vendor_application

8/7/2019 Vendor_Application

http://slidepdf.com/reader/full/vendorapplication 1/17

Fax all application documents to 215-486-3238 or email to [email protected]

ASSET MANAGEMENT SPECIALISTS, INC.220 Rittenhouse Circle

Bristol, PA 19007Office (866) 699-1734

**Please fax all application documents to:

215-486-3238

BUSINESS INFORMATION: (Please print legibly)

Business Name: Contact Person:

Business Address:

City:State:

Phone: Mobile Phone:

Fax Number:

Email:

Home Address:

City: State:

TAX IDENTIFICATION INFORMATION

Social Security Number:OrEmployer Identification Number:

Please ensure the following documents are included with your application documents.(Check each as they are included)

□ Tax Identification Certificate (W-9)□ Drivers License□ Social Security Card□ Certificate of Insurance (Work Comp required on Sole Proprietors)




INSURANCE INFORMATION:

Insurance Company:

Agent’s Name:

Insurance Address:

City: State & Zip Code:

POLICY LIMITS:

General Liability:

Errors and Omissions:

Workmans Comp

CAPABILITIES:(Please check all you have experience with)

□ Lock change □ Painting

□ Winterization □ Pool Maintenance

□ Lawn Maintenance □ Repairs

□ Trash Removal □ Construction

□ Housekeeping Services □ Snow Removal

□ Evictions □ Window Boarding

Other:

Discount Rate: __________

Applicable licenses or certificates:

REFERENCES:

COMPANY NAME CONTACT NAME PHONE NUMBER



Business Ownership Information

Business Name Contact Name

Business Address City

State Zip Code

Tax ID

Yes NO

2. Small Disadvantaged Business

Ownership:

1. Small Business

2e. If you answered yes to question 2d above, what is the full and exact name under which your business appears in thePRO-Net database?

1a. Has your business avoided any material change in its disadvantaged ownership and control since itscertification?

2a. Has your business been certified as a small disadvantaged business consistent with the requirements of 13 C.F.R.124, Subpart B?

2b. Has your business avoided any material change in its disadvantaged ownership and control since its certification?

2c. If your business is owned by one or more disadvantaged individuals, is the net worth of each individual upon whomthe certification is based $750,000 or less, after taking into account the exclusions at 13 C.F.R. 124.104(c)(2)?

2d. Is your business currently identified as a certified small disadvantaged business in the PRO-Net databasemaintained by the SBA athttp://www.pronet.sba.gov/?HTOWASP_CSRFTKN=4lBsssjOZvzktQs32s4HclOxGtSGdRC8siT72WCigu8s?

3. Veteran Owned Business

National Certification Exp. Date Certification Number Other Certification Exp. Date Certification Number

Veteran-Owned Business

3a. Is your company at least 51 percent owned, managed and controlled by a veteran(s)? The definition of "veteran" isprovided in 38 U.S.C 101(2).

4a. Is your company at least 51 percent or more owned, operated and controlled by a service-disabled veteran? Service-disabled veteran means a veteran, as defined in 38 U.S.C. 101(2), with a disability that is service-connected, as definedin 38 U.S.C. 101(16).

2f. Is your business a current participant in the Small Business Administration (SBA) 8(a) program?

4b. Has your company been certified as a Disabled Veteran Business Enterprise (DVE) by a certifying organization(s)?

4c. Provide the name of the certifying organization, certification Number and expiration date of the certification for eachDVE certification your company has obtained.



5. HUBZone Qualified Business

6. Woman-Owned Business Enterprise (WBE)

National Certification Exp. Date Certification Number Regional Certification Exp. Date Certification Number

State Certification Exp. Date Certification Number Local Certification Exp. Date Certification Number Other Certification Exp. Date Certification Number

7. Minority-Owned Business Enterprise (MBE)

African American Woman Owned Minority Woman Owned Asian Pacific Island American

Native American/Alaskan Subcontinent Asian American Asian Indian American Other

Hispanic American

7a. Is your company at least 51 percent owned, managed and controlled by a member(s) of a minority group of U.S.Citizenship?

5a. Is your business currently on the List of Qualified HUBZone Small Business concerns maintained by the SmallBusiness Administration at eweb1.sba.gov/hubzone/internet?

6a. Is your company at least 51 percent owned, managed and controlled by one or more women of U.S. Citizenship?

6b. Has your company been certified as a woman-owned enterprise (WBE) by one or more certifying organization(s)?

6c. Provide the name of the certifying organization, certification number and the expiration date of the certification foreach WBE certification your company has obtained:

National Certification Exp. Date Certification Number Regional Certification Exp. Date Certification Number

State Certification Exp. Date Certification Number Local Certification Exp. Date Certification Number Other Certification Exp. Date Certification Number

8. Disabled Business Enterprise (DBE)

9. US Citizen? Yes NO

7b. Has your company been certified as a Minority-Owned Business Enterprise (MBE) by any certifying organization(s)?

7c. Provide the name of the certifying organization, the certification number and the expiration date for each MBEcertification you company has obtained:

8b. Have you provided an affidavit and supporting documentation to be considered eligible for this designation?

8a. Is your company at least 51percent of more owned, operated and controlled by a person with a permanent physicalor mental impairment that substantially limits one or more of the major life activities and which has a significant impacton the company's ability to compete?




Asset Management Specialists, IncSubcontractor Agreement

This AGREEMENT for Services is made effective as of by and between ASSETMANAGEMENT SPECIALISTS, INC (AMS)of 2021 HARTEL STREET, LEVITTOWN,PA 19057andof

. In this AGREEMENT, the party who is contracting to receive services will be referred to as “AMS”, andthe party who will be providing the services will be referred to as “CONTRACTOR.”

1. DESCRIPTION OF SERVICES.Beginning on effective date above, CONTRACTOR will provide to AMS theservices described in the attached Exhibit (collectively, the “Scope of Work”).

2. COMPLETION DATE.All “Scope of Work” shall be completed and documented no later than 48 hours of the completion date on assigned service order (work order).

3. PAYMENT FOR SERVICES. In exchange for the Services AMS will pay CONTRACTOR according to the

following schedule :

a. NET 45 DAYS from last day of date of acceptance (Note: acceptance must occur prior topayment and the invoice should be mailed on the date it is submitted). The billing cycle isdefined by a period beginning the first day to the last day of the month in which contractedservices are completed. Payment will only be issued only upon completion of assigned work, andservices which have been deemed acceptable by AMS. All work order additions and or omissionsmust be approved by AMS. CONTRACTOR will accept all financial responsibility for any servicescompleted by CONTRACTOR that is not covered in this agreement or that is not approved by AMSManagement.

b. NET 15 DAYS (Prompt Payment) from last day of billing cycle. The billing cycle is defined by aperiod beginning the first day to the last day of the month in which contracted services arecompleted. When a discount for prompt payment is to be taken, payment will be made as closeas possible to, but not later than, the end of the discount period. Discounts for Prompt Paymentare as approved by AMS. Example, a discount of 4% - 20 days offered on a $10,000 invoice should result in a payment of $9,600 within 20 days after the date of the invoice . The discount forprompt payment procedure should help in at least two ways. (1) The due date would becomputed from the date of the invoice rather than the date of acceptance , and (2) the "discountfor Prompt Payment" offer would overcome the requirement at that AMS shall not make invoicepayments earlier than 7 days prior to the due date specified on the invoice. The offer for adiscount for prompt payment should appear prominently on the invoice (perhaps underlined). Itmay be helpful to discuss this with the designated paying office in order to get theirrecommended format. It is not the intent of AMS to encourage or discourage use of thediscount for prompt payment procedure. Payment will only be issued only upon completion of

assigned work, and services which have been deemed acceptable by AMS. All work orderadditions and or omissions must be approved by AMS Management. CONTRACTOR will accept allfinancial responsibility for any services completed by CONTRACTOR that is not covered in thisagreement or that is not approved by AMS.

4. PURCHASE ORDER \ INVOICE.All payments made to CONTRACTOR in reference to this agreement will betracked by AMS Invoice number unless agreed to prior to completion of work.

5. PERFORMANCE. CONTRACTOR is required to meet all reasonable completion schedules set forth by AMStherefore CONTRACTOR agrees to, supply as many workers as needed, or work as many hours as needed,to meet these completion schedules as well. Performance includes but is not limited to quality of services




confidential. This provision will continue to be effective after the termination of this Contract. Upontermination of this Contract, CONTRACTOR will return to AMS all records, notes, documentation andother items that were used, created, or controlled by CONTRACTOR during the term of this Contract.CONTRACTOR may use non-public information obtained solely for the purpose of achieving the goals of the “scope of work”. This use includes communication to the issuer and the exchange of informationbetween contracting authorities, unless the providing Authority expressly objects to this communication.

CONTRACTOR must obtain the prior consent of the providing authority before disclosing non-publicinformation received. If consent is not obtained from the Providing Authority, the parties will consult todiscuss the reasons for withholding approval of such use and the circumstances, if any, under which theintended use by the receiver might be allowed.

