Corporation El S Corporation ❑ Partnership ❑ Trust/estate
instructions on page 3):
H
C
single -member LLC
Exempt payee code (if any)
v
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) IN,
o 2
Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check
Exemption from FATCA reporting
M
LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is
a S
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that
code (if any)
2
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
d
D.
Other see instructions ❑ ( ) ►
(Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions.
Requester's name and address (optional)
d
13117 NW 42ND AVE
6 City, state, and ZIP code
OPA-LOCKA, FL 33054
7 List account number(s) here (optional)
MiUM It axpayer Ictentitication Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding. For individuals, this is generally your social security number (S. However, fora _ m —
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. or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and I Employer identification number
Number To Give the Requester for guidelines on whose number to enter. fT1
92"OVM"WAMMM
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. 1 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. 1 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 11, later.
Sign Signature of p �1
Here U.S. person ► y//fJM'9J/�Jrl�
Date ►
General Instrucii6ns
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/F`ormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, ir%lud(ng those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
Form W-9 (Rev. 10-2018) Page 2
By signing the filled -out form, you:
1. Certify that the TIN you are 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 exemption from 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 What is
FATCA 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 the laws 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, it 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
withholding on its allocable share of net income from the partnership
conducting 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 grantor trust with a U.S. grantor or other U.S. owner,
generally, the U.S. grantor 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 grantor 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 elected 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, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
Nonresident alien who becomes a resident alien. Generally, only a
nonresident alien individual may 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 income even 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 alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the
saving clause and its exceptions.
4. The type and amount of income that qualifies for the exemption
from tax.
5. Sufficient facts to justify the exemption from tax under the terms of
the treaty article.
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 United States. A Chinese
student who qualifies for this exception (under paragraph 2 of the first
protocol) 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, 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 withholding under 4 above (for reportable interest and dividend
accounts opened after 1983 only).
Certain payees and payments are exempt from backup 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 FATCA Reporting?
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 TIN changes for the account; for example, 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 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.
Form W-9 (Rev. 10-2018)
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.
Specific Instructions
Line 1
You must enter one of the following 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 joint account, 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 fast
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, line 1 a. This should also be the same as the
name you entered on the Form 1040/1040A/1040EZ you filed with your
application.
b. Sole proprietor or single -member LLC. Enter your individual
name as shown on your 1040/1040A/1040EZ on line 1. You may enter
your business, trade, or "doing business as" (DBA) name on line 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 DBA name on
line 2.
d. Other entities. 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 DBA 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, DBA 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
classification of the person whose name is entered on line 1. Check only
one box on line 3.
Page 3
IF the entity/person on line 1 is
THEN check the box for ...
a(n) ..
• Corporation
Corporation
• Individual
Individual/sole proprietor or single -
Sole proprietorship, or
member LLC
• Single -member limited liability
company (LLC) owned by an
individual and disregarded for U.S.
federal tax purposes.
• LLC treated as a partnership for
Limited liability company and enter
U.S. federal tax purposes,
the appropriate tax classification.
• LLC that has filed Form 8832 or
(P= Partnership; C= C corporation;
2553 to be taxed as a corporation,
or S= S corporation)
or
• LLC that is disregarded as an
entity separate from its owner but
the owner is another LLC that is
not disregarded for U.S. federal tax
purposes.
• Partnership
Partnership
• Trust/estate
Trust/estate
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting,
enter in the appropriate space on line 4 any code(s) that may apply to
you.
Exempt payee code.
• Generally, individuals (including sole proprietors) are not exempt from
backup withholding.
• Except as provided below, corporations are exempt from backup
withholding for certain payments, including interest and dividends.
• Corporations are not exempt from backup withholding 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(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 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)
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.
IF the payment is for ...
THEN the payment is exempt
for...
Interest and dividend payments
All exempt payees except
for 7
Broker transactions
Exempt payees 1 through 4 and 6
through 11 and all C corporations.
S corporations must not enter an
exempt payee code because they
are exempt only for sales of
noncovered securities acquired
prior to 2012.
