HomeMy WebLinkAboutPSA Phil BacklundPROFESSIONAL SE CES AGREEMENT
This Agreement dated is made by and between Kittitas County (hereinafter "the
County") and Phil Backlund (hereinafter "Contractor"). The County and Contractor agree
as follows:
General Conditions; Attachment A (Scope of Work); Attachment B
(Compensation, Special Terms and Conditions); Attachment C (Proof of
lnsurance);Attachment D (Retirement status Form);Attachment E (Form w-
e).
copies of which are attached hereto and incorporated herein by this reference as fully as if
set forth herein.
The term of this Agreement shall commence upon mutual approval of this agreement
by County and Contractor and end upon project completion on June 2nd, 2021. Any party
may terminate this Agreement by giving thirty (30) days' notice in writing either personally
delivered or mailed postage-prepaid by certified mail, return receipt requested, to the party's
last known address for the purposes of giving notice under this paragraph.
Contractor acknowledges and by signing this Agreement agrees that the
lndemnification provisions set forth in Paragraphs 7 (lndependent Contractor), 9 (Taxes),
15 (Defense and lndemnity Agreement), 22 (PatenUCopyright lnfringement) and 25
(Confidentiality), are totally and fully part of this Agreement and have been mutually
negotiated by the parties.
Professional Services Agreement
Page 1
IN SS WHEREOF, the parties have executed this Agreement this
l.s't-, day
2421
APPROVED:
BOARD OF COUNTY COMMISSIONERS
KITTITAS COU HINGTON
(
Brett ith, Chair
of
Phil Backlund
(Date
?nit
Print Name of Signatory
Gontractor Address
Phil Backlund
2418 Wheaton Court
Ellensburg, WA 98926
Project Gontact:
Phil Backlund
Professional Services Agreement
Page 2
cory
Vice-Chair
mtsstoner
Gounty's Address:
Kittitas County
205 West 5th Avenue,
Ellensburg, WA 98926
Project Contact:
Cory Wright
PROFESSIONAL SERVICES AGREEMENT
This Agreement dated is made by and between Kittitas County (hereinafter "the
County") anO Ftril Backlund (hereinafter "Contractor''). The County and Contractor agree
as follows:
General Conditions; Attachment A (Scope of Work); Attachment B
(Compensation, Special Terms and Conditions); Attachment C (Proof of
lnsurance);Attachment D (Retirement Status Form);Attachment E (Form W-
e).
copies of which are attached hereto and incorporated herein by this reference as fully as if
set forth herein.
The term of this Agreement shallcommence upon mutualapprovalof this agreement
by County and Contractor and end upon project completion on June 2d,2021. Any party
may terminate this Agreement by giving thirty (30) days' notice in writing either personally
delivered or mailed postage-prepaid by certified mail, return receipt requested, to the party's
last known address for the purposes of giving notice under this paragraph.
Contractor acknowledges and by signing this Agreement agrees that the
lndemnification provisions set forth in Paragraphs 7 (lndependent Contractor), 9 (Taxes),
15 (Defense and lndemnity Agreement), 22 (PatenUCopyright lnfringement) and 25
(Confidentiality), are totally and fully part of this Agreement and have been mutually
negotiated by the parties.
Professional Services Agreement
Page 1
GENERAL CONDITIONS
1. Scope ef Contractor's Services:
Contractor agrees to provide to the County services and any materials set forth in the prolect
narrative identified in Attachment "A" during the Agreement period. No material, labor, or
facilities will be furnished by the County, unless othenrvise provided for in the Agreement.
2. Performance of Work:
Contractor shall perform work in accordance with, and shall comply with, all of the provisions
of this Agreement. All work shall comply with applicable laws, codes ordinances and
agreements.
3. Schedule of Performance:
Unless directed otherwise by the County, Contractor shall perform the work in accordance
with any schedules made a part of this Agreement.
4. Definitions
4.1
4.2
4.3
4.4
"Additional lnsured's" means the County, its successors and assigns, and
the respective directors, officers, employees, agents and representatives of
the County and its successors and assigns.
"Subcontractor" is any service provider or other vendor contracted by the
Contractor to provide consumer services or any other work for the purpose of
meeting the Contractor's obligations under this Agreement.
"Support" means the following: Contractor's directors, officers, employees,
agents and representatives; and sub-Contractors of any tier; the respective
directors, officers, employees, agents and representatives of these sub-
Contractors of any tier; and any other person or entity acting under the
direction or control of, or on behalf of, Contractor or any Contractor's sub-
Contractors of any tier in connection with or incident to the performance of the
Work or this Agreement.
The "Work" means all of the duties listed in Attachment "A" and the
performance of all other obligations, under this Agreement by Contractor or
its Support.
5. Accountino and for Contractor Services:
Payment to the Contractor for services rendered under this Agreement shall be as set forth
in Attachment "B". Where Attachment "8" requires payments by the County, payment shall
be based upon billings, supported unless otherwise provided in Attachment "8", by
documentation of units of work actually performed and amounts earned, including where
appropriate, the actual number of days worked each month, total number of hours for the
month, and the total dollar payment requested. Unless specifically stated in Attachment "B"
or approved in writing in advance by the Kittitas County Board of Commissioners, the County
will not reimburse the Contractor for any costs or expenses incurred by the Contractor in
performance of this Agreement.
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Where required, the County shall, upon receipt of appropriate documentation, compensate
the Contractor, no more often than monthly, through the County voucher system, for the
Contractor's service pursuant to the fee schedule set forth in Attachment "8".
6. Assiqnment and Subcontractinq:
No portion of this Agreement may be assigned or subcontracted to any other individual, firm
or entity without the express and prior written approval of the County. Contractor intends to
subcontract with Spanish language translators for digital and print media when requested
by the County. This subcontracting and associated fees must be pre-approved by the
County.
7. lndeoendent Contractor:
The Contractor's services shall be furnished by the Contractor as an independent Contractor
and nothing herein contained shall be construed to create a relationship of employer-
employee or master-servant, but all payments made hereunder and all services performed
shall be made and performed pursuant to this Agreement by the Contractor as an
i ndependent Contractor.
The Contractor acknowledges that the entire compensation for this Agreement is specified
in Attachment "B" and the Contractor is not entitled to any County benefits including, but not
limited to: vacation pay, holiday pay, sick leave pay, medical, dental, or other insurance
benefits, or any other rights or privileges afforded to Kittitas County employees.
Contractor will defend, indemnify and hold harmless the County, its Additional lnsured's,
officers, agents or employees from any loss or expense, including but not limited to
settlements, judgments, setoffs, attorneys' fees or costs incurred by reason of claims or
demands because of breach of the provisions of this paragraph.
8. No Guarantee of Employment:
The performance of all or part of this Agreement by the Contractor shall not operate to vest
any employment rights whatsoever and shall not be deemed to guarantee any employment
of the Contractor or any employee of the Contractor or any sub-Contractor or any employee
of any sub-Contractor by the County at the present time or in the future.
9. Taxes:
The Contractor understands and acknowledges that the County will not withhold Federal or
State income taxes. Where required by State or Federal law, the Contractor authorizes the
County to make withholding for any taxes other than income taxes (i.e. Medicare). All
compensation received by the Contractor will be reported to the lnternal Revenue Service
at the end of the calendar year in accordance with the applicable IRS regulations. lt is the
responsibility of the Contractor to make the necessary estimated tax payments throughout
the year, if any, and the Contractor is solely liable for any tax obligation arising from the
Contractor's performance of this Agreement. The Contractor hereby agrees to indemniff
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the County against any demand to pay taxes arising from the Contractor's failure to pay
taxes on compensation earned pursuant to this Agreement.
