046-20 - Summit Law Group - ContractCITY OF PORT ORCHARD
CONTRACT FOR PROFESSIONAL SERVICES
Contract No. 046-20
This Agreement is entered into by and between the City of Port Orchard, a Washington municipal
corporation ("City"), and Summit Law Group ("Consultant") whose principal office is located at 315
5th Ave. South, Suite 1000, Seattle, Washington 98104.
WHEREAS, the City has determined the need to have certain services performed for the residents
of the City of Port Orchard, requiring specific expertise, and
WHEREAS, the City desires to have the Consultant perform such services pursuant to certain
terms and conditions,
NOW THEREFORE, in consideration of the mutual benefits and conditions hereinafter
contained, the parties hereto agree as follows:
1. Scope and Schedule of Services to be Performed by Consultant. The Consultant shall
perform those services described in Exhibit "A" of this Agreement. In performing such services, the
Consultant shall at all times comply with all Federal, State, and local laws and regulations applicable to
the performance of such services. The Consultant shall perform the services diligently and completely
and in accordance with professional standards of conduct and performance. The Consultant shall request
and obtain prior written approval from the City if the scope or schedule is to be modified in any way.
2. Compensation and Method of Payment. The Consultant shall request payment for work
performed
The City shall pay Consultant [Check applicable method of payment]:
X According to the rates set forth in Exhibit "A." Rates may be adjusted on an annual
basis by written agreement of the parties as an addendum to this Agreement.
The Consultant shall complete and return to the City Exhibit "B," federal tax Form W-9, prior
to or along with the first billing invoice. The City shall pay the Consultant for services rendered within
ten (10) days after City Council voucher approval.
3. Duration of Agreement. This Agreement shall commence upon mutual execution and
shall terminate on December 31, 2021 ("Termination Date'), unless terminated sooner by either Party as
provided herein, provided the City shall have the right to extend the Agreement beyond the Termination
Date for an additional two (2) years by written notice to the Consultant in advance of the Termination
Date. Time is of the essence of this agreement in each and all of its provisions in which performance is
required.
4. Ownership and Use of Documents. Any records, files, documents, drawings,
specifications, data or information, regardless of form or format, and all other materials produced by the
Consultant and submitted to the City in connection with the services provided to the City, shall be the
property of the City, whether the project for which they were created is executed or not.
5. Independent Consultant. The Consultant and the City agree that the Consultant is an
independent Consultant with respect to the services provided pursuant to this Agreement. The
Consultant will be solely responsible for its acts and for the acts of its agents, employees, subconsultants
or representatives during the performance of this Agreement. Nothing in this Agreement shall be
considered to create the relationship of employer and employee between the parties. Neither Consultant
nor any employee of Consultant shall be entitled to any benefits accorded City employees by virtue of
the services provided under this Agreement. The City shall not be responsible for withholding or
otherwise deducting federal income tax or social security or contributing to the State Industrial Insurance
Program, or otherwise assuming the duties of an employer with respect to the Consultant, or any
employee of the Consultant.
6. Indemnification.
A. Consultant shall protect, defend, indemnify and hold harmless the City, its officers,
officials, employees, agents and volunteers from any and all costs, claims, injuries, damages, suits, losses
or liabilities of any nature, including attorneys' fees, arising out of or in connection with the acts, errors
or omissions of the Consultant, its officers, employees and agents in performing this Agreement.
B. Should a court of competent jurisdiction determine that this Agreement is subject to
RCW 4.24.115, then, in the event of liability for damages arising out of bodily injury to persons or
damages to property caused by or resulting from the concurrent negligence of the Consultant and the
City, its officers, officials, employees, and volunteers, the Consultant's liability, including the duty and
cost to defend, hereunder shall be only to the extent of the Consultant's negligence. IT IS FURTHER
SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE INDEMNIFICATION
PROVIDED HEREIN CONSTITUTES THE CONSULTANT'S WAIVER OF IMMUNITY UNDER
INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OF THIS
INDEMNIFICATION. THIS WAIVER HAS BEEN MUTUALLY NEGOTIATED BY THE
PARTIES.
C. The provisions of this section shall survive the expiration or termination of this
Agreement.