Barter exchange transactions and
Exempt payees 1 through 4
patronage dividends
Payments over $600 required to be
Generally, exempt payees
reported and direct sales over
1 through 52
$5,000'
Payments made in settlement of
Exempt payees 1 through 4
payment card or third party network
transactions
' 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 account 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 providing you with a Form 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)(i)
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)
Page 4
M—A tax exempt trust under a section 403(b) plan or section 457(g)
plan
Note: You may wish to consult with the financial institution requesting
this Corm 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 payor 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 apply for an SSN, get Form SS-5, Application for a Social Security
Card, from your local SSA office or get this form online at
www.SSA.gov. 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 SS-4, Application for Employer
Identification Number, to apply for an EIN. You can apply for an EIN
online by accessing the IRS website at www.irs.gov/Businesses and
clicking on Employer Identification Number (EIN) under Starting a
Business. Go to www.irs.gov/Forms to view, download, or print Form
W-7 and/or Form SS-4. Or, you can go to wwwJrs.gov/OrderFcrms to
place an order and have Form W-7 and/or SS-4 mailed to 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 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: 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 )ojnt 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) Page rJ
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 (including payments to corporations), payments to
a nonemployee 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 Requester
For this type of account: f 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 more U.S. persons
Qoint account maintained by an FFI)
4. Custodial account of a minor
(Uniform Gift to Minors Act)
5. 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
6. Sole proprietorship or disregarded
entity owned by an individual
The individual
The actual owner of the account or, if
combined funds, the first individual on
the account'
Each holder of the account
The minor
The grantor -trustee'
The actual owner'
The owner'
7. Grantor trust filing under Optional The grantor'
Form 1099 Filing Method 1 (see
Regulations section 1.671-4(b)(2)(i)
(A))
For this type of account:
8. Disregarded entity not owned by an
individual
9. A valid trust, estate, or pension trust
10. Corporation 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 mufti -member LLC
13. A broker or registered nominee
Give name and EIN of:
owner
Legal entity'
For this type of account: I Give name and EIN of:
14. Account with the Department of The public entity
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
15. Grantor trust filing under the Form The trust
104f Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulations section 1.671-4(b)(2)(i)(B))
' 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 DBA name on the "Business name/disregarded entity"
name line. You may use either your SSN or EIN (if you have one), but the
IRS encourages you to use your SSN.
° List first and circle the name of the 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.) Also see Special
rules for partnerships, earlier.
*Note: The grantor also must provide 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 information, without 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
notice from 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 lost 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, may be eligible for
Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
calling the TAS toll -free case intake line at 1-877-777-4778 or TTY/TDD
1-800-829-4059.
The corporation protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of email and websites designed to
mimic legitimate business emails and websites. The most common act
The organization is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
private information that will be used for identity theft.
The partnership
The broker or nominee
Form W-9 (Rev. 10-2018) Page 6
The IRS does not initiate contacts with taxpayers via emails. Also, the
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers, passwords, or similar secret access
information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishing@irs.gov. You may also report misuse
of the IRS name, logo, or other IRS property to the Treasury Inspector
General for Tax Administration (TIGTA) at 1-800-366-4484. You can
forward suspicious emails to the Federal Trade Commission at
spam@uce.gov or report them at www.ftc.gov/complaint. You can
contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338).
If you have been the victim of identity theft, see www.identityTheft.gov
and Pub. 5027.
Visit www.irs.gov/IdentityTheft to learn more about identity theft and
how to reduce your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your
correct TIN to persons (including federal agencies) who are required to
file information returns with the IRS to report interest, dividends, or
certain other income paid to you; mortgage interest you paid; the
acquisition or abandonment of secured property; the cancellation of
debt; or contributions you made to an IRA, Archer MSA, or HSA. The
person collecting this form uses the information on the form to file
information returns with the IRS, reporting the above information.
Routine uses of this information include giving it to the Department of
Justice for civil and criminal litigation and to cities, states, the District of
Columbia, and U.S. commonwealths and possessions for use in
administering their laws. The information also may be disclosed to other
countries under a treaty, to federal and state agencies to enforce civil
and criminal laws, or to federal law enforcement and intelligence
agencies to combat terrorism. You must provide your TIN whether or
not you are required to file a tax return. Under section 3406, payers
must generally withhold a percentage of taxable interest, dividend, and
certain other payments to a payee who does not give a TIN to the payer.
Certain penalties may also apply for providing false or fraudulent
information.