Except for disclosures in accordance with this protocol, each Authority intends to keep confidential non-public communications information received. Under this protocol the content of such communications,and any other non-public matters arising under the “scope of work”, including consultations between oramong the Contracting authorities:

i. In the event that non-public information furnished pursuant to this protocol includesdeliberative and consultative materials, the parties intend that such disclosure will not

constitute a waiver of privilege or confidentiality of such information.

ii. In the event of termination of cooperation between Asset Management Specialists, Incand the contracting authorities the work plan, information obtained under this protocolwill continue to be treated in the manner prescribed.

15. INDEMNIFICATION. CONTRACTOR agrees to indemnify and hold AMS harmless from all claims, losses,expenses, fees including attorney fees, costs, and judgments that may be asserted against AMS that resultfrom the acts or omissions of CONTRACTOR and/or CONTRACTOR’s employees, agents, orrepresentatives.

16. HEALTH AND SAFETY.CONTRACTOR shall be responsible to the Contractor for compliance with all healthand safety rules and regulations. CONTRACTOR shall defend, indemnify and save harmless the Contractorfrom any and all expense incurred by the Contractor for fines, penalties and corrective measures thatresult from acts of commission or omission by the CONTRACTOR, his agents, employees, and assigns infailure to comply with such health and safety rules and regulations.

17. WARRANTY. CONTRACTOR shall provide its services and meet its obligations under this AGREEMENT in atimely and workmanlike manner, using knowledge and recommendations for performing the serviceswhich meet generally acceptable standards in CONTRACTOR’s community and region, and will provide astandard of care equal to, or superior to, care used by service providers similar to CONTRACTOR on similarprojects.

18. GUARANTEE.CONTRACTOR shall repair at its own expense and at the convenience of Owner any defectsin workmanship or materials within two (2) years from the date of acceptance of the Work. CONTRACTOR shall pay for all damage to the building resulting from defects in the Work and all expenses necessary to remove, replace and/or repair Work and any work which may be damaged in removing or repairing Work.

19. PERMITS AND REGULATIONS.CONTRACTOR shall obtain and pay for all necessary permits, fees andlicenses pertaining to Work and agrees to comply with all Federal, State and local laws, ordinances,building codes, rules and regulations, including the Board of Fire Underwriters, without additional chargeor expense to Contractor. CONTRACTOR shall indemnify and defend Contractor from all loss, expense,damage or injury resulting directly or indirectly from CONTRACTOR’s noncompliance.




20. SECURITY AND CLEAN-UP.CONTRACTOR shall effectively secure and protect its Work and shall bearand be liable for all lesser damage of any kind which may occur to Work at any time prior to finalcompletion and acceptance by Owner. CONTRACTOR shall, as required by AMS, clean all of his materialsand remove from the site all dirt, debris and rubbish caused by CONTRACTOR in the execution of theWork.

21. CONDUCT AND APPEARANCE.CONTRACTOR, and all its employees, agents, or representatives shallconduct themselves in a professional manner at all times while representing AMS and AMS Clients.Appearances by CONTRACTOR’s workers shall meet the guidelines set forth by AMS. (i.e. No worn attirewith offensive language or symbols).

22. INJURIES. CONTRACTOR acknowledges CONTRACTOR's obligation to obtain appropriate insurancecoverage for the benefit of CONTRACTOR (and CONTRACTOR’s employees, if any). CONTRACTOR waivesany rights to recovery from AMS for any injuries that CONTRACTOR (and/ CONTRACTOR’S employees)may sustain while performing services under this Agreement and that are a result of the negligence of CONTRACTOR or CONTRACTOR‘s employees.

23. INSURANCE REQUIREMENTS.Upon signing the agreement to provide services for AMS, theCONTRACTOR must provide documentation of insurance which shall be obtained andmaintained during the period of performance of all services.

Insurance Coverage Insurance Limit(s)

(i) General Liability Insurance, or comparablecoverage, to include Contractual Liability . AMS will be named as an additional insured.

Occurrence Limit $1,000,000

General Aggregate $1,000,000

(ii) Automobile Liability limits Combined Single Limit $1,000,000

(iii) Workers’ Compensation and EmployersLiability

StatutoryRequirements

Proof of insurance coverage, in the form of a certificate of insurance, must be provided to AMS with the

signed Subcontractor Service Agreement . Under no circumstances should work start on a project prior toAMS receiving the certificate of insurance.

Additionally, the following conditions apply:

a. Failure to provide documentation of Workers’ Compensation and Employers’ Liability insurancewill result in your payment for any work being reduced by 1%. This is necessary because AMS’sWorkers’ Compensation carrier will charge a premium for any subcontractor who has notprovided proof of having their own Workers’ Compensation coverage.

b. If the CONTRACTOR provides professional services, such as, but not limited to, electrical work,plumbing, or roofing, then proof of Professional Liability insurance with a limit of $1,000,000must be included on the certificate of insurance.

c. AMS will not pay for a subcontractor to purchase or maintain the required insurance.d. The Certificate Holder on the certificate of insurance should be listed as follows: Asset

Management Specialist, Inc, 2021 Hartel Street, Levittown, PA 19057




e. If your insurance policies expire during the period of performance on a project, a certificate of insurance for your renewed coverage will be required.

24. REMEDIES. In addition to any and all other rights a party may have available according to law, if a partydefaults by failing to substantially perform any provision, term or condition of this AGREEMENT (includingwithout limitation the failure to make a monetary payment when due), the other party may terminate theAGREEMENT by providing written notice to the defaulting party. This notice shall describe with sufficientdetail the nature of the default.

f. The party receiving such notice shall have 10 working days from the effective date of such noticeto cure the default(s). Unless waived by a party providing notice, the failure to cure thedefault(s) within such time period shall result in the automatic termination of this Contract.

g. Dispute \ Audit Process. A Dispute shall be defined as an event where the validity of thetransaction itself is in question specific to whether the transaction actually occurred or was theresult of a assignment by a valid AMS representative.

i. CONTRACTOR disputes shall be initiated by contacting AMS billing contact inwriting through electronic or mail submission designated for accountquestions.

ii. AMS Disputes reasons shall include but not limited to – suspected duplicatetransactions, suspected fraud, a request to validate signature on assignedservices, improper adherence to AMS policy and procedure, lack of supportingdocumentation for completed services or questionable transaction activity.

iii. A CONTRACTOR dispute shall only be accepted by AMS when initiated by theAMS billing contact on record or contact on record within the same hierarchy.A CONTRACTOR dispute must be received within ten (10) days of the receipt of AMS billing contact’s disputes designated for account questions.

iv. When proactively researching potential AMS dispute issues, CONTRACTOR mayissue a request to AMS, which shall be subject to the same process forresolution as a dispute initiated by an AMS billing contact.

v. If the CONTRACTOR is unable to provide a written response within the ten (10)day window, the Transaction shall be considered invalid and a systematicchargeback to the CONTRACTOR will occur.

vi. If the CONTRACTOR is able to supply sufficient proof of completed services nolater than the expiration of the ten (10) day window, the chargeback will bereversed and the disputed amount will be reapplied to the account.

vii. In the event the dispute is found in AMS’s favor, the disputed transaction shallbe permanently removed from the account as an amount due.

viii. AMS Billing Contact / Accounting Department will clear dispute liabilities inaccordance with the timeframes, which is normally shall not exceed ninety (90)days from the central processing date. However, the allowable time to clear adispute may vary slightly by type of dispute. Any account’s unpaid amount notreconciled against an open valid dispute shall be considered past due andsubject to Suspension at ninety ( 90) days past due.

25. ENTIRE AGREEMENT. This AGREEMENT contains the entire agreement of the parties, and there are noother promises or conditions in any other agreement whether oral or written concerning the subjectmatter of this AGREEMENT. This AGREEMENT supersedes any prior written or oral agreements betweenthe parties.

26. SEVERABILITY.If any provision of this AGREEMENT will be held to be invalid or unenforceable for anyreason, the remaining provisions will continue to be valid and enforceable. If a court finds that anyprovision of this AGREEMENT is invalid or unenforceable, but that by limiting such provision it wouldbecome valid and enforceable, then such provision will be deemed to be written, construed, and enforcedas so limited.




27. AMENDMENT. This AGREEMENT may be modified or amended in writing, if the writing is signed by theparty obligated under the amendment.

28. GOVERNING LAW. This AGREEMENT shall be construed in accordance with the laws of the State of Pennsylvania.

29. NOTICE. Any notice or communication required or permitted under this AGREEMENT shall be sufficiently

given if delivered in person or by certified mail, return receipt requested, to the address set forth in theopening paragraph or to such other address as one party may have furnished to the other in writing.

30. ASSIGNMENT. Neither party may assign or transfer this AGREEMENT without the prior written consent of the non-assigning party, which approval shall not be unreasonably withheld.

Service Provider: CONTRACTOR

By: ________________________________________ Date:____________

Authorized Representative (SIGN)

________________________________________

Authorized Representative (PRINT)

________________________________________

CONTRACTOR “company name” (PRINT)




220 Rittenhouse CircleBristol, PA 19007

Phone 866.699.1734Fax 215.486.3238

Prompt Payment

To request Net 15 payment terms as outlined on Page 1 of the Subcontractor Agreement, please submitthis form with your application documents.

If your application is submitted without this page, by default, your elected payment terms will be Net 45days as outlined on Page 1 of the Subcontractor Agreement.