7. Insurance. The Consultant shall procure and maintain for the duration of this Agreement,
insurance against claims for injuries to persons or damage to property which may arise from or in
connection with the performance of the work hereunder by the Consultant, its agents, representatives, or
employees.
A. Minimum Scope of Insurance. Consultant shall obtain insurance of the types
described below:
1. Automobile Liability insurance covering all owned, non -owned,
hired and leased vehicles. Coverage shall be written on Insurance Services Office
(ISO) form CA 00 01 or a substitute form providing equivalent liability
coverage. If necessary, the policy shall be endorsed to provide contractual
liability coverage.
2. Commercial General Liability insurance shall be written on ISO
occurrence form CG 00 01 and shall cover liability arising from premises,
-2-
operations, independent Consultants and personal injury and advertising
injury. The City shall be named as an additional insured under the Consultant's
Commercial General Liability insurance policy with respect to the work
performed for the City.
3. Workers' Compensation coverage as required by the Industrial
Insurance laws of the State of Washington.
4. Professional Liability insurance appropriate to the Consultant's
profession.
B. Minimum Amounts of Insurance. Consultant shall maintain the following
insurance limits:
1. Automobile Liability insurance with a minimum combined single
limit for bodily injury and property damage of $1,000,000 per accident.
2. Commercial General Liabili1y insurance shall be written with
limits no less than $1,000,000 each occurrence, $2,000,000 general aggregate.
3. Professional Liability insurance shall be written with limits no less
than $1,000,000 per claim and $1,000,000 policy aggregate limit.
C. Other Insurance Provision. The insurance policies are to contain, or be endorsed
to contain, the following provisions for Automobile Liability, Professional Liability, and Commercial
General Liability insurance (as applicable to each line of coverage):
1. The Consultant's insurance coverage shall be primary insurance as
respects the City. Any insurance, self-insurance or insurance pool coverage maintained
by the City shall be in excess of the Consultant's insurance and shall not contribute with
it.
2. The Consultant shall provide thirty (30) days written notice by certified
mail, return receipt requested, to the City prior to the cancellation or alteration of
coverage.
3. The City will not waive its right to subrogation against the Consultant.
The Consultant's insurance shall be endorsed to waive the right of subrogation against
the City., or any self-insurance, or insurance pool coverage maintained by the City.
4. If coverage is written on a "claims made" basis, then a minimum of a three
(3) year extended reporting period shall be included with the claims made policy, and
proof of this extended reporting period provided by the City.
D. Acceptability of Insurers. Insurance is to be placed with insurers with a current
A.M. Best rating of not less than A:VII.
E. Verification of Coverage. The Consultant shall furnish the City with original
certificates for all policies and a copy of the amendatory endorsements, including but not necessarily
-3-
limited to, the additional insured endorsement for Automobile Liability and Commercial General
Liability, evidencing the insurance requirements of the Consultant before commencement of the work.
8. Record Keeping and Reporting.
A. The Consultant shall maintain accounts and records, including personnel,
property, financial and programmatic records which sufficiently and properly reflect all direct and
indirect costs of any nature expended and services performed pursuant to this Agreement. The
Consultant shall also maintain other such records as may be deemed necessary by the City to ensure
proper accounting of all funds contributed by the City to the performance of this Agreement.
B. The foregoing records shall be maintained for a period of seven (7) years after the
termination of this Agreement unless permission to destroy them is granted by the Office of the Archivist
in accordance with RCW Chapter 40.14 and by the City.
9. Audits and Inspections. The records and documents with respect to all matters covered
by this Agreement shall be subject at all times to inspection, review or audit by the City during the
performance of this Agreement.
10. Termination. This Agreement may at any time be terminated as follows:
A. The City reserves the right to terminate or suspend this Agreement at any time,
with or without cause, upon thirty (30) days prior written notice.
B. In the event of termination or suspension, all finished or unfinished documents,
data, studies, worksheets, models, reports or other materials prepared by the Consultant pursuant to this
Agreement shall promptly be submitted to the City.
B. In the event this Agreement is terminated or suspended, the Consultant shall be
entitled to payment for all services performed and reimbursable expenses incurred to the date of
termination.
C. This Agreement may be canceled immediately if the Consultant's insurance
coverage is canceled for any reason, or if the Consultant is unable to perform the services called for by
this Agreement.