The County will pay sales and use taxes imposed on goods or services acquired by the
County hereunder as required by law. The Contractor must pay all other taxes including,
but not limited to: Business and Occupation Tax, taxes based on the Contractor's gross or
net income, or personal property to which the County does not hold title. The County is
exempt from Federal Excise Tax.
10. Reoulations Requirement:
This Agreement shall be subject to all laws, rules and regulations of the United States of
America, and State of Washington, and political subdivisions of the State of Washington,
and to any other provisions set forth herein or in the attached Attachments.
11. Rioht to Review:
This contract is subject to review by any Federal or State auditor. The County or its designee
shall have the right to review and monitor the financial and service components of this
program by whatever means are deemed expedient by the County. Such review may occur
with or without notice, and may include, but is not limited to, on-site inspection by County
agents or employees, inspection of all records or other materials which the County deems
pertinent to the Agreement and its performance, and any and all communications with or
evaluation by service recipients under this Agreement. The Contractor shall preserve and
maintain all financial records and records relating to the performance of work under this
Agreement for 6 years after contract termination, and shall make them available for such
review, within Kittitas County, State of Washington, upon request.
12. Modifications:
12.1
12.2
12.3
12.4
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Either party may request changes in the Agreement. Any and all agreed
modifications shall be in writing, signed by each of the parties.
The County may, at any time, by written notice thereof to Contractor ("Change
Notice") makes changes in the Work within the general scope of this
Agreement, including, but not limited to: (a) changes in, revisions to,
substitutions for, additions to or deletions of any Work; (b) changes in
schedule; and (c) acceleration, deceleration or suspension of performance of
any Work.
lf any change in the Work causes an increase or decrease on Contractor's
cost of, or the time required for, performance of the Work, an equitable
adjustment in the compensation to Contractor and in the schedule for the
performance of the Work shall be made to reflect such an increase or
decrease.
Notwithstanding any dispute or delay in arriving at a mutually acceptable
equitable adjustment, Contractor shall proceed in accordance with all Change
Notices. Contractor must, within thirty (30) days after receipt of any Change
12.5
Notice that does not set forth any acceptable adjustment, submit to the County
a written statement setting forth any adjustment claimed.
lf any change results in a decrease in the Work performed, Contractor shall
be entitled to compensation associated with changing the work, such as
revising design already completed, revising calculations already performed,
and revising documents.
13. Terminatio for Default:
lf the Contractor defaults by failing to perform any of the obligations of the Agreement,
including violating any law, regulation, rule or ordinance applicable to this Agreement, or
becomes insolvent or is declared bankrupt or commits any act of bankruptcy or insolvency
or makes an assignment for the benefit of creditors, the County may, by depositing written
notice to the Contractor in the U.S. mail, postage prepaid, terminate the Agreement, and at
the County's option, obtain performance of the work elsewhere. lf the Agreement is
terminated for default, the Contractor shall not be entitled to receive any further payments
under the Agreement until all work called for has been fully performed. Any extra cost or
damage to the County resulting from such default(s) shall be deducted from any money due
or coming due to the Contractor. The Contractor shall bear any extra expenses incurred by
the County in completing the work, and all damage sustained, or which may be sustained
by the County by reason of such default.
lf a notice of termination fordefault has been issued and it is laterdetermined forany reason
that the Contractor was not in default, the rights and obligations of the parties shall be the
same as if the notice of termination had been issued pursuant to the Termination for Public
Convenience paragraph hereof.
14. Termination for blic Convenience:
The County may terminate the Agreement in whole or in part whenever the County
determines, in its sole discretion that such termination is in the best interests of the County.
Whenever the Agreement is terminated in accordance with this paragraph, the Contractor
shall be entitled to payment for actual work performed at unit contract prices for completed
items of work. ln the event of such termination, an equitable adjustment shall be made in
the compensation payable to Contractor.
An equitable adjustment in the contract price for partially completed items of work will be
made, but such adjustment shall not include provision for loss of anticipated profit on deleted
or uncompleted work. Termination of this Agreement by the County at any time during the
term, whether for default or convenience, shall not constitute a breach of contract by the
County.
15. Termination Due to Change in Fundinq. lf the funds upon which the County relied to
establish any Program Agreement are withdrawn, reduced or limited, or if additional or
modified conditions are placed on such funding, the County may terminate this Agreement
Professional Services Agreement
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by providing at least thirty (30) calendar days written notice to the Contractor. The
termination shall be effective on the date specified in the notice of termination.
16. Defense & lnde mnitv Aoreement:
The Contractor agrees to and shall defend, indemnifo and hold harmless the County, its
Additional lnsured's, appointed and elective officers, agents and employees, from and
against all loss or expense, including but not limited to judgments, settlements, attorney's
fees and costs by reason of any and all claims and demands upon the County, its Additional
lnsured's, its elected or appointed officials, agents, or employees for damages because of
personal or bodily injury, including death at any time resulting therefrom, sustained by any
person or persons and on account of damage to property including loss of use thereof, if
such injury to persons or damage to property is due to the negligence of the Contractor, its
sub-Contractors, its elected officers, employees or their agents, except only such injury or
damage as shall have been occasioned by the negligence of the County, its Additional
lnsured's, appointed or elected officials, agents, or employees. lt is further provided that no
liability shall attach to the County by reason of entering into this contract, except as expressly
provided herein.
17. lndustrial lnsu rance Waiver:
With respect to the performance of this Agreement and as to claims against the County, its
Additional lnsured's, officers, agents and employees, the Contractor expressly waives its
immunity under Title 51 of the Revised Code of Washington, the lndustrial lnsurance Act,
for injuries to its employees and agrees that the obligations to indemnifiT, defend and hold
harmless provided in this agreement extend to any claim brought by or on behalf of any
employee of the Contractor. This waiver is mutually negotiated by the parties to this
Agreement.
18. Venue and Choice of Law:
ln the event that any litigation should arise concerning the construction or interpretation of
any of the terms of this Agreement, the venue of such action of litigation shall be in the
Superior Court of the State of Washington in and for the County of Kittitas. This Agreement
shall be governed by the law of the State of Washington.
19. Withholdinq Payment:
ln the event the Contractor has failed to perform any obligation to be performed by the
Contractor under this Agreement within the time set forth in this Agreement, then the County
may, upon written notice, withhold all monies due and payable to Contractor, without
penalty, until such failure to perform is cured or othenruise adjudicated.
20. Future Non-Allocation of Funds:
lf sufficient funds are not appropriated or allocated for payment under this Agreement for
any future fiscal period, the County will not be obligated to make payments for services or
amounts incurred after the end of the current fiscal period. No penalty or expense shall
accrue to the County in the event this provision applies.
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The County shall give prior written notice of the lack of available funding not later than 30
days priorto the end of the current fiscal period and the contract may be terminated pursuant
to paragraph 15 hereof.
21 . Contractor Commitments.rranties and Representations:
The Contractor represents and warrants to the County as follows:
21.1 The Contractor is validly existing and in good standing under the laws of
the State of Washington, and has all requisite power and authority to enter
into and to perform its obligations under this Agreement.
21.2 The Contractor has the authority to execute this Agreement, to make the
representations and warranties set forth in it and to perform the obligations
of the Contractor under this Agreement in accordance with its terms.
21.3 This Agreement has been validly executed by an authorized
representative of the Contractor and constitutes a valid and legally binding
and enforceable obligation of Contractor.
21.4 The Contractor has or will obtain prior to the commencement date such
licenses, permits and other authorizations from federal, state and other
governmental authorities, as are necessary for the performance of its
obligations under this Agreement.
21.5 The Contractor is not in violation of any applicable law, ordinance or
regulation the consequence of which will or may materially affect
Contractor's ability to perform its obligations under this Agreement. The
Contractor is not subject to any order or judgment of any court, tribunal or
governmental agency which materially and adversely affects its operations
or assets in the State of Washington, or its ability to perform its obligations
under this Agreement.