I, (name)_______________________ ________of (company)__________________________________request expedited payment (Net 15 days) . I understand that electing this payment option discounts my

invoice by 4%.

Authorized Representative (Sign) Date:

Authorized Representative (Print)




SUB CONTRACTOR QUESTIONNAIRE

Business Name: Contact Person:

Address:

City:State:

Phone: Mobile Phone:

Fax Number:

Email:

1. Are you willing to work nights and/or weekends?

2. What COUNTIES can you operate in on a regular basis?

3. What type of services does your business provide (ie. Home cleanouts, lawnmaintenance, home repairs, home cleaning, etc.)

4. How many employees work for your company?

Number of field employees: Number of office staff:

5. Do you complete all of your work in-house or do you sub-out as well? If you sub-out,what percentage of work do you sub-out?

6. How many years of experience do you have in the home business?

7. What are some major clients you have worked for in the past?

8. How many crews of workers do you have at your disposal?




9. What type of trucks do these crews have to use (ie. Lawn care pick-up, debris removal dumptruck)?

10. Do you have experience with using computers (email, internet, uploading digital photos)?

11. Is your company capable of the following? (Check boxes)

□ Pressure test plumbing system□ Trim Bushes□ Have a contact for vehicle removal□ Board windows□ Re-glaze broken windows□ Install earthquake stripping

(California only)□ Regular email communication

12. Please list the type, size, and make of the following equipment your company uses.

EdgerWeed whacker

15 cyd dump truck or trailerCell phones on trucks

Commerical lawn mowersGenerators

Compressors

13. How many lawns/inspections can your company do PER DAY? __________14. How many cleanouts/trashouts can your company do PER DAY? __________

15. Are there any specialized skill sets within your company?

16. Does your company have workmans comp and general liability insurance for 1 million?



Give form to therequester. Do notsend to the IRS.

Form W-9 Request for TaxpayerIdentification Number and Certification

(Rev. October 2007)Department of the TreasuryInternal Revenue Service Name (as shown on your income tax return)

List account number(s) here (optional)

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

City, state, and ZIP code

P r i n

t o r

t y

p e

S e e

S p e c

i f i c I n s

t r u c t i o n s o n p a g e

2 .

Taxpayer Identification Number (TIN)

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

Social security number

or

Requester’s name and address (optional)

Employer identification numberNote. If the account is in more than one name, see the chart on page 4 for guidelines on whosenumber to enter. Certification

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 I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the InternalRevenue 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 hasnotified me that I am no longer subject to backup withholding, and

2.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backupwithholding 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 retirementarrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you mustprovide your correct TIN. See the instructions on page 4. SignHere

Signature ofU.S. person

Date

General Instructions

Form W-9 (Rev. 10-2007)

Part I

Part II

Business name, if different from above

Cat. No. 10231X

Check appropriate box:

Under penalties of perjury, I certify that:

Use Form W-9 only if you are a U.S. person (including aresident alien), to provide your correct TIN to the personrequesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you arewaiting 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 aU.S. person, your allocable share of any partnership income froma U.S. trade or business is not subject to the withholding tax onforeign partners’ share of effectively connected income.

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

A person who is required to file an information return with theIRS must obtain your correct taxpayer identification number (TIN)to report, for example, income paid to you, real estatetransactions, mortgage interest you paid, acquisition orabandonment of secured property, cancellation of debt, orcontributions you made to an IRA.

Individual/Sole proprietor

Corporation

Partnership

Other (see instructions)

Note. If a requester gives you a form other than Form W-9 torequest your TIN, you must use the requester’s form if it issubstantially similar to this Form W-9.

● 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 UnitedStates, ● An estate (other than a foreign estate), or

Definition of a U.S. person. For federal tax purposes, you areconsidered a U.S. person if you are:

Special rules for partnerships. Partnerships that conduct atrade or business in the United States are generally required topay a withholding tax on any foreign partners’ share of incomefrom such business. Further, in certain cases where a Form W-9has not been received, a partnership is required to presume thata partner is a foreign person, and pay the withholding tax.Therefore, if you are a U.S. person that is a partner in apartnership conducting a trade or business in the United States,provide Form W-9 to the partnership to establish your U.S.status and avoid withholding on your share of partnershipincome. The person who gives Form W-9 to the partnership forpurposes of establishing its U.S. status and avoiding withholdingon its allocable share of net income from the partnershipconducting a trade or business in the United States is in thefollowing cases: ● The U.S. owner of a disregarded entity and not the entity,

Section references are to the Internal Revenue Code unlessotherwise noted.

● A domestic trust (as defined in Regulations section301.7701-7).

Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership)Exemptpayee

Purpose of Form



Form W-9 (Rev. 10-2007) Page 2

Sole proprietor. Enter your individual name as shown on yourincome tax return on the “Name” line. You may enter yourbusiness, trade, or “doing business as (DBA)” name on the“Business name” line.

Other entities. Enter your business name as shown on requiredfederal tax documents on the “Name” line. This name shouldmatch the name shown on the charter or other legal documentcreating the entity. You may enter any business, trade, or DBAname on the “Business name” line.

If the account is in joint names, list first, and then circle, thename of the person or entity whose number you entered in Part Iof the form.

Specific Instructions Name

Exempt Payee

5. You do not certify to the requester that you are not subjectto backup withholding under 4 above (for reportable interest anddividend accounts opened after 1983 only). Certain payees and payments are exempt from backupwithholding. See the instructions below and the separateInstructions for the Requester of Form W-9.

Civil penalty for false information with respect towithholding. If you make a false statement with no reasonablebasis that results in no backup withholding, you are subject to a$500 penalty. Criminal penalty for falsifying information. Willfully falsifyingcertifications or affirmations may subject you to criminalpenalties including fines and/or imprisonment.

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

Misuse of TINs. If the requester discloses or uses TINs inviolation of federal law, the requester may be subject to civil andcriminal penalties.

If you are an individual, you must generally enter the nameshown on your income tax return. However, if you have changedyour last name, for instance, due to marriage without informingthe Social Security Administration of the name change, enteryour first name, the last name shown on your social securitycard, and your new last name.

If you are exempt from backup withholding, enter your name asdescribed above and check the appropriate box for your status,then check the “Exempt payee” box in the line following thebusiness name, sign and date the form.

4. The IRS tells you that you are subject to backupwithholding because you did not report all your interest anddividends on your tax return (for reportable interest anddividends only), or

3. The IRS tells the requester that you furnished an incorrectTIN,

2. You do not certify your TIN when required (see the Part IIinstructions on page 3 for details),

You will not be subject to backup withholding on paymentsyou receive if you give the requester your correct TIN, make theproper certifications, and report all your taxable interest anddividends on your tax return.

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

What is backup withholding? Persons making certain paymentsto you must under certain conditions withhold and pay to theIRS 28% of such payments. This is called “backup withholding.”Payments that may be subject to backup withholding includeinterest, tax-exempt interest, dividends, broker and barterexchange transactions, rents, royalties, nonemployee pay, andcertain payments from fishing boat operators. Real estatetransactions are not subject to backup withholding.

Payments you receive will be subject to backupwithholding if:

If you are a nonresident alien or a foreign entity not subject tobackup withholding, give the requester the appropriatecompleted Form W-8.

Example. Article 20 of the U.S.-China income tax treaty allowsan exemption from tax for scholarship income received by aChinese student temporarily present in the United States. UnderU.S. law, this student will become a resident alien for taxpurposes if his or her stay in the United States exceeds 5calendar years. However, paragraph 2 of the first Protocol to theU.S.-China treaty (dated April 30, 1984) allows the provisions of

Article 20 to continue to apply even after the Chinese studentbecomes a resident alien of the United States. A Chinesestudent who qualifies for this exception (under paragraph 2 ofthe first protocol) and is relying on this exception to claim anexemption from tax on his or her scholarship or fellowshipincome would attach to Form W-9 a statement that includes theinformation described above to support that exemption.

Note. You are requested to check the appropriate box for yourstatus (individual/sole proprietor, corporation, etc.).

4. The type and amount of income that qualifies for theexemption from tax. 5. Sufficient facts to justify the exemption from tax under theterms of the treaty article.

Nonresident alien who becomes a resident alien. Generally,only a nonresident alien individual may use the terms of a taxtreaty 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 maypermit an exemption from tax to continue for certain types ofincome 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 exceptioncontained in the saving clause of a tax treaty to claim anexemption from U.S. tax on certain types of income, you mustattach a statement to Form W-9 that specifies the following fiveitems: 1. The treaty country. Generally, this must be the same treatyunder which you claimed exemption from tax as a nonresidentalien. 2. The treaty article addressing the income.

3. The article number (or location) in the tax treaty thatcontains the saving clause and its exceptions.

Also see Special rules for partnerships on page 1.

Foreign person. If you are a foreign person, do not use FormW-9. Instead, use the appropriate Form W-8 (see Publication515, Withholding of Tax on Nonresident Aliens and ForeignEntities).

● The U.S. grantor or other owner of a grantor trust and not thetrust, and ● The U.S. trust (other than a grantor trust) and not thebeneficiaries of the trust.

Limited liability company (LLC). Check the “Limited liabilitycompany” box only and enter the appropriate code for the taxclassification (“D” for disregarded entity, “C” for corporation, “P”for partnership) in the space provided. For a single-member LLC (including a foreign LLC with adomestic owner) that is disregarded as an entity separate fromits owner under Regulations section 301.7701-3, enter theowner’s name on the “Name” line. Enter the LLC’s name on the“Business name” line. For an LLC classified as a partnership or a corporation, enterthe LLC’s name on the “Name” line and any business, trade, orDBA name on the “Business name” line.




Part I. Taxpayer IdentificationNumber (TIN) Enter your TIN in the appropriate box. If you are a residentalien 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 nothave an ITIN, see How to get a TIN below.

How to get a TIN. If you do not have a TIN, apply for oneimmediately. To apply for an SSN, get Form SS-5, Applicationfor a Social Security Card, from your local Social Security

Administration office or get this form online at www.ssa.gov . Youmay also get this form by calling 1-800-772-1213. Use FormW-7, Application for IRS Individual Taxpayer IdentificationNumber, to apply for an ITIN, or Form SS-4, Application forEmployer Identification Number, to apply for an EIN. You canapply for an EIN online by accessing the IRS website atwww.irs.gov/businesses and clicking on Employer IdentificationNumber (EIN) under Starting a Business. You can get Forms W-7and SS-4 from the IRS by visiting www.irs.gov or by calling1-800-TAX-FORM (1-800-829-3676). If you are asked to complete Form W-9 but do not have a TIN,write “Applied For” in the space for the TIN, sign and date theform, and give it to the requester. For interest and dividendpayments, and certain payments made with respect to readilytradable instruments, generally you will have 60 days to get aTIN and give it to the requester before you are subject to backupwithholding on payments. The 60-day rule does not apply toother types of payments. You will be subject to backupwithholding on all such payments until you provide your TIN tothe requester.

If you are a sole proprietor and you have an EIN, you mayenter either your SSN or EIN. However, the IRS prefers that youuse your SSN. If you are a single-member LLC that is disregarded as anentity separate from its owner (see Limited liability company (LLC) on page 2), enter the owner’s SSN (or EIN, if the ownerhas one). Do not enter the disregarded entity’s EIN. If the LLC isclassified as a corporation or partnership, enter the entity’s EIN. Note. See the chart on page 4 for further clarification of nameand TIN combinations.

Note. Entering “Applied For” means that you have alreadyapplied for a TIN or that you intend to apply for one soon. Caution: A disregarded domestic entity that has a foreign owner

must use the appropriate Form W-8.

9. A futures commission merchant registered with theCommodity Futures Trading Commission, 10. A real estate investment trust,

11. An entity registered at all times during the tax year underthe Investment Company Act of 1940, 12. A common trust fund operated by a bank under section584(a), 13. A financial institution,

14. A middleman known in the investment community as anominee or custodian, or 15. A trust exempt from tax under section 664 or described insection 4947.

THEN the payment is exemptfor . . .

IF the payment is for . . .

All exempt payees exceptfor 9

Interest and dividend payments

Exempt payees 1 through 13. Also, a person registered underthe Investment Advisers Act of1940 who regularly acts as abroker

Broker transactions

Exempt payees 1 through 5

Barter exchange transactionsand patronage dividends

Generally, exempt payees1 through 7

Payments over $600 requiredto be reported and directsales over $5,000 See Form 1099-MISC, Miscellaneous Income, and its instructions. However, the following payments made to a corporation (including grossproceeds paid to an attorney under section 6045(f), even if the attorney is acorporation) and reportable on Form 1099-MISC are not exempt frombackup withholding: medical and health care payments, attorneys’ fees, andpayments for services paid by a federal executive agency.

The chart below shows types of payments that may beexempt from backup withholding. The chart applies to theexempt payees listed above, 1 through 15.

1 2

7. A foreign central bank of issue, 8. A dealer in securities or commodities required to register in

the United States, the District of Columbia, or a possession ofthe United States,

2

The following payees are exempt from backup withholding: 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 orinstrumentalities, 3. A state, the District of Columbia, a possession of the UnitedStates, or any of their political subdivisions or instrumentalities, 4. A foreign government or any of its political subdivisions,agencies, or instrumentalities, or 5. An international organization or any of its agencies orinstrumentalities. Other payees that may be exempt from backup withholdinginclude: 6. A corporation,

Generally, individuals (including sole proprietors) are not exemptfrom backup withholding. Corporations are exempt from backupwithholding for certain payments, such as interest and dividends. Note. If you are exempt from backup withholding, you shouldstill complete this form to avoid possible erroneous backupwithholding.

1

1. Interest, dividend, and barter exchange accountsopened before 1984 and broker accounts considered activeduring 1983. You must give your correct TIN, but you do nothave to sign the certification. 2. Interest, dividend, broker, and barter exchangeaccounts opened after 1983 and broker accounts consideredinactive during 1983. You must sign the certification or backupwithholding will apply. If you are subject to backup withholdingand you are merely providing your correct TIN to the requester,you must cross out item 2 in the certification before signing theform.

Part II. Certification

For a joint account, only the person whose TIN is shown inPart I should sign (when required). Exempt payees, see ExemptPayee on page 2.

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 signby the withholding agent even if items 1, 4, and 5 below indicateotherwise.

Signature requirements. Complete the certification as indicatedin 1 through 5 below.




Give name and EIN of:

For this type of account:

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

A valid trust, estate, or pension trust

6.

Legal entity4

4. Other payments. You must give your correct TIN, but youdo not have to sign the certification unless you have beennotified that you have previously given an incorrect TIN. “Otherpayments” include payments made in the course of therequester’s trade or business for rents, royalties, goods (otherthan bills for merchandise), medical and health care services(including payments to corporations), payments to anonemployee for services, payments to certain fishing boat crewmembers and fishermen, and gross proceeds paid to attorneys(including payments to corporations).

The corporation

Corporate or LLC electingcorporate status on Form 8832

7.

The organization

Association, club, religious,charitable, educational, or othertax-exempt organization

8.

5. Mortgage interest paid by you, acquisition orabandonment of secured property, cancellation of debt,qualified tuition program payments (under section 529), IRA,Coverdell ESA, Archer MSA or HSA contributions ordistributions, and pension distributions. You must give yourcorrect TIN, but you do not have to sign the certification.

The partnership

Partnership or multi-member LLC

9.

The broker or nominee

A broker or registered nominee

10.

The public entity

Account with the Department of Agriculture in the name of a publicentity (such as a state or localgovernment, school district, orprison) that receives agriculturalprogram payments

11.

Privacy Act Notice

List first and circle the name of the person whose number you furnish. If only one personon a joint account has an SSN, that person’s number must be furnished. Circle the minor’s name and furnish the minor’s SSN. You must show your individual name and you may also enter your business or “DBA”name on the second 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 TINof the personal representative or trustee unless the legal entity itself is not designated inthe account title.) Also see Special rules for partnerships on page 1.

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.

Disregarded entity not owned by anindividual

The owner

12.

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

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest,dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, orcontributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return.The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federalnontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

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2 3

4

Secure Your Tax Records from Identity Theft Identity theft occurs when someone uses your personalinformation such as your name, social security number (SSN), orother identifying information, without your permission, to commitfraud or other crimes. An identity thief may use your SSN to geta job or may file a tax return using your SSN to receive a refund.

What Name and Number To Give the Requester Give name and SSN of:

For this type of account:

The individual

1.

Individual The actual owner of the account or,

if combined funds, the firstindividual on the account

2.

Two or more individuals (jointaccount)

The minor2

3.

Custodian account of a minor(Uniform Gift to Minors Act) The grantor-trustee

1

4.

a. The usual revocable savingstrust (grantor is also trustee) The actual owner

1

b. So-called trust account that isnot a legal or valid trust understate law The owner

3

5.

Sole proprietorship or disregardedentity owned by an individual

Call the IRS at 1-800-829-1040 if you think your identity hasbeen used inappropriately for tax purposes.

1

To reduce your risk: ● Protect your SSN, ● Ensure your employer is protecting your SSN, and ● Be careful when choosing a tax preparer.

Victims of identity theft who are experiencing economic harmor a system problem, or are seeking help in resolving taxproblems 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 lineat 1-877-777-4778 or TTY/TDD 1-800-829-4059. Protect yourself from suspicious emails or phishingschemes. Phishing is the creation and use of email andwebsites designed to mimic legitimate business emails andwebsites. The most common act is sending an email to a userfalsely claiming to be an established legitimate enterprise in anattempt to scam the user into surrendering private information

that will be used for identity theft. The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed informationthrough email or ask taxpayers for the PIN numbers, passwords,or similar secret access information for their credit card, bank, orother financial accounts. If you receive an unsolicited email claiming to be from the IRS,forward this message to [email protected]. You may also reportmisuse of the IRS name, logo, or other IRS personal property tothe Treasury Inspector General for Tax Administration at1-800-366-4484. You can forward suspicious emails to theFederal Trade Commission at: [email protected] or contact them atwww.consumer.gov/idtheft or 1-877-IDTHEFT(438-4338).

Visit the IRS website at www.irs.gov to learn more aboutidentity theft and how to reduce your risk.

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