D. The Consultant reserves the right to terminate this Agreement on thirty (30) days
prior written notice in the event that outstanding invoices are not paid within sixty (60) days.
E. This provision shall not prevent the City from seeking any legal remedies it may
otherwise have for the violation or nonperformance of any provisions of this Agreement.
11. Business License. The Consultant shall obtain a City of Port Orchard business license
before commencing work under this Agreement.
12. Discrimination Prohibited. The Consultant shall not discriminate against any employee,
applicant for employment, or any person seeking the services of the Consultant under this Agreement,
on the basis of race, color, religion, creed, sex, sexual orientation, age, national origin, marital status,
presence of any sensory, mental or physical disability, or other circumstance prohibited by federal, State
or local law or ordinance, except for a bona fide occupational qualification.
13. Assignment and Subcontract. The Consultant shall not assign or subcontract any portion
of the services contemplated by this Agreement without the written consent of the City.
14. Conflict of Interest. The Consultant represents to the City that it has no conflict of interest
in performing any of the services set forth in Exhibit "A." in the event that the Consultant is asked to
perform services for a project with which it may have a conflict, Consultant will immediately disclose
such conflict to the City.
15. Confidentiality. All information regarding the City obtained by the Consultant in
performance of this Agreement shall be considered confidential. Breach of confidentiality by the
Consultant shall be grounds for immediate termination.
16. Employment of State Retirees. The City is a "DRS-covered employer" which is an
organization that employs one or more members of any retirement system administered by the
Washington State Department of Retirement Systems (DRS). Pursuant to RCW 41.50.139(1) and WAC
415-02-325(1), the City is required to elicit on a written form if any of Consultant's employees providing
services to the City retired using the 2008 Early Retirement Factors (ERFs), or if the Consultant is owned
by an individual who retired using the 2008 ERFs, and whether the nature of the service and
compensation would result in a retirement benefit being suspended. Failure to make this determination
exposes the City to significant liability for pension overpayments. As a result, before commencing work
under this Agreement, Consultant shall determine whether any of its employees providing services to
the City or its owners retired using the 2008 ERFs, and shall immediately notify the City using the form
attached hereto as Exhibit "C". This notification to DRS could impact the payment of retirement benefits
to the employee or owners of Consultant. Consultant shall indemnify, defend, and hold harmless the City
from any and all claims, damages, or other liability, including attorneys' fees and costs, relating to a
claim by DRS of a pension overpayment caused by or resulting from Consultant's failure to comply with
the terms of this provision. This provision shall survive the termination of this Agreement.
17. Non -appropriation of Funds. If sufficient funds are not appropriated or allocated for
payment under this Agreement for any future fiscal period, the City will so notify the Consultant and
shall not be obligated to make payments for services or amounts incurred after the end of the current
fiscal period. This Agreement will terminate upon the completion of all remaining services for which
funds are allocated. No penalty or expense shall accrue to the City in the event that the terms of the
provisions are effectuated.
18. Entire Agreement. This Agreement contains the entire agreement between the parties,
and no other agreements, oral or otherwise, regarding the subject matter of this Agreement shall be
deemed to exist or bind either of the parties. If there is a conflict between the terms and conditions of
this Agreement and the attached exhibits, then the terms and conditions of this Agreement shall prevail
over the exhibits. Either party may request changes to the Agreement. Changes which are mutually
agreed upon shall be incorporated by written amendments to this Agreement.
19. Notices. Notices to the City shall be sent to the following address;
City of Port Orchard
Debbie Lund
Human Resources Coordinator
216 Prospect Street
-5-
Port Orchard, WA 98366
Notices to the Consultant shall be sent to the following address:
Summit Law Group
Sofia Mabee
315 5'h Ave. S. Suite 1000
Seattle, WA 98104
sofiam SummitLaw.coni
206-676-7112
20. Applicable Law, Venue, Attorneys Fees. This Agreement shall be governed by and
construed in accordance with the laws of the State of Washington. In the event any suit, arbitration, or
other proceeding instituted to enforce any term of this Agreement, the parties specifically understand
and agree that venue shall be exclusively in Kitsap County, Washington. The prevailing party in any
such action shall be entitled to its attorney's fees and costs of suit, which shall be fixed by the judge
hearing the case, and such fee shall be included in the judgment.