21.6 None of the representations or warranties in this Agreement, and none of
the documents, statements, certificates or schedules furnished or to be
furnished by Contractor pursuant hereto or in connection with the
performance of the obligations contemplated under this Agreement,
contains or will contain any untrue statement of a material fact or omits or
will omit to state a material fact necessary to make the statements of fact
contained therein not misleading.
22. PatenUCopvriqht lnfrinqement:
Contractor will defend and indemnify the County from any claimed action, cause or demand
brought against the County; to the extent such action is based on the claim that information
supplied by the Contractor infringes any patent or copyright. The Contractor will pay those
costs and damages attributable to any such claims that are finally awarded against the
County in any action. Such defense and payments are conditioned upon the following:
22.1 Contractor shall be notified promptly in writing by County of any notice of such
claim.
22.2 Contractor shall have the right, hereunder, at its option and expense, to obtain
for the County the right to continue using the information, in the event such
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claim of infringement is made, provided no reduction in performance or loss
results to the County.
23. Disputes:
23.1 General
Differences between the Contractor and the County, arising under and by
virtue of the Agreement Documents shall be brought to the attention of the
either party at the earliest possible time in order that such matters may be
settled or other appropriate action promptly taken. Except for such objections
as are made of record in the manner hereinafter specified and within the time
limits stated, the records, orders, instructions, and decisions of the Kittitas
County Commissioners shall be final and conclusive.
23.2 Notice of Potential Claims
The Contractor shall not be entitled to additional compensation which
otherwise may be payable, or to extension of time for (1) any act or failure to
act by the County, or (2) the happening of any event or occurrence, unless
the Contractor has given the County a written Notice of Potential Claim within
ten (10) days of the commencement of the act, failure, or event giving rise to
the claim, and before final payment by the County. The written Notice of
Potential Claim shall set forth the reasons for which the Contractor believes
additional compensation or extension of time is due, the nature of the cost
involved, and insofar as possible, the amount of the potential claim. Contractor
shall keep full and complete daily records of the work performed, labor and
material used, and all costs and additionaltime claimed to be additional.
23.3. Detailed Claim
The Contractor shall not be entitled to claim any such additional
compensation, or extension of time, unless within thirty (30) days of the
completion of the portion of the work from which the claim arose, and before
final payment by the County, the Contractor has given the County a detailed
written statement of each element of cost or other compensation requested
and of all elements of additional time required, and copies of any supporting
documents evidencing the amount or extension of time claimed to be due.
24. Ownership of ltems Produced:
All writings, programs, data, public records or other materials prepared by the Contractor
and/or its consultants or sub-Contractors, in connection with performance of this Agreement
shall be the sole and absolute property of the County.
25. Confidentialitv:
The Contractor, its employees, Sub-Contractors, and their employees shall maintain the
confidentiality of all information provided by the County or acquired by the Contractor in
performance of this Agreement, except: 1) as provided below, 2) upon the prior written
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consent of the Kittitas County Prosecuting Attorney; or 3) upon an order entered by a court
after having acquired jurisdiction over the County. Contractor shall immediately give to the
County notice of any judicialproceedings seeking disclosure of such information. Contractor
shall indemniff and hold harmless the County, its Additional lnsured's, officials, agents or
employees from all loss or expense, including, but not limited to settlements, judgments,
setoffs, attorneys' fees and costs resulting from Contractor's breach of this provision.
26. Notice:
Except as set forth elsewhere in the Agreement, for all purposes under this Agreement,
except service of process, notice shall be given by the Contractor to the department head
of the department for whom services are rendered, and to the Kittitas County
Commissioners, 205 W sth Ave, Suite 108, Ellensburg, WA 98926. Notice to the Contractor
for all purposes under this Agreement shall be given to the address reflected on the
signature page. Notice may be given by delivery or by depositing in the U.S. Mail, first class,
postage prepaid.
27. Severability:
lf any term or condition of this Agreement or the application thereof to any person(s) or
circumstances is held invalid, such invalidity shall not affect other terms, conditions or
applications which can be given effect without the invalid term, condition or application. To
this end, the terms and conditions of this Agreement are declared severable.
28. Miscellaneous
28.1
28.2
28.3
28.4
29. Waiver:
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Either party's failure or delay to insist upon strict performance of any of the
provisions of this Agreement or to exercise any rights or remedies under this
Agreement shall not be construed as a waiver or relinquishment to any extent
of its right to assert or rely upon any such provisions, rights or remedies in that
or any other instance; rather the same shall be and remain in full force and
effect.
This Agreement embodies the entire Agreement between the County and
Contractor, and supersedes any and all prior agreements, regarding the
Work. No change, amendment or modification of any provisions of this
Agreement shall be valid unless set forth in a written instrument signed by the
party to be bound thereby.
The rights and remedies of both parties set forth in any provision of this
Agreement are in addition to and do not in any way limit any other rights of
remedies afforded to the party by any other provisions of this Agreement, by
any of Contractor's Support or by law.
The headings of sections and paragraphs of this Agreement are for
convenience of reference only and are not intended to restrict, affect or be
of any weight in the interpretation or construction of the provisions of such
sections or paragraphs.
Waiver of any breach or condition of this Agreement shall not be deemed a waiver of any
prior or subsequent breach. No terms or conditions of this Agreement shall be held to be
waived, modified or deleted except by an instrument, in writing, signed by the parties hereto.
30. Survival:
The provisions of paragraphs 7, 9, 11, 13, 14, 15, 16, 17 ,18, 19, 20,21,22,23, 24, 25,29,
31, and 32, shall survive, notwithstanding the termination or invalidity of this Agreement for
any reason.
31. Nondiscrimination
31.1 The County is an equal opportunity employer
31.2 ndiscrimination in Em
ln the performance of this Agreement, the Contractor will not
discriminate against any employee or applicant for employment on the
grounds of race, creed, color, national origin, sex, sexual orientation,
marital status, age or the presence of any sensory, mental or
physical handicap; provided that the prohibition against discrimination
in employment because of handicap shall not apply if the particular
disability prevents the proper performance of the particular worker
involved. The Contractor shall ensure that applicants are employed,
and that employees are treated during employment without
discrimination because of their race, creed, color, national origin, sex,
sexual orientation, marital status, age or the presence of any sensory,
mental or physical handicap. Such action shall include, but not be
limited to: employment, upgrading, demotion or transfers, recruitment or
recruitment advertising, layoff or termination, rates of pay or other
forms of compensation, and programs for training including
apprenticeships. The Contractor shall take such action with respect to
this Agreement as may be required to ensure full compliance with
local, state and federal laws prohibiting discrimination in employment.
31.3 Nondiscrim ination in Services
The Contractor will not discriminate against any recipient of any services
or benefits provided for in this Agreement on the grounds of race,
creed, color, national origin, sex, sexual orientation, marital status, age or
the presence of any sensory, mental or physical handicap.
31.4 lf any assignment and/or subcontracting has been authorized by the
County, said assignment or subcontract shall include appropriate
safeguards against discrimination. The Contractor shall take such
action as may be required to ensure full compliance with the
provisions in the immediately preceding paragraphs herein.
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32. Prevailinq Waqe
Contractor shall pay the prevailing rate of wages to all workers, laborers, or mechanics
employed in the performance of any part of the Work in accordance with RCW 39.12
and the rules and regulations of the Department of Labor and lndustries. The schedule
of prevailing wages rates for the locality or localities of the Work is determined by the
lndustrial Statistician of the Department of Labor and lndustries. lt is the Contractor's
responsibility to verify the applicable prevailing wage rate. lt is understood that the
Contractor is responsible for obtaining and completing all required government forms
and submitting same to the proper authorities.
Disputes regarding prevailing wage rates shall be referred for arbitration to the Director
of the Department of Labor and lndustries. The arbitration decision shall be final and
conclusive and binding on all parties involved in the dispute as provided for by RCW
39.12.060.
33. Debarment Certification:
The Contractor certifies that it:
33.1 ls not presently debarred, suspended, proposed for debarment, declared
ineligible or voluntarily excluded from covered transactions by any Federal
department or agency.
33.2 Has not within a three-year period preceding the execution of this contract
with Kittitas County, been convicted of or had a civiljudgment rendered
against them for commission of fraud or a criminal offense in connection
with obtaining, attempting to obtain, or performing a public or private
agreement or transaction, violation of Federal or State antitrust statutes or
commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, tax evasion, receiving
stolen property, making false claims, or obstruction of justice.
33.3 ls not presently indicted for or othenruise criminally or civilly charged by a
governmental entity (Federal, State, or local) with commission of any of
the offenses enumerated in paragraph 33.2 of this section.
33.4 Has not within a three-year period preceding the preceding the execution
of this contract with Kittitas County had one or more public transactions
(Federal, State, or local) terminated for cause of default.
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ATTACHMENT "A"
SCOPE OF WORK
Workshop Outline
Contractor to develop and execute 1-day workshop with BOCC on June 2nd,2021.
Proposed workshop to be based on a process known as EOS (Entrepreneur Operating
System).
The EOS system has six key components. Vision, data, people, issues, process, and traction
Vision. A common problem of many groups or organization is that more than one
vision (or different perceptions of the one vision) exists. A clear vision reduces
mistakes, repeated actions, contradictory actions, or wasted actions.)
People. Confusion can happen if not everyone agrees on who does what. The EOS
system helps clarify individual roles and responsibilities and provides methods for
holding individuals accountable for their responsibilities.
Data. Data helps you see things objectively. lt eliminates assumptions, guesses,
emotions, and egos. The system includes methods and measurables to help track
progress.
lssues. These are the things that need to be improved, fixed, or changed. The
EOS system helps develop an issues list and issues solving track.
Process. \Mthin the EOS system, the idea is to have standard core processes that
everyone understands and has agreed to. lt focuses on documenting the processes,
looking for efficiency, exploring the best way to do things, and checking on the value
added for each step.
Traction. ln EOS, traction means "pedal to the medal" and getting things done. Are
people accountable? Do things get done? ls there a focus on discipline, execution,
accountability? With Traction, things get done.
Workshop Aqenda Development
Contractor to develop and conduct workshop with BOCC on the EOS system using the
following points:
1. lntroduction and overview of session
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2. lndividual commissioner core values and core focus
3. Ten-year target development
4. Marketing strategy
5. Three-year strategic focus
6. One-year strategic focus
7. 90-day goal development
8. Obstacle/challenge identification and mitigation
9. Future steps and accountability systems planning
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ATTACHMENT "B"
COMPENSATION AND FEE SCHEDULE
As full compensation for satisfactory performance of the work, the County shall pay the
Contractor the following compensation :
. $4,500 upon completion of workshopo All material, supplies, and technology required for project to be supplied
by contractor at contractor's expense.
Please submit an invoice upon project commencement:
Julie Kjorsvik
205 West Sth Avenue, Suite 108
Ellensburg, WA 98926
i u lie. kiorsvik@co. kittitas.wa. us
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Page 15
ATTACHMENT "C''
The Contractor shall secure and maintain in effect at all times during performance of the
Work such insurance as will protect Contractor, its Support and the Additional lnsured's
from all claims, losses, harm, costs, liabilities, damages and expenses arising out of
personal injury (including death) or property damage that may result from performance of
the work or this Agreement, whether such performance is by Contractor or any of its
Support.
Contractor's insurance policies shall be occurrence-based, be primary insurance and
shall be non-contributing with any other insurance maintained by Kittitas County.
All insurance shall be issued by companies admitted to do business in the State of
Washington and have a rating of A-, Class Vll or better in the most recently published
edition of Best's Reports unless otherwise approved by the County. lf an insurer is not
admitted, all insurance policies and procedures for issuing the insurance policies must
comply with Chapter 48.15 RCW and 284-15 WAC.
The Contractor shall provide proof of insurance as indicated by "X" below:
! Commercial General Liabilitv lnsurance.. Coverage limits not less than:. $1,000,000 per occurrence per projecto $2,000,000 general aggregate. $1,000,000 personal and advertising injury, each offense. Certificate Holder - Kittitas County
' The Certificate must name the County as additional insured as defined in the
Agreement. Sixty (60) days written notice to the County of cancellation
of the insurance policy.
Stop Gap/Employers Liabilitv.. Coverage limits not less than:. $1,000,000 each accident. $1,000,000 disease - policy limit. $1,000,000 disease - each employee. Thirty (30) days written notice to the County of cancellation
of the insurance policy.
r Commercial Automo ile Liabilitv lnsurance
Professional Services Agreement
Page 16
Automobile Liability for owned, non-owned, hired, and leased vehicles, with
an MCS 90 endorsement and a CA 9946 endorsement attached if 'pollutants'
are to be transported.
Coverage limits not less than:. $1,000,000 combined single limit
Thirty (30) days written notice to the County of cancellation
of the insurance policy. t
tr Workers' Compensation
Workers' Compensation in amounts required by law
Contractor shall furnish the County a Certificate of lnsurance with Endorsement as
evidence that policies providing insurance required by this Agreement are in fullforce and
effect. Contractor hereby waives all rights of recourse, including any right to which another
may be subrogated, against Kittitas County for personal injury, including death, and
property damage. Contractor's insurance policies required above shall be primary
insurance and shall be non-contributing with any other insurance maintained by Kittitas
County.
The Contractor shall assume full responsibility for all loss or damage from any cause
whatsoever to any tools, Contractor's employee-owned tools, machinery, equipment, or
motor vehicles owned or rented by the Contractor, or the Contractor's agents, suppliers
or contractors as well as to any temporary structures, scaffolding and protective fences.
The Contractor shall have sole responsibility for ensuring the insurance coverage and
limits required are obtained by subcontractors.
NOTE: No contract shall form until and unless a copy of the Certificate of Insurance with
Endorsement, properly completed and in the amount required, is attached hereto.
Professional Services Agreement
Page 17
ATTACHMENT'D"
RETTREMENT STATUS FORM (S|GNATURE REQUTRED)
COUNTY REIA'ruS THIS FORM
ALL CONTRACTORS, SERVICES CONTRAGTORS, AND INDEPENDENT
CONTRACTORS MUST COMPLETE AND SIGN
SECTION 1: GONTRACTOR COMPLETES TH|S SECTTON
1. Did you retire from one of the State of Washington Retirement Systems?
n yrs ,F*o2. Did you retire before age 65 using the 2008 early retirement factors (ERF)?
nves F*o3. will you be receiving direct compensation for these services?
FYES [ ruo
4. will you be receiving indirect compensation for these services?I vrs F*o
coNTRAcroR (Full name of contractor as in DRS filings-please print):
Signature
Last Four Digits of Social Security Number;th/
Date
Professional Services Agreement
Page 18
RETTREMENT STATUS FORM (STGNATURE REQUTRED)
COUNTY RETA'A'S THIS FORM
SECTION 2: COUNW COMPLETES THIS SECTION (Use Member Reporting
Verification (MRV) to verify the past retirement membership and document below)
1. Contractor has been a member of a Washington State Retirement System?
[] vEs n rvo
lf yes, which system and plan?
tr Teacher's Retirement System (TRS):
I ptan't f]ptan z I plan g
I School Employees' Retirement System (SERS):
I Plan 2 D Plan 3
tr Public Employees' Retirement Systems (PERS):
flPtant IPlanz IPlang
n Public Safety Employees' Retirement System {PSERS):
I ptan z
I Law Enforcement Officers'& Fire Fighters'Retirement System (LEOFF):
nptanl I Ptanz
n Washington State Patrol Retirement System (WSPRS):
f]Ptant n Plan2
n Judicial Retirement System (JRS)
2. ls the Contractor a retiree of a Washington State Retirement System?flvrs lruo
3. Did the Contractor retire before age 65 using the 2008 ERF?lvgs lruo
I have verified the information above using MRV or by contacting DRS.
COUNTY REPRESENTATIVE (Please Print)
Signature Date:
Professional Services Agreement
Page 19
GOUNTY RETAINS THIS FORM
ATTACHMENT'E*
Form W-9
Request for Taxpayer ldentification Numher and Gertification
REMAINDER OF THIS PAGE LEFT BLANK
SEE FOLLOWING PAGES FOR FORM W-9 AND INSTRUCTIONS
Professional Services Agreement
Page 20
Fornr llll-g
tFe. Oelober 20141
Deparlmnl of flt€ T€asu'y
hlernst REwndE SEslce F*i ro
Request for T*xpayer
ldentifisrtion Numher flnd Certification Give Forrn to lhe
requester, Do not
sand tothe lB.S.
€nd ltB
r Form 1{H9-D|V {diviCsnds, includifig
lunds]
t Form 'ltlgg-Mls* {verious typss of inc6m€, prE€s, arrards, or grcss
pioceeds]
. Fsnn 1{1gg'B {stork 6r muluel tufid sshs snd a€rtcin othcr
tranescli*ns by blok€ rsl
. Farm 10gg.S {pro.eeds fiorn r€al €ststs transa{lbn.al
. Forrn 1099"K tnerehenl {erd Errd third party n€tv/€* translctionsl
r Farm 1Oi8 (hcme rnortgaqo int€r€s{, 109&-E {studsnt losn int€r€s4.
10S8-T lruili4n]
. Form 10gt.S {cencsledd€bt}
r Fornr 1899.A {acqu isition or ebandonm€nt af secur€d prop€ rlyl
Llse F$rm W-e {3n1r' if "t'clJ er€ a U.$. person (irrclrdinE a r€sidant
af!.n!. tc provrda ./ourcorr€ct Tihl.
I/Jioff do fiof r6fr#.1 Foffti W-g td lk raqffs$fe/ lrrilh e ilJrl. lioff ffiEAt
be si.Jbilet ts bcc8ilpw;thhrndittg. Se€ Vvhat i9 backup vrithholding.
,bfa1-
4
€s
.!faoLi
ot*u?:a- (lC
E
&0qul
4 Eg€siptar€ tsols appl! od! It
€darf, 6t0ts, rEttndrvrduala €s
,ffitl#iofl o. Pa4F 3l;
Bsn$t srts c6d6sl anli_
Asnrgton fof,r FATCA €porliq
ccd8 if antl
tt#b &..rn* ddrdrtld H! u,Ar
Nol6i It tha eccounl [s in ]rrors lhafi ong nems, ss€ tha in$lruction$ lor lirrs 1 , Also s€ !1h*t ldems snd
trt{rnesr Ia GiuB ffte S6+Jssts/ lxr guidalings on whoes numbsr to €nt€r.
on
Undsr tlanall of p€rj!F/, I tbat:
1. The nunrber *hovn on lhie f6rm is ny ccrr€ct terpayer id.ntificalion o0fib{r (*r I am waitifig for a nunbsr to bs issuedto ftel: end
?. lam nol .subj€.rtt*backupu/ilhholdifig beces.*: tsl lsm€x€ffiFlfram backupv/ithholdinq,or[b] lha]B notbBen notiti€dqrh€lnrsrnalFe\.1enue
Sstuh€ flR$ rhar I sm srbjsct to backrp lr/ithholdifig es e r€suh si e failurs to r€port ell i01€rcsl sr divldondc. or fci th€ lRg h6s nstifhd ms ther I em
fio ting€r subiect to beckup vdirhiroldingt snd
3. I arn e U.S. f itizdrr or sthsf U.-8. person [dsfined bslov4; end
+ Th€ FATOA.c{dsts} €nt€radon thislorm (ifeng ifidicetinB thstlcfir sxsmpttr6rn FATfiA r€trorting iecorr€cr.
Conuhafhn lndtructloflf,, Ynu flru$t cio*$ oul it€rn ? eb0v6 if you hom bean
rFu hads iailed to lgport 4ll irrt€rest r0d
acquililhn sr ebsrdonfiionl of Escul€d
dirJil€ndson ysut le( rdturn. For 163l
*snoellelion ot debt,
other lhao intorsr snd diuid€nds,fnt ,eq$i€d to
Here
General ln from or mutuel
€sction r€f€r€ncss ars lo th€ lfi t€rnei R6v€n us Cod€ unlsss oth€ fl,lise
nst€d.
Futuro dsvsloFm*nts. For ths l*t€st intarmeti$n abcutd€',sioFrn€sts
i€latsC to Form ,,V.9 and its instructions, such es lagisletlxn €rlect€d
elt€r lha't \4€r€ publiehsd, go to il/rlw.i,rg.Ef6y/ForrltryS
Purpnse of Form
As in'divlCual or sntity [Fom lA.-f rsqusst€rJ vJha is r.aquirsd to fil€ en
informaliln r{turn with th€ l*s, must ilbtsin lour con€ct tsxFlyor
Hsntificetbn numb€r ffliui whidh rnay b€ your .eo.ials€curiry nuftber
F.gNI, indivdual te\peysr idsntiticetbn nunber llTlNl. adsption
t4xpeye r iddnlificetion numbsr F:Ill.ll. or €filpb,lter idantilieatlon nrmber
{ElNl. ro repon on en infoffiletion relurfi ths ern'tunt peid to you, or oth€r
elnount r€tfrtebl€ 6n en informathn rdturn. Exsmpls.s sf inforrnation
tsturns includs, but er€ not lirrit€dro. th€ follc{x/ifig.
r Fom 16S9.|MT (inrsrsstetrn€dor treidl
g Clsk tp! Epnrta b(st lor fuder6l i4 c{iEsriRton df thi p86ofi r}s6 fR0r€ rs sr,bFi on ft F t , CtE* ort! on3 sf ltE
ldtdrirrE #an bft*,
lopne{Er or fl c €argar+ton ff ,Scorprrs.ton E partmrst p ff Trutretare
LLC
f] UnrtsdldUtlrtrwrrrF{ny.Ei'tErttFt*d#{rtrstqnlGfre{Foraton,$.SErBo.atan.FPr.rt€aft!}}-
sdra€ea.dEd io0r tlE ff€r sIE{drtEt tiEaoo@q0ata Eq ,orttE ta d#rist6n ql rts sfns.
Fart I
Fart ll
FlJ.S.
Sgnatur€ of
Dri6 F
Professional Services Agreement
Page 2'l
Cal. No. 1Coel*FBf(B W-9iFEa. l$20r4l
Fornt W-S (Fe. lS?018)PamE
By signing th€ tilhd-outlorrn, you:
'1. Cenify lhet thi TIN you are giv ing is consct ht you ar€ l#ait ing for s.
numb€r to be issued|.
2. C€ rtify thet you ars not subJ€ct to backu p w hhholdlng, or
J. ClAim sxsmption ltom hackup wkhholdihg if r/ou ete a U;S. €x€mpt
Faye€. lf epFlicebls, you a}s A[so c€nfiing thet as e U..9. psrson, your
albcable shere of eny pann€rshiF lncom€ from a [J..S. trads or busin€ss
E not subjsct to th€ u/ithhslding 1+\ o.n fordigr pann€rs'Ehers of
€tf€clill€V {onnscl€d iicoms, aM
4 C€rtifythel'FATCAc+Jstsl snt€rsdon thtsform [if anyJ lndiceting
thelycu srs sx€mpt from fiq FATSA r€poning, iscolr€ct. gi€-Wllgl is
IAICA taryliilg, let€r. for turlh€r information,
ltolg: ll you srs a. U.,g. pe rson and a requ€sts r g i'i€s you a lorm other
then Form W-g io l€qu€St yollr TlN, yau must uee rhc r€qu€st€r',r iorm ilI issubdantialty sim ilar to this Form'W.9.
Deflnhlon of e U,8. perron, br lederalta:l Furposss. )iou are
consld€rsds, lJ,S. per+rn -lf.,pou ersl
. An indiiidusl \i/ho ls a U.S. cittr{n or U.S, r€iidsnt alian:
. A Fsrtn€rship, corporetion. cornFeny, or e.sgccktion cr€etsd or
crgsnizsd in th€ United$tetssor uirderthe lawsol lh€ U0itsdStet€sl
..An €stats [other than e icr€ign sslets]: or
.Adomsstic trust [as delined ln Fequhtlonssection l0'1.??01-?1.
Speclal rulee fo r pannerehl p*, Partnsrshlp,s that conduct a fade or
busirissr in th€ Unit€d Sletss are generally required to pey e wit hholding
trx ilnd6r ssction 1l+6 tiri any foreign peftn€rs' sher€ ot €tf€cti!fiely
oonngctsd tsxebl€ incoffs tlom guch busins.Es. Furthsr. ln osnein casss
v,hs19 e Forrn W'9 hes 0ot bsan rscsi'ied. Ih€ rule,s undBr.ssction 1446
taquim e partnership 10 pfA.sum€ that e pArln€t is e for€hn p€rson, qnd
Fay th€ s€ction 1444 withholdinq tex. Th€isfor€, if you ar€ a U.g psrson
lhal is e Fann€r in e Fann€rshiF conducting a tad€ sr builnsss in tha
United Statss, ptoviCe Form W.g ts th€ panri€rshiF to €stEblish your
U.S. status and evoH ssction 1 446 with holding on lEu r shar€ of
pannership income.
ln ths ca€ss bsls!'/, lhe foll<lrlilng person must gfua Form W.9 to ths
FEnn€rship for purposeso{ €istablishing its U.$, steitl.e.end avoidifig
uiithholding ori itsalhcebta shera of n€t i0com€ from th€ fartn€rship
condlcting a fiad€.or busin€ss i[ rhE U n it€d Stst€€,
.ln rh€ ce.sg af a dhi€gerded € nlily with a U.S. {$rrn€r. thd U.S. {i,$nsr
of .th€ dl,er€gerded €nlity and not.ths €flliry:
r.ln ths ca,9e ol a grantor trlst iililh a U.g. grantor or other U.S, {r'vnsr,
g€n€relly, th€ U.S. grentor or other U.$, <y{i rer of the grenlor trustand
nolthg trusti efid
..ln ths ca.ss of e U.S. lrust(oth€rthan agrantortrust, ths U.$. lrust
hth€r then e qrsntot trustl ej]d not thc bsn€iichrhs 01 th€ trust.
Fomlgn pelsbn, lf you ar.a a fotabn F€rson oi thA U;s, blanch ot a
brsitn barlk thet he.s €lgct€d ta bs tr€at€d ss.e U.S. p€r.g,:in, do not uss
Form W-9. lns'tsed, use th€ aFproprhls Fofin W.8 or Form 8233 (ss€
Fub. 515. Withholding of Tex on Nonr€sidsnt Ali€ns and For€tqn
Enriths|:
Elrclrpls, Articf€ 20 of rh€ U.s.-Chirla incom€ te( tr€aty allfi4s sn
o{€mFtion trom tEx for schohrship incom€ r€c€iwd $r achin€s€
sludsnt t€lilpoisrily pr€sirqt in th€ Unit€d Stetsg- Undsr U;S, law, lhi€
stud€ nt vrill becorn€ e r€silant'sliisn tor tNX rurpog€s if his or hsi.stay in
ths Unn€d Stat€s cxc€€dls 5 Cahndai yeqrs. Hcrrrevor, faraqreph 2 of
ths tirsl Prorocolto th€ US..China tr€aly {dat€d April 30, 1,9841 ellovrs
ths Frovieions of Anicld 20 to corltinue to ai:pty ewn After.ths Chin€s€
Etude nt b€com€E s r€siCsnt elhfi ot th€ j U nit€d Slatss, A C h insss
.gtudentwhoquglifi{.E fisr'rhis€xc€ptlon [und€r peragraph 2 oJ th€ first
Frotocol end is rsFing sn this€xc€Ftion tochim en s€mFtion lrom tEX
on his or her echshr.sliip or t€ll{r#ship incons uJs!ld ettach to Form
W-g a stat€m€nt that includ€s th€ intormation d€€cribsd ebo\is to
suppon fiet €xsmplion.
It you are q nonresident el'len ore fqr€ign €ntity, qiw ths rsqu€stdr tha
aFproprials cornpleted Form W.8 or Form €233.
Backup Withholding
Whst b bsckup wlthhbldlhg?.. F€rsdns making csnein paymentE ts ysu
must undEr cort3in condftions withhold aiid pey to th€ lRS.2494 of.silch
paym€nts. This E calhd .backup withholding." Faym€nts that mey b€
. s u bl€ct to beck u F wlth hold ing inc ludd intere.sl, tax.sx€ fi pt int€ r9st,
divids nds, brok€ r end.bart€ rs(chanqs transactbns, r€ nts. ro^/alti€s,
none nr p lq/'s€ ray, payrte nls rtr.ads in $ett l€ me nt of peyme nt cerd and
lhird partY nstltrork fisn.4ectiofl€. and oenairr peym€nts from fishing boet
cpsrelors, Rsel sstat€ trgnsacthos ers not,subjsct td backup
vi ithholding.
You wil I nol b€.su biect to bec k uF with hold inq ofi pajms nts you
tgcdi\€ ifyou ghi\sih€ r€qu€.st€ryourcon€ctTlN, rreks the proper
o€rtiliCelionst end r€pofi tll,your t:xabls inu r€st end dividends on your
tax rdturn,
Fryment€ you recolve wlll b€ €ublegt ro backup wlrhholdlng lfr
1. You do not lurnish your TIN tc, lh€ r€qu€sl€r,
2, You do. not c$fiity irour -IlN whsn r€quir€d lsqe th€ instructionslor
Part ll for dsralts],
3. Th€. IRS t€lts the r€q!€.st€r that.!'fiu furnished en lncorr€ct TlN,
4 Th€ IRS t€lte you thet you ar€'subiei:.lto.beskup withholdhg
because you did nol r€pon allyour int€r€.st and divld€nds on yourtii
r€tu rn ffor'r€lrcneble int€ r€.st end diviJs nds onl{, c i
5- You do notc€rtify,toth€ r€qu€.el€rthetyou ars not subjoctto
ha]:kup loithholding und€r 4 abd,is ltor r€Fartebls intsr€.Et end diviC€nd
.eccountg opsn€d aft€r.1983 onM.
Cenein paysqs end paym€ntE sr€ sx€mFt frcm beckuF withholding
S€€ Fxemptpejr€e coda, ht€r, andlhe ssperelq lnstrijctionslotths.R+quester
of Form W-g lor more lnforrnation.
AEo se€ SFscielriltef, tor.pe/trtsrsft ,Fs. €arlisr:
What is FATCA Feporting?
Ths Fsr€ign AccountTex Cofipligno€ Act [FATgAl rsquir€.sa
panlcipalhg tor€hn linanci{l institutbn to r€Fort all.Unitqd 8t$€s
eccount holdsrs that ar€ Sp€citEd Unlted Stet€s psr.eons. C€rtsin
payses ers o{€mpt from FATCA reporting. 3€s Exemptlnn lrom FAICA
{epo.f fifl g ccd€. ht€r, and th€ ln.structbfs fi)r ths R€qus$er. of Fotm
W-g for mor€ inlorfielion'
Updaling Your lnlormation
You must provlde updetsd lnformation to any person tc whom you
cleimsd to be en €x€rnft pay€€ il you are no longer en sx€mpt pay€€
sndsnthipet€.r€ceivlh.{ riponebl€ Feymsnts in th€ fr.ilur€ lrom this
psr.!on. For.€*amFE. you meJ nsgd ro provids uFdal€d inftfftaflon if
you arc a.C ccrpolration thatehcls to bq an S corpAreliofi, ot fivou no
lonqelar+ lq' gx€mpt. ln sddition, you m!$ lurnieh.a n€w.Form W.9 if
th€ nam€ orTlN chengss.for lhq eccount: licrgxgmFh; ifth€ grafitor of e
!14ntor,lrust dhs,
Fenalties
FellurEio furnlrhTlH, lf you fail roturnleh yourcorisctTll.,l toa
MqU€$€r, yqu ere sub]€ct ta s Fenatty:61$5q forsach such iailure
unlose youf isllur€ is dus to ree.roaabh ceir€€ end not to willtril nsglsft.
Clsll Fdilelrlfor fslc€ l#crms[on wlrh ru*p€dt to rfflrhhbldlng, ll you
m3k€ afsles stat€m€nt with no reeronebl€ basG that r€sults in no
backup u/ithholding, you ar€ subFcila a t500 psiielly,
Nonr€€ldem rllqn who beooms s tr€ldefi allen; €snsfelly, onv a
nonrssident ell€n iidlv.iCual nray use the t€rmc ot e tax teaty io raduce
of slimindts u.s. tax oil eqn4in t/p€s of incorn€. l-kysbswf, most.t*
f€atieG4orilain a prcvisb0.knovn as e *seving cleuse.i' Exceptions
sF€cif i€d in lh€ seving chuse may Fsrmlt a! qx€nlFlb.n fforr l€tf ro
continu€ for csrtein typss ot hcome,evsn Afisr th€ peyss hai'othst14iss
hecom€ s U,S. residentalisn lof.t$( purFossg,
tf you sra e U.S. r€sklsnl alien who is r€Ving on en €xc€Ftion
contsinsd in thb seving cleus€ ot e lEx lr€ety 10 chim an €x€mption
froill U.S. tat on certain tvD€s 6f incom€. vou must attach e.stat€rn€nt
lo Forrh W"9 that EpBcifie:s the follo\#ing fiw itens.
1. -Ths tEely counlry. G€n€rally. this iriust b€ th€ sam€ trsety undar
whlch you chifi€d exemFtion from 1A)( es a nonr€skCsnt elt€n.
2, Th€ tr€EBenicb addressirig the incoma-
3. The articl€ number [or lodetbnl'ln ih€ tax traety that contains thegevinq chus€ gnd rts o(c€ptions.
, +, .Th€ typ€ ehd amoutll of incoms that quslifi€c tor th€ €xsmption
fron t€x,
. 5. Suf f icl€nt lacts to jusl iF/ th€ €i€ mption trorn tsr und€ r th€ t€rfirs offis lr€evenich.
Professional Services Agreement
Page22
FoJf, r W-S (tle!. I S?il r8J Pae3
Crltnlnsl Feiialrylor felrlttlng lrilormsrlon, \lillfully falsifyih€
osrtiticaticft$ or Afi irmat ions may subject you to c ri minal po nslt i€s
including filss and/or imprEonment.
MEll*eolTlNt. lf lhg rsqu€st€rdiecloss$or us€sTlNs in v'tolatlonaf
{sdarel hw. the Fquest€r msy be subj+rcr tobivila0d €rlminat pen4ftins-
Specitic lnstructions
Line I
Yo! rilust €nt€r ofii of rh€ follc\#ing on this lifi'€i do nor l€avlr this lin€
btank"'lhe nems should netch lh€ nem€ sn ytur.to< return,
ff thir Form.W:9 ls for e jgint accou nt [olh€r than en accqunt
fiaintained by a lor€ign financAl ilEtituthn IFFl]]. fEr first, end th€ n
circle, tha nams of lhs p€r,so.n or sntity' whoe€ num!er you snt€r€d ln
Pen I of Forrn W.g. lf tiou ers providiig Forn W-g to er FFI lo docum€nt
a Joint accounr. €ech holdsr ot th€ acccunt thatii a U.$. p*rson must
praviJe a Fornr V{.8.
a. lndlrlduel, Gene rally. gnt€i ths nams shoujn on your tax r€turn. lf
lou hew cheng€d your last name rvithout informing th€ Sc4hlS€cljrity
Admlninration [$SAl ot tfE namc ctrange. €ntsr yout iirst nam€. th€ hst
nsm€ a*sh{ylvn ot yOur.sCcial.securifycard, andyour ner,v lest namg,
time; ltlN appllcami Entsr laur indivldual name as itwes sntersd on
lour Form W.7 sFplicatlon. lins 1s. Thls sh6ub sl.so b6 rhd Eem€ e.s th€
nsms.you €ntsr.€don tha Form 104{/1{4,0A.{04.{EZ you filsdr,rrith your
epplhdtion.
b. 60l€ proprtetoror *ll6le.member LLC, Ent€r your individual
nerrre ae shd!#n on )(}!r 10.4.0f104.0A./1oq{EZ on lin€ 1. You fiey snt€r
your buslness, tracki. of "tlsing busin€sg as" pBAJ nemd on line 2.
c. Peff*lrshlp, LLC rhfl l€ ndt e rlngl€;msfibor LLC. C
rorporellon, or S.corporstlon, Entsr ths €ntity'€ nEm€ ai shown on th€
€ntityls te{ r€turn on ling 1 and any hUsinsss, fteds, or DBA neme on
lin€ 2,
d. Other endtlec, Ent€r your n€ms as shovn on.requimd U.$, lodsrel
lex documsnts on line L -This nems should mElch th€ n€rili .shotvn on th€
cherter or other hgildocument cmaiinE ths soti.ty. You may aniJrany
bu.slnsss, tisds, or DBA n€me on lin{i 2.
e Qlqrs6erdad 4mlv, F<ir U..S, fsdsrEltax purpos€s, en sntity thet te
drsr€gardad es en €nt it/.es farat€ f rom its fl/n€r is tr€at€d es a
'disngarded entity.!' 8{€ F€g uhtlons sgcticn 301.??01.2tdj[2]tii[. Entsr
fts cA#ner'.s narile on lins J. Tha nems of th€ entitv snter€d on lin€ 1
ehould ns\€r bs E diEr€gardad €ntity. Th€ name on lins 1 should H lhd
nsff€ sho,rrn on th€ incoms tsx rsturn on uJhhh th€ income should'be
lgponed. For€xempl€, fi e tor€ign LLC that is tr€at€d a,s a disr€qerdsd
€nl{ty for U.S. f€dereltsx purposes has a singl€ l}#nsr that h a U.S.
F€ rson, th€ U,g. fi#hsr's nam€ ie fdqulr€d to b€ Frov lCsd on lln€ I . It
th€.diEct or,vn€r ot th€ €nl ity iE elso e dhrsgsrdBi entiiy, enter the first
c$[Fr tha! is not dlsr€gardad for f€d€fql ts pufposis. Ent€t th€
dlsr€gerd€d sfitity's nam€ on.lins 2, 'Bu6in€ss name/dirregarded entity
riAmo." ll th€ d,i/n€i of th€ disregerd€d €ntrty ls a for€ign person. the
(wngr muEtcompl€t€ an epproprisl€ Fstm W.8.inst€ad of e Form W-9,
Thtq bthsce$a b!€n if ths for€iEn p41eon ft.asa U.S.nH.
Line.I.
lf lsu hella 5 busirrg.ss nemq, ttede nam€, DBA nams, or dlsr€gerd€d
€ntlttr nam€, !'oU may snt€r iton |ins 2.
Line S
Ch€ck thg eFpfoFrhte br)l( on lihs 3 lorthe U.S. f€d€relta*
cbBsjtio.ation oJ th€ Fsrson whos€ namq ls €nt€rsd on lln€ I , Check only
one hc'[ on lih€ 3.
Line 4, Exemptions
lf you are exempl irom hackupwhhholding encl/rrr FATCA regntling,
intef in th€ aFproprifia spaad on lihs + sny cod€(sl thal rbay sppv to
you.
Bempt peysa code,
. €ensralty, lndiylduats (includinq sola FropristotEl ar€ nol€x€mFtfrom
bdckuF $ithholdin€.
. Erc€pt e,s provided bslq#. corporetions ar€ bx€ryrFt trom backup
i,/ ithhelding toi i€ rtAin paym€ 0ts, incl uding int€ r€sr and div iCands.
. Corporathns are not €x€ m pt f rom bac kup wlth holding for paym*nts
mad€ in ssttlerddntol F4ymant c+rd or thrd psrlv nsrr,$rk trsn.lactions.
. Colporetbns er€ nnt€isrnptfrdn bahkrp wirhholdlng altfr rsspgct to
ettorn€ys' fis.e.or gross Froc€€ds paiC lo attorn€y$, end cotporations
th.t provld€ mgdicalor h€ahh catd .Edruic€s srs flot €x€rnFl with r€spsct
to Fayim€ntr reporleblr on Fsrm I0SS-M|SC,
Th.e folk:r,vlng ccde.s id€ntify pa.res.s thatere exempl.from backup
withholdlng. Ent€i. th6 epFro$iata coe ih rhe sfac€ in lh€ +,
'l-An organization €x€mft from tEX undar ssction s01[a]. eny IRA, or
e custodrel srcotlnt u[dsr,ssclion 4{3[b][?] if ths eccount satisfies ths
r€qu irsril€ nt6 of ssction 44 1 [it2l
2*Th€ Unit€d Stat€s or qny of.fts eg€nchs oi instrum€ntelit'Es
3-A stits, thd Dlstrict of Colunbh e U,.S. commonvreblth or
possassion, or any of thsir tDlitical eubdiiisions or instrumentelrtlss
4-:A forslgn gor,i€rnm€nt or eny of its political subdiviehnri, eg€nclBs,
or inslrumgnialities
5-A colporslion
6-A deel€r in struriti€.s or comftlcdities requlred to regist€r in th€
LJnit€d Statss, th€ District ot Columbh, ore.U.$. common\$ealth sr
Fggsdssiofi
i-AJutui*s comrn igsion msEhant regisrered with ltfC €oifimodity
Futures Trading Commission
8-A rsele$tats lnv€sim€nt tru,El
g-:An entily regletersdatsll timssduring lh€ tax'yBer undsrlhe
lnwstment Company Act of 194.{l
'l{ -A iomtrron tr!.st tund sperAt€d 4 + bank undar,sBction 584(e}
{ 1 -A finsncial ifistitution
12-A mirCdleman kncrrfh in th€ invcstmontcotrimunlty.e^sa nominss oi.
cuslodhn
1l - A.trust€xsffpt from tax undgr s€ctiorr 6t4 or dq.scnbad ln ssctk)n
49+7
Professional Services Agreement
Page 23
lF r4re emfulpeneon on lln6 1 l€
efn), . ,
THEN check tlte bax.for , , ,
. Corporatbn Corporat'nn
. lodivldual
r Sole Frqpri€tqrship, or
. Singh.msrnb€r limitsd lhbiliry
oompeBy [LLC] ov/n€d bv dn
indtrdui lnd disrflqenk'ator U.e.
hdsreltff purpos€s.
lhdiyiduetfsots propriAtor or singl€.
nEmb€f LLC
. LLC trsetsd a.E a [lAnn€rship for
U.,S, l€d€ rel tex furpqE€.s;. LLC thet haslil€d Fgrn 88f,2 frr'
2551 to b€ ls€d aE e cofForation,
oI'
. LLC thet isdilr€garded a,s en
0ntity s€Feret€ lrom it"g ot./n€r but
hd cl\{ner is arroth€r LLC thai ls
not dlsr€qerd€d bt U.S. f€ds rel tax
pufposs.s.
Limit€d liebility company and ente
fi€ epproprht€ lex ch^ssilicalion.
p= Parlnership; C=C cor:poratlon
s.S=.$ coiporationl
. Penn€r.shlp FennsrshiF
r Trui#egtatc Trusf/sstet€
Fornt !t.S iR*. rOZOr6t 6,--a
Th€
lor i
&oker F:te
s(€
sld
Fx€ry,pt
Fetronegs nds
$s,{osl
and dir€ct selss o|/lsr 1 throubh s2
mpt
orlhird pery
M- A ax exempt vust undsr a gdcriolr 4.(ll tb) plan or ssctkln 4€ ? bl
plan
tlqte;'Vou may wl*h to consult wlth ths llnenchl institutbn r€qu€€ting
this fofm to d€tertnine lehfth€r th€ FATtiA s€ds encilorsi€ ln pt paysi
iods should ba complBted.
Line 5
Enldr ltoureddrsss (ftumbst str€€t, and epenm€nt or suit€ nunber!,
This is whsre th€ requs$i€r of this Form l r,g will meil your irrtotmAtion
Et! tns" lt t h ls addre-rs differs f 1pm th€ on€ ih€ r.€qu€.st€r eksaih he^s on
file, writ€ l.lEWet lh€ top; lf e n€v/ addrsss is provijed, lh€r€ is stille
chanc€ ths. old eddrdss will bq u$sd uirtil ths pewi changss your
addr€iie in th€ir l€cord.E.
Llne d
Enur your.city, srali. and ZIF ccde.
Part l. Taxpalrer ldentifieation ttlumber fIlN|
Enrer your TIN ln th* epproprlate box. fi you ere a r€siJsnt ells n and
you do nor have and eid not €llgible to g€r an $SN, rcurTlN is your lR$
individuelte{pey€r idsntificatton number I,ItlNt, Entsi ir in th€ scchl
securlty number lnx. lf !i3! do not hatB'an lTlN, ssilHri,r/ togste lff{
b€low.
ll you ere a sole Fro$htor arld you hew gn El N, yo! rnay snt€ r €ith€r
youiSSN or ElN"
lf liou ers a slngls -tne mb€ r LLC fiet ls disr€osrdsd A.s an € ntity
.s€parale ffom ils oi.v[sfi €nt€r ths or,./n€r's SSN [or ElN. if th€ own€r hes
enbl, qo not€nt€ithd disrdgarded€ntity's ElN. llthb LLC iscla^$,silkdeE
4corporathn or Fannsrship. €nt€r the entiry's EIN;
l.lote; $ee l,Ifiaf /{afl,s and Nilfibar Io Gffe the f;squsshr, ht€ r, lor
ilnh€r chriflcAlion of nsm€ and TIN combinstlons,
Howto 0€taTlH, li you do not haw a TlN, epfV lor on€ imm€diat€V.
To eppv foran SSN. g€t Form S$.5, Application bre StrhlS€curity
Cerd, lrom your localