mr. bear logistics, inc.mrbearlogistics.com/wp-content/uploads/2016/05/setup_package_mr… · mr....

Mr. Bear Logistics, Inc. 13781 Roswell Ave. Ste# H, Chino CA 91710 / Phone: 909-536-1635 / Fax: 800-878-9164

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Requirements for Carrier Setup:

1. Carrier Profile

2. Equipment & Service List

3. Signed DOT/FMCSA Safety Compliance Agreement

4. Current Year Form W-9

5. Signed Contract Carrier-Broker Agreement

6. Certificate Of Insurance With “ MR BEAR LOGISTICS INC ” as the certificate holder

Minimum Insurance Requirement:

a. Motor Truck Cargo $100,000

b. Auto Liability $1,000,000

7. Copy of Original Operating Authority along with any re-entitlements.

Holder Information:

MR BEAR LOGISTICS INC

13781 ROSWELL AVE., STE# H

CHINO CA 91710


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Billing / Payment Requirements:

• Carrier name and remittance address on all invoices

• Mr Bear Logistics Inc’s Order/Load number on all invoices

• One invoice per Order/Load number

• Required Paperwork

� Legible signed deliver receipt ( we do not accept cell phone copies)

� Scale Tickets, Lumper Receipts and/or Gate Passes if applicable

� Detention forms and/or in & out times if applicable

Invoices that do not meet our requirements run the risk of being paid late or being returned. If you cannot

provide a legible signee livery receipt and we have to retrieve it from the consignee, there will be a $100.00

deduction from your payment.

Billing Delivery methods:

• E-MAIL: [email protected]

• Fax : 800-878-9164

• Post Mail: 13781 Roswell Ave., Ste# H, Chino, CA 91710

Mr Bear Logistics has 5% Quickpay option (with a $10 minimum). Upon receiving the ORIGINAL Bills, we will

process payment and issue a check for the entire amount minus 5% within a 48 hours period.

COMPANY NAME: _____________________________________________________________________

ADDRESS: ____________________________________________________________________________

CITY ______________________________________ STATE __________ ZIP CODE __________

PRINTED NAME : ______________________________

SIGNATURE: __________________________________

DATE : _______________________________________


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CARRIER PROFILE:

Company Name: ____________________________________________________________________

DBA: _____________________________________________________________________________

President or Owner’s name: _________________________________________________________

MC# __________________ DOT# __________________ SCAC: __________________

Physical Address: __________________________________________________________________

City: ________________________________ State ________ ZIPCODE ___________

Mailing Address: __________________________________________________________________

City: ________________________________ State ________ ZIPCODE ___________

Toll Free: _________________________ Ext. ________ Main Fax: ______________________

Phone: _________________________ Ext. ________ Other Fax: ______________________

E-Mail: _________________________________________________________________________

Web Address: _____________________________________________________________________

Dispatch Contact: Name: _________________________ Phone: ____________________Ext._____

E-Mail: _________________________________________________

Afterhours : Name: _________________________ Phone: ____________________Ext._____

E-Mail: _________________________________________________

Claims Contact: Name: _________________________ Phone: ____________________Ext._____

E-Mail: _________________________________________________

Manager Contact: Name: _________________________ Phone: ____________________Ext._____

E-Mail: _________________________________________________

Billing Contact: Name: _________________________ Phone: ____________________Ext._____

E-Mail: _________________________________________________

FACTORED? YES NO (if yes) Factoring Company: _________________________________

Insurance Company / Contact: _________________________________________________________

Ins. Phone#: ___________________________ Ext. ______ Ins. Fax# _____________________________

E-Mail: _________________________________________________


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Carrier name: __________________________________________ MC# _______________________

Equipment: Please fill the quantity of each of the following equipment in the space provided.

Power Unit ______________________ Drivers ________________________

Vans

45’ ___________ 48’ ___________ 53’ ___________ Vented ___________

Curtain Side ___________ Plated Trailers ___________ E-Track ___________ Logistics Post ___________

Lift Gate ___________ Open Top ___________ Pups ___________ Vented ___________

Flatbeds

45’ ___________ 48’ ___________ 53’ ___________ Stepdeck ___________

Double Drop ___________ Ext. Lowboy ___________ Lowboy ___________ Loaders ___________

RGN (Specify Axles) ____________________________ Conestoga ___________ Sides ___________

Vans

48’ ___________ 53’ ___________

Other Equipments

________________________________________________________________________________

_____________________________________________________________________________________

Services: Please check all services that apply

Hazmat ___________ Team ___________ Power Only ___________ Drop Trailers ___________

Canada ___________ Mexico ___________ Pallet Excg. ___________ LTL ___________

Drayage ___________ Bulkhead ___________ Bonded ___________ Liquor Lic. ___________

Blanket Wrap ___________ Trailer Interchange ___________

Other Services

________________________________________________________________________________

_____________________________________________________________________________________


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DOT / FMCSA Safety Compliance

As a condition of contracting with MR BEAR LOGISTICS INC to transport freight for its shipper customers,

you are required to provide assurance of your compliance with DOT and FMCSA safety regulations including, but

not limited to, 49 C.F.R Parts 382-396. The purpose of this letter is to specifically request your written

confirmation that you are, and will continue to operate, in compliance with all safety requirements of U.S. DOT

and FMCSA during the term of your agreement with MR BEAR LOGISTICS INC.

DOT and FMCSA safety compliance includes, but not limited to, carriers following a written safety plan

which addresses the following:

1. No drivers are currently employed or will be employed who:

a. Have more than three moving violation in the past twenty-hour month period.

b. Have been cited for causing a fatal accident

c. Have violated or violate any drug or alcohol testing regulation

2. Carrier compliance with:

a. Inspection, repair, and maintenance file on all equipment showing compliance with federal

regulations

b. Carrier must not have a FMCSA Safety Rating of “Unsatisfactory” or “ Conditional” and agrees to

notify MR BEAR LOGISTICS INC immediately if carrier’s safety rating changes to “Unsatisfactory”

or “Conditional”

Company Name: ________________________________________________________________________

Signature: ________________________________________________________________________

Print Name: ________________________________________________________________________

Title: ________________________________________________________________________

Date: ________________________________________________________________________


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BROKER-CARRIER AGREEMENT

This Broker-Carrier Agreement (“Agreement”) is entered into this ______ day of

_________________, 20____ by and between ____________________________________(“Carrier”), a______________________ organized under the laws of ______________________________, MC-___________ (“Carrier”), and MR BEAR LOGISTICS INC, a S-Corporation organized under the laws of CALIFORNIA, MC- 960017 (“Broker”)(or collectively “Parties”) is entered into for the purpose of specifying the terms and conditions under which Broker will engage Carrier to perform motor contract carriage and related services for Shippers (the “Services”), and under which Carrier will render those Services.

WHEREAS, Broker shall from time to time offer Carrier the opportunity to transport freight within the United States, Canada, or Mexico; and

WHEREAS, Carrier wishes to have the opportunity of transporting such freight; NOW THEREFORE, in consideration of one dollar ($1.00), the mutual promises contained

herein and other good and valuable consideration the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

This Agreement shall be effective as of the date written above and shall continue for a period of one (1) year. This Agreement shall thereafter continue in effect from year to year on the same terms and conditions, unless terminated by either party upon ten (10) days advance written notice. Unless later provisions of this Agreement provide otherwise, Broker and Carrier expressly and mutually waive to the extent permissible under law any and all rights and remedies each may have under Part B of the Interstate Commerce Commission Termination Act of 1995, 49 U.S.C. § 13101-14914 (“ICCTA”) including but not limited to provisions of 49 U.S.C. § 14101. Carrier’s Rules Circular (if any) and tariff rates & provisions (if any) shall be of no legal force or effect and the terms of this Agreement shall supersede any such circulars, tariff rates and provisions. However, nothing in this Agreement shall be construed as waiving any provision governing Carrier’s compliance with registration, insurance and/or safety fitness related requirements relative to motor carriers.

2. In the performance of the services relating to this Agreement Carrier shall be an independent

contractor to Broker and shall not be or act as an agent or employee of the Broker. Broker shall not have the right to control the time, manner nor method by which Carrier or its employees or contractors execute the work performed by Carrier. This Agreement shall be construed in all respects taking into consideration the overriding intention of the parties that Carrier be an independent contractor and not an employee of Broker or Broker’s customer(s). Broker is not an agent for carrier, shipper, consignee or any other person or entity associated with transportation of the loads, except for the limited purpose of

Initials: Carrier: _________


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carrying out its duties as a freight broker. No joint venture relationship exists between Carrier and Broker.

3.

Broker, at Broker’s sole discretion, may offer Carrier the opportunity to transport goods (hereinafter “loads”) for Broker’s customers (who may be shippers, consignors, consignees or others). The parties’ representatives shall negotiate Carrier’s freight charges (including accessorial charges and fuel surcharge) and any additional terms pertaining to each load and upon agreement, the load details and freight charges for each load shall be set forth in a rate confirmation form (“the Confirmation”) which shall be signed by the parties’ representatives. Unless set forth in the Confirmation, or in any supplemental Confirmation (which must be signed by the parties’ representatives) pertaining to each load, Carrier shall not be entitled to bill or collect any additional rates or charges.

4. The Shipper or Carrier may issue a standard uniform straight Bill of Lading (“BOL”) for all

loads, however, regardless of who prepares the BOL, Carrier will ensure that each BOL will name Carrier, and not Broker, as the as the carrier. In the event that Broker (or any other person/entity other than Carrier) is erroneously designated as the carrier of the load, such shall not change Broker’s status as a property broker or Carrier’s status as the carrier of such load. Carrier shall become fully responsible and liable for each load pursuant to the Carmack Amendment (49 USC 14706) and as may otherwise be provided in this Agreement and the Confirmation. Cargo lost and damaged shall be valued and paid by Carrier at Broker’s customer’s invoice price at destination. Cargo claim processing shall be as provided by 49 CFR 370. Carrier’s cargo liability shall be primary notwithstanding that Broker may enter into an agreement with Broker’s customer whereby Broker assumes joint liability with Carrier or Broker otherwise assumes some degree of liability for cargo loss, damage or delay. Carrier agrees that any Broker agreement made with Broker’s customer whereby Broker assumes any liability for cargo loss, damage or delay shall constitute an assumption of liability only as between Broker and Broker’s customer and that Carrier shall not be a third-party beneficiary of any such agreement. As between Broker and Carrier Broker shall have no cargo liability.

5. Carrier shall pick-up, transport, and delivers the load with reasonable dispatch within time-

frames set forth in the Confirmation. Carrier shall not agree to transport a load and shall not transport a load unless it can do so utilizing a driver or drivers who are compliant in all regards with applicable laws and who can pick-up, transport, and deliver the load within applicable hours of service regulations. Carrier shall utilize its own equipment which shall be in safe and sound condition, suitable for the freight to be transported, and compliant with all applicable laws and the Confirmation requirements. Carrier shall not cut or otherwise tamper with the seal on sealed trailers or containers without a signed written authorization from Broker or Broker’s customer expressly authorizing such. Carrier shall not salvage any cargo goods without a signed written authorization from Broker or Broker’s customer Initials: Carrier: _________


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expressly authorizing such. Carrier shall be fully responsible for any dishonest acts of its employees, contractors and agents. Although Broker may from time to time communicate with Carrier regarding pick-up, transport, and delivery of the loads, any routing communication/instructions from Broker to Carrier are for information purposes only. Under no circumstances shall Carrier’s driver communicate in any manner with any of Broker’s personnel when doing so would be unsafe or would violate any law prohibiting such communication.

6. (A) Upon Carrier’s completion of its obligations with regard to each load, Carrier shall promptly

provide Broker with the applicable signed bill of lading, signed delivery receipt, and any other proof of delivery and related documents which Broker may request. Upon receipt of such documents and Carrier’s invoice, and provided that Carrier has fully completed performance of its obligations without loss, damage, or delay, Broker shall pay Carrier’s freight charges within thirty (30) days. Broker shall conduct all billing services to shippers and other responsible parties. Unless Broker breaches its payment obligation to Carrier and Carrier’s written notice of such to Broker, Broker’s customer’s payment of freight charges to Broker shall constitute payment to Carrier and Carrier shall not contact Broker’s customers regarding freight charges nor bill or attempt to collect freight charges from any entity other than Broker.

(B) Carrier’s receipt of full payment from Broker shall constitute an assignment by Carrier to

Broker of all of Carrier’s rights to collect freight charges from any shipper, consignor, consignee, or any other person or entity for transportation of the load(s) for which Carrier has been fully paid by Broker. Such assignment includes, but is not limited to Carrier’s collection rights and rights to sue. Said assignment shall occur automatically upon Carrier’s receipt of full payment from Broker for such load(s) without the necessity of any further documentation of such assignment, however, upon Broker’s request Carrier shall execute and deliver to Broker a separate document (in form reasonably satisfactory to Broker) setting forth and memorializing such assignment.

7. Carrier Agrees, Represents And Warrants That During the Term of this Agreement That Carrier: (A) Is duly licensed, permitted, and authorized by all federal, state and local authorities to

perform the carrier transportation services to be performed hereunder and will not transport any load if any federal, state or local license, permit or authority is revoked, suspended or rendered inactive for any reason or if transporting a load would be illegal or unsafe for any reason;

(B) Shall safely pick-up, transport & deliver loads under its own operating authority; (C) Shall not re-broker, assign or interline the loads without prior written consent of Broker. If



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Carrier breaches this provision, Broker shall have the right of paying the monies otherwise due Carrier directly to the delivering carrier, in lieu of payment to Carrier. Upon Broker’s payment to delivering carrier Broker and Broker’s customer(s) shall be released from any liability to Carrier, however, Carrier shall not be released from any liability to Broker under this Agreement;

(D) Is in, and shall maintain compliance during the term of this Agreement with all applicable

federal, state and local laws relating to the provision of its services and operators of its equipment; (E) Shall provide appropriate equipment and qualified personnel for safe completion of the

transportation services. Carrier will strictly comply with all FMCSA and other applicable federal, state and local laws pertaining to registration, insurance and/or safety fitness related requirements relative to carriers and drivers. Carrier will carefully select and monitor all drivers and equipment utilized in transporting the loads and shall not utilize unsafe drivers or equipment. Carrier shall not use equipment that has previously been used to transport hazardous materials or wastes, solid or liquid;

(F) Shall have no lien and hereby expressly waives its right to any lien on any cargo, freight or property transported pursuant to this Agreement;

(G) Shall pay all environmental clean-up costs, fines, or assessments and all licenses, fees, taxes,

fuel tax payments, road taxes, equipment use fees or taxes, equipment license fees, driver’s license fees, tolls and any other costs, fees and fines that may be assessed on its equipment, operations and services hereunder; and

(H) Shall indemnify and hold Broker and Broker’s customer(s) harmless against all claims, liabilities, damages, losses and judgments (including expenses of litigation and attorneys fees) caused by or arising out of Carrier’s services hereunder, including Carrier’s breach of this Agreement and Carrier’s negligent performance or failure to perform its legal obligations.

8. Broker Agrees, Represents and Warrants That It: (A) Is duly licensed, permitted and authorized by all federal, state and local authorities to provide

brokerage services relating to transportation of property under contracts with shippers and receivers of general commodities;

(B) Is in, and shall maintain compliance during the term of this Agreement with all applicable federal, state and local laws relating to the provision of its services; and

(C) Shall maintain a surety bond/trust fund on file with the FMCSA in the form and amount

required by that agency’s regulations. Initials: Carrier: _________


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9.

Carrier shall maintain and furnish to Broker certificate(s) from Carrier’s insurer(s) naming Broker as a certificate holder, and shall maintain in force continuously throughout the term of this Agreement and with respect to each load, the following types of insurance: (i) comprehensive general liability insurance with coverage which shall be at least One Million Dollars ($1,000,000.00); (ii) all-risk non-scheduled vehicle cargo insurance (which shall not contain any exclusion for dishonest acts of Carrier’s employees, agents and contractors) with a per unit minimum liability limit of at least One Hundred Thousand Dollars ($100,000.00); (iii) motor carrier vehicle liability insurance (with a MCS-90 endorsement) with coverage for all owned, hired and non-owned vehicles which shall be at least One Million Dollars ($1,000,000.00); (iv) workers compensation and employers liability as required by law; (v) trailer interchange insurance with limits of at least Thirty Thousand Dollars ($30,000) per unit; and (vi) such other insurance as may be required by Broker. Said insurance policies shall inure to the benefit of Broker and Broker’s customers and shall provide advance notice of cancellation or termination. Except for the higher coverage limits which may be specified above, the insurance policies shall comply with the minimum requirements of the FMCSA and any other applicable laws. Carrier’s insurance shall apply with respect to all loads whether Carrier transports loads under contact carrier authority or common carrier authority. Nothing in this Agreement shall be construed to avoid or limit Carrier’s liability due to any exclusion or deductible in any insurance policy. Carrier will notify Broker immediately if any of its insurance required hereunder is threatened to be or is terminated, cancelled, suspended, or revoked for any reason. Carrier shall immediately notify its insurers of any claim of loss or damage pertaining to a load and hereby authorizes Broker and Broker’s customers to communicate with Carrier’s insurers pertaining to Carrier’s insurance and any claims.

10. During the term of this Agreement and for a period of one (1) year following termination of this

Agreement (regardless of cause), Carrier will not directly, or by assisting others, within the continental United States, solicit any of Broker’s customers whose traffic lanes were first introduced by Broker to Carrier for the purpose of Carrier providing or arranging provision of carrier transportation of goods for or on behalf of such customer(s). Customers as to whom these non-solicitation restrictions shall apply are any customer(s) of the Broker for whom Carrier transported goods by motor carrier pursuant to this Agreement within the last two (2) years of this Agreement.

11. Carrier acknowledges that Carrier will or may acquire information and/or materials from or

related to Broker and its customers (including but not limited to customer contact information, customer shipping or other logistics needs, amounts received by Broker for brokerage services, freight charges on customer loads, as well as other information concerning Broker and Broker’s customer(s) not generally available through public information sources. Carrier agrees that all such knowledge, information and Initials: Carrier: _________


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materials (collectively “Confidential Information”) are and will be the trade secrets and confidential and proprietary information of Broker. Carrier will hold such Confidential Information in strict confidence, and will not disclose it to others or use it in any way unless specifically authorized in writing by Broker. Carrier’s obligations regarding Confidential Information and trade secrets as set forth herein shall apply during the term of this Agreement and will survive any termination of this Agreement (for any reason - with or without cause) for a period of two (2) years from the date of termination.

12. (A) This Agreement will be governed by the laws of the State of Georgia. The parties

irrevocably stipulate and agree that any lawsuit pertaining to this Agreement and/or the subject matter hereof shall only be filed in the Superior Court or State Court or Magistrate Court of Floyd County, Georgia. In the event any lawsuit is filed, each party hereto hereby submits itself/himself/herself to the personal jurisdiction of such Court(s) and acknowledges that venue is appropriate in such Court(s) and that such Court(s) shall have exclusive subject matter and personal jurisdiction regarding any claims relating to this Agreement and/or the subject matter hereof. (B) Except as to Broker’s customer(s), who may elect to be a third party beneficiary of this Agreement, the parties do not intend that the general public or any other person be a third party beneficiary or an intended beneficiary of any of the provisions of this Agreement. The duties and obligations of the parties as provided herein are specifically intended to create duties and obligations only as between the parties hereto and do not create duties, obligations, or standards of conduct or care owed to any other person or entity.

(C) If any provision of this Agreement becomes or is found to be illegal or unenforceable for any reason, such clause or provision shall be severed from the remainder of the Agreement to allow the remainder of the Agreement to remain in full force and effect.

(D) The parties agree that copies of this Agreement, whether such copies are in the form of facsimiles, scanned documents, electronic signature via “click & sign”, or otherwise, shall be duplicate originals and shall be of the same legal force and effect as original documents.

(E) This Agreement and the rate Confirmation shall constitute the entire agreement between the parties and supersede any prior understandings or written or oral agreements between the parties and such shall not be amended, altered or changed except by a written agreement signed by the parties hereto or by reformation or modification by a Court of competent jurisdiction. The parties stipulate and agree that this Agreement shall not be construed more stringently against one party as opposed to another. Initials: Carrier: _________


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IN WITNESS WHEREOF this Agreement has been executed and shall become effective as of

the date shown above.

MR BEAR LOGISTICS INC. (Broker) _________________________________ (Carrier) _________________________________ _________________________________ Authorized Signature: Authorized Signature: _________________________________ _________________________________ Printed Name & Title: Printed Name & Title: _________________________________ _________________________________ Date: Date:


FEDERAL MOTOR CARRIER SAFETY ADMINISTRATIONACCEPTANCE REPORT

Run Date:

Run Time:

03/28/16

15:30

Data Sorce: Licensing & Insurance

li_acceptPage 1 of 2

USFIREUSER ID:

MC-960017

Docket

615986970

WEB92199

03/28/2016 15:30:20

UNITED STATES FIRE INSURANCE CO.

UNITED STATES FIRE INSURANCE CO. (05230-00)

TRANSMISSION NUMBER:

TRANSMITTED ON:

COMPANY NAME:

SUMITTED BY:

Form/Type Policy Number Effective Date

04/01/2016BMC-84/SURETY

Values in FMCSA Licensing & Insurance Database:

Legal Name: MR BEAR LOGISTICS INC

3873 SCHAEFER AVE STE B

CHINO CA US 91710

3873 SCHAEFER AVE STE B

CHINO CA US 91710-5459

Address:

91X Coverage(Type/Max/Underlying):

Action

ACCEPTED

Total: 1

Form W-9(Rev. December 2014)

Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the

requester. Do not

send to the IRS.

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See S

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.

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

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

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

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Sign Here

Signature of

U.S. person Date

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

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, including 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? on 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? on page 2 for further information.

Cat. No. 10231X Form W-9 (Rev. 12-2014)

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