21. Severability. Any provision or part of this Agreement held to be void or unenforceable
under any law or regulation shall be deemed stricken, and all remaining provisions shall continue to be
valid and binding upon the City and the Consultant, who agree that the Agreement shall be reformed to
replace such stricken provision or part with a valid and enforceable provision that comes as close as
reasonably possible to expressing the intent of the stricken provision.
IN WITNESS WHEREOF, the parties have executed this Agreement on this 3D day of April
2020.
CITY OF PORT ORCHARD, WASHINGTON
By: _ N7neA�
Robert Putaans , Mayor
ATTEST/AUTHENI IC,1 TE:
By:—
Brgid—Rinearson, M , City Clerk
APPROVED Atl.Sr-T() FORM:
By:
flarlotte A. '4I'pAgr City Atto y
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SUMMIT LAW GROUP
al
Sofia Mabee, Partner
DocuSign Envelope ID: 92E003A6-9B61-4A4D-9399-67AC8E2EECFC
0 SUMMIT
101 LAW GROUP
SOFIA D. MABEE
DID: (206) 676-71 12
EMAIL: soflainoy sunimillaw. coin
Via email: dlund@cityofportorchard. us
April 15, 2020
Mayor Robert Putaansuu
City of Port Orchard
216 Prospect Street
Port Orchard, WA 98366
Re: Engagement Letter
Dear Mayor Putaansuu:
Exhibit A
315 Fifth Ave S Suite 1000
Seattle, Washington 98104
phone • 206 676.7000
fax • 206.676.7001
Thank you for considering hiring Summit Law Group to represent the City of Port
Orchard with regard to labor and employment matters. We will represent the City's interests
vigorously and do our very best to be prompt, thoughtful and practical in everything we do on
its behalf.
If you have not yet had an opportunity to view the background of Summit Law Group,
please take a moment to visit our website (www.summitlaw.com). Summit Law Group was
founded on the principle that a modern law firm should be focused on its customers, not its
lawyers. We designed Summit to be leaner, more efficient and more customer -responsive than
traditional law firms. We want to form productive working partnerships with our customers,
delivering a better product at greater value.
Fee Arrangements. We will build a working partnership with you to enable you to
maintain control over the scope and cost of the City's legal work. We are especially interested
in fee arrangements that provide incentives for us to be cost effective and that reward us for
superior results. Unless we agree otherwise, however, we will charge for our services by the
billable hour. We encourage you to consider and suggest other ways of measuring the value of
our services during the course of our relationship. Whether you choose to be billed by the
hour, or some other fee arrangement, we, unlike any other law firm we know of in the country,
invite the City to pay in accordance with its perception of the value of our legal services. To
that end, within 30 days of our invoice, you are free to adjust our billed amount —upward or
downward —based on your perception of the value that you have received.
At present, my current hourly rate applicable to this engagement is $330. The billing
rates and contact information of the Summit team members who are available to assist with this
engagement are included in the Appendix to this letter.
DocuSign Envelope ID: 92E003A6-9B61-4A4D-9399-67AC8E2EECFC
Mayor Putaansuu
April 15, 2020
Page 2
Unless otherwise agreed in writing, we will provide you with full itemized electronic
billing information on a monthly basis, including people working on your engagement, their
hours and rates and a detailed description of services performed. Payment of our bill is due
upon receipt of our invoice and bills not paid within thirty (30) days of the date of the invoice
will accrue interest at a rate of l% per month. We do not charge for telephone, photocopying,
computerized legal research, local travel, or other costs that are properly part of our cost of
doing business. We charge our actual costs for out-of-town travel and meals, working meals,
and other vendor expenses (e.g., for high volume photocopying, courier and messenger services
and other extraordinary expenses). We also charge for certain third -party vendor expenses
related to document processing and discovery, electronic or otherwise (which may include the
use of artificial intelligence). Our billings are monthly, unless otherwise agreed.
Attached to this letter is an Appendix that includes additional terms of this engagement.
Together, this letter and the Appendix constitutes the agreement between you and us regarding
our professional services. if the terms of our representation as described above and in the
Appendix are acceptable, please date and sign this letter where indicated below and return it to
me via mail, facsimile or electronic mail. This agreement will take effect on the date of your
signature or when we first perform services, whichever is earlier.
Sincerely,
SUMMIT LAW GROUP, PLLC
Sofia D. Mabee
AGREED AND ACCEPTED:
City of Port Orchard
By
Title u .� r
Dated J 4L) • o�L) �t)
DocuSign Envelope ID: 92E003A6-9B61-4A4D-9399-67AC8E2EECFC
APPENDIX TO ENGAGEMENT LETTER OF
SUMMIT LAW GROUP, PLLC
The term "you" below refers to the client in this engagement. If the client is an entity,
then we have addressed the accompanying engagement letter to the client's authorized
representative, but the term "you" below refers to the entity client.
IDENTITY OF CLIENT.
In representing a client which is an entity, we do not thereby also separately represent
affiliates or other constituents of the entity, nor do we separately represent the owners, officers,
directors, founders, managers, members, partners, fiduciaries, or employees of the entity in their
individual capacities or with respect to their individual affairs. We will rely upon you to inform
them of this fact where appropriate. Unless we agree otherwise in writing, we do not by virtue of
our representation of you also represent any entity that controls you, is controlled by you or is
under common control with you. We will look to the addressee of the engagement letter for our
instructions on behalf of the entity, unless you inform us otherwise in writing.
SCOPE OF ENGAGEMENT.
The scope of this engagement is described in the accompanying engagement letter. The
scope of our engagement may change if you ask us to provide different or additional services and
we agree in writing to provide them or we actually proceed to provide them and bill you for
them. If our engagement changes, the terms set out in the accompanying engagement letter and
this Appendix will apply to the changed engagement, unless we enter into a further agreement
modifying this one. Our engagement may be terminated by either one of us upon written notice
to the other.
SUMMIT TEAM ASSIGNED TO THIS ENGAGEMENT.
At Summit Law Group, we assign a team to your engagement. Your team includes the
individuals listed below:
Professional
Direct Dial
Email
Hourly Rate
Sofia D. Mabee
(206) 676-7012
sofiam@summitlaw.com
$330
Otto Klein
(206) 676-7034
ottok@summitlaw.com
$355
Rodney Younker
(206) 676-7080
rody@summitlaw.com
$355
Shannon Phillips
(206) 676-7092
shannonp@summitlaw.com
$330
Beth Kennar
(206) 676-7068
bethk@summitlaw.com
$330
Kristin Anger
(206) 676-7023
kristina@summitlaw.com
$330
Mike Bolasina
(206) 676-7006
mikeb@sunzmitlaw.com
$330
Seth Berntsen
(206) 676-7020
sethb@summitlaw.com
$330
Dan Swedlow
(206) 676-7024
dans@summitlaw.com
$320
Quinn Oppenheim
(206) 676-7106
quinno@summitlaw.com
$315
DocuSign Envelope ID: 92E003A6-9B61-4A4D-9399-67AC8E2EECFC
Professional
Direct Dial
Email
Hourly Rate
John Lee
(206) 676-7057
johnl@summitlaw.com
$285
Rachael Curtis
(206) 676-7022
rachaelc@summitlaw.com
$275
Laura Davis
(206) 676-7017
laurad@summitlaw.com
$260
Hathaway Burden
(206) 676-7040
hathawayb@summitlaw.com
$260
We may in the future add other professionals to your team depending on the time and
experience required by your matters, which may include contract personnel with appropriate
credentials to complete certain work under our supervision. We will charge you for the time of
these individuals at rates established by us based on their experience and expertise, the same as
we do for our employees and partners.
BILLING AND PAYMENT.
We review and make changes to our hourly rates from time to time, usually on an annual
basis. Changes may or may not apply across the board to all timekeepers.
Timely payment in full is a condition to our continuing provision of services. You agree
that we may suspend or terminate our services and may withdraw from this engagement in the
event our fees and other charges are not timely paid, subject to applicable rules governing
attorney withdrawal. In extreme cases, we may pursue recovery of unpaid fees through
collection actions or litigation. If our engagement is terminated by either you or us for any
reason, you will remain obligated to pay us all fees and other charges properly incurred up to the
termination date.
Although on occasion we will in good faith attempt to estimate in advance the fees and
costs of an engagement, we are not bound by any such estimate unless agreed in writing. Also,
we are not obligated to revise, amend or correct any such estimate if subsequent developments
make it inaccurate.
If we have more than one client in this engagement, then each is jointly and severally
obligated to pay us unless we agree otherwise in writing. Any outside arrangements you may
have for allocation, reimbursement, insurance, indemnification or the like will not relieve you of
your obligation to pay amounts due.
CONFLICT CHECK.
At the beginning of each engagement we conduct a review of potential conflicts of
interest to ensure compliance with the Rules of Professional Conduct, using names that you have
provided. As we move forward, please be sure to immediately provide us with any new or
different names of adverse or interested parties so that we may update our conflict check.
COMMUNICATIONS WITH SUMMIT.
Our communications with you may include legal advice and information that is protected
by the attorney -client privilege, the work product doctrine, or other protections from disclosure.
To maintain these privileges and protections, both you and Summit must take reasonable
DocuSign Envelope ID: 92E003A6-9B61-4A4D-9399-67AC8E2EECFC
measures to safeguard the confidentiality of our communications. Please be aware that if you
reveal information to a third party, including by communicating with us on an email system
accessible by a third party or on a mobile device that you do not control, protections of privilege
and confidentiality may be lost. You should also be aware that there may be circumstances in
which we have an independent ethical duty to reveal privileged information.
FRAUD PREVENTION.
During the course of our engagement, there may be a need or desire to arrange for the
electronic transfer of funds to Summit or to other parties. In the event that you receive a request
for a funds transfer, wire transaction, or other matter involving your financial accounts or your
account at Summit, please confirm the legitimacy of the request verbally with a known contact at
Summit before you proceed with the transaction.
OWNERSHIP AND RETURN OF FILES.
By executing our engagement letter, you agree that the files generated or accumulated as
a result of our representation belong to Summit Law Group. If you desire an electronic copy of
the files at the conclusion of our representation, you will be provided with an electronic copy of
the files. Under our document retention policy, we normally destroy client records, including
electronic records, seven years after the conclusion of a matter unless other arrangements are
made or the nature of the matter requires a longer retention period. E-mails that are duplicative,
routine or otherwise not part of the client file may be destroyed before the end of the seven-year
period, without prior notice to you.
DISPUTE RESOLUTION AND ARBITRATION.
If you become dissatisfied with any aspect of our relationship, including the quality or
adequacy of our representation, you agree to bring that to our attention, and we each agree to
negotiate in good faith to resolve the matter. If we cannot reach agreement, we each agree to
comply with any mandatory dispute resolution procedures that apply to any such dispute. If such
applicable mandatory dispute resolution procedures have been completed or waived, and a
dispute still exists between us, we each agree that the dispute will be submitted for mediation
under the rules of JAMS. If such mediation fails, and a dispute still exists between us, we each
agree that the dispute will be submitted to binding arbitration under the rules of JAMS. In
arbitration, there is no right to a trial by jury and the arbitrator's legal and factual determinations
are generally not subject to appellate review.
By signing this agreement, you acknowledge that the agreement to arbitrate results in a
waiver of your right to a court or jury trial for any fee dispute or malpractice claim. This also
means that you are giving up your right to discovery and appeal. If you later refuse to submit to
arbitration after agreeing to do so, you may be ordered to arbitrate pursuant to the provisions of
Washington law. You acknowledge that before signing this agreement and agreeing to binding
arbitration, you are entitled to, and have been given, a reasonable opportunity to seek the advice
of independent counsel.
Exhibit B
W=9
Request for Taxpayer
Give Form to the
Form
Identification Number and Certification
requester. Go not
(Rev. October2018)
Department of the Treasury
send to the IRS.
Internal Revenue Service
► Go to www.irs.gov/FormW9 for Instructions and the latest information.
1 Name (as shown on your Inc amo tax return). Namo Is required on this lino; do not leave this line blank
2 &csiness nameldlsragarded entity name, If different from above
y
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 entitles, not IndivldUEls; see
a
Instructions on page 3);
a
❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
C
single -member LLC
Exempt payee code (If any)
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ►
Nate: Check the appropriate box in the line above far the tax olassiftcation of the single-murnber owner. Do not check
Exemption from FATCA reporting
LLC If the LLC is elasslned as a single -member LLC that is disregarded from the owner unless lho owner or the LLC Is
code (If any)
C —
anolhar LLC that Is not disregarded from She owner fir U.S. federal ta+ purposes. Otherwise. a single-rrtamber LLC that
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Is disregarded from the owner should check the appropriate box for the tax classification of Its owner.
V
❑ Other (see Instructions) ■
(Applies to eccounts maintained ouislde the U.S.J
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5 Address (number, street, and apt, or suite no,) See Instructions.
Retfueslers name and address (optional)
s City, state, and ZIP code
7 List account number(s) here loptfonall
W91
Me Taxpayer Identification 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
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For individuals, this Is generally your social security number (SSN). However, fora
backup withholding. sole
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later, For other
n,MM sx It Is trmrr wmnlntiwr Irtannflratlnn niimhnr fFIN1. If vnti rin not hava a number. see Now to aet a
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TIN, later. - or
Note: If the account is In more than one name, see the instructions for line 1. Also see What Name and Empteyer
Number To Give the Requester for guidelines on whose number to enter. I I I
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 trat 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.
Codification instructions. You must cross out Item 2 above If you have been notified by the IRS that you are currently subject to backup withholding :)eeause
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
Here U.S. person ■ Date►
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest Information about developments
related to Form W-9 and Its instructions, such as legislation enacted
after they were published, go to www.lrs.gov/FormlN9.
Purpose of Form
An Individual or entity (Form W-9 requester) who Is required to flle 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
(FIN), to report on an Information return the amount paid to you, or other
amount reportable an an information return. Examples of information
returns Inolude, 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.
lryou 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)
By slgning 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 allen;
• 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, If 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
Entitles).
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." Exceptlons
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 allen who Is relying on an exception
contained In the saving clause of a tax treaty to clai n an exemplion
from U.S. lax on certain types of income, you must attech a statement
to Form W-9 that speclfles 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 allen,
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.
Page'2
Example. Article 20 of the U.S.-China Income tax treaty allows an
exemptlon 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
certlflcatlons, 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 19B3 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 speclfled 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 dles.
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 last
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." Sae Regulations section 301.7701-2(c)(2)(111). 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
entlly for U.S. federal tax purposes has a single owner that Is a U.S.
person, the U.S. owner's name Is requlred to be provided on IIne t, 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 ...
e(n) ...
• Corporation
Corporation
• Individual
Individual/sole proprietor of 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 corp:)ratlon;
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 report ng,
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 exemot 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 RA, or
a custodial account under section 403(b)(7) it 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. 10-2016)
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'
Exempt payees 1 through 4
Payments made In settlement of
payment card or third party network
transactions
1 See Form 1099-MISC, Miscellaneous Income, and its Instructions.
2 However, the following payments made lc a corporation and
reportable on Form 1099-MISC are not exempt Irom 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)(1)
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 form 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/Buslnesses 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 www.irs.gov/OrderForms to
place an order and have Form W-7 and/or SS-4 malled 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 joint 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 certiflcatlon as indicated In
Items 1 through 5 below.
Form W-9 (Rev. 10-2018)
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
19M. You must sign the certificatian 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, royattles, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to
a non employee for services, payments made in setttemant 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, aanceliatlon at debt, qualified tuition program
payments (under section 1529), ABLE accounts (under section 529A),
IRA, CoverdeII ESA, Archer MSA a HSA contributl one 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:
Give name and SSN of: _
_
1. Individual
The Individual
2. Two or more Individuals ljolnt
The actual owner of the account or, If
account) other than an account
combined funds, the first Individual on
maintained by an FFI
the account
3. Two or more U.S, persons
Each holder of the account
(Jolnt account maintained by an FFI)
4. Custodial account of a minor
The minW
(Uniform Gift to Minors Act)
5. a. The usual revocable savings trust
The grantor -trustee'
(grantor Is also trustee)
b. So-called trust account that Is not
The actual owner
a legal or valid trust under state law
6. Sole proprietorship or disregarded
The owner3
entity owned by an Individual
7. Grantor trust filing under Optional
The grantor'
Form 1099 Filing Method 1 (see
Regulations section 1.671-4(b)(2)(1)
(A))
For this type of account:
Give name and EIN of:
The owner
B. Disregarded entity not owned by an
Individual
9. A valid trust, estate, or pension trust
Legal entlty4
10, Corporation or LLC electing
The corporation
corporate status on Form 8832 or
Form 2553
11. Association, club, religious,
The organization
charitable, educational, or other tax-
exempt organization
12. Partnership or multl-member LLC
The partnership
13. A broker or registered nominee
The broker or nominee
Page 5
For this type of account: I Give name and EIN of:
14. Accoi ml 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
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Flegdallons section 1.671-4(b)(2)(I}(9))
1 List first and circle the name of the person whose number you furnlsh.
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,
You must show your individual name and you may also enter your
business or DBA name on the "Business nari e/d I sragarded entity"
name line. You may use either your SSN or EIN (if you have one), but the
IRS encourages you to use your SSN.
4 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 identlfying Information, without your
permission, to ccmmit fraud or other orlmes. An Idantlty 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.
It your tax records are not currently affected by Identity theft but you
think you are at risk due to a lost or stolen pumas or wallet, questionable
credit card activity or credit report, contact the IRS Identity Theft Hotllne
at 1-800-908-4490 or submit Form 14039,
For more information, see Pub. 5027, Identity Theft Information for
Taxpayers.
Vlctlms of Identity theft who are experlencing 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-B77-777-4778 or TTY/TDD
1-800-629-4059,
Protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of emalI and websites designed to
mimic legitimate business smalls and websltes. The most common act
is sending an small 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 usod for Identity theft.
Form W-9 (Rev, 10-2018)
The IRS does not Initiate contacts with taxpayers via emalls. 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 small 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-B00-366-4484, You can
forward suspicious smalls to the Federal Trade Commission at
spam®uce.gov or report them at www.Rc.gov/complaint. You can
contact the FTC at www.ftc.govlfdtheft 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//dentityTheft to learn more about Identity theft and
how to reduce your risk.
Page 6
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,
1 Contractor or Third -Party Worker Contact Information for
Retirement Status Verification DRS Employer Support Services
360,664.7200, option 2
A1160
N,k},,,yG,ON „„ 800.547.6657, option 6, option 2
i]aljartment of This form is for employers to use to verify the retirement status employersupport@drs.wa.gov
Retirement Systems of a worker paid through accounts payable or a third party.
Employer Information
Failure to report a retiree to DRS can result in a significant liability to the employer for pension overpayments,
Some workers are considered to be employees of both your agency and the third party (dual employers).
A retiree who is in an employee/employer relationship with your agency is subject to the same
retiree -return -to -work (RRTW) rules as an employee paid through payroll.
Additionally, workers under age 65 who retired using the 2008 Early Retirement Factors (ERF) are subject to
stricter return -to -work rules and cannot perform services in any capacity for a DRS-covered employer and
continue to receive a benefit.
Employer Instructions
• Use Member Reporting Verification (MRV) to review the worker's retirement status.
Did the worker retire from a DRS-covered plan? ❑ Yes ❑ No
If yes and in an employee/employer relationship with your agency, report using RRTW rules.
• Did the worker retire using the 2008 ERF? ❑ Yes ❑ No
If yes, contact Employer Support Services (ESS) immediately.
• Sign and date this form.
• Retain this form for three years beyond your relationship with the worker.
Worker Information
Worker Name (Last, First, Middle)
Social Security Number
If your agency doesn't directly pay the worker, name the company or contractor paying the worker
Identify the Type of Worker (Check Only One)
❑ Employee Hired Through a Third Party (Staffing Agency, Temp Agency, Etc.)
❑ Independent Contractor
❑ Worker Provided by Company or Contractor Your Agency Hired to Perform Services
Employer Signature
I have verified the information above using MRV or by contacting a DRS representative. I acknowledge that failure to properly report
a 2008 ERF retiree to DRS can result in a liability to the employer.
Employer Signature Date
DRS MS 346 4/18 111111Ip1IIIRIIIIsIIIIMIIIIs1IIIIIIII4IIIIs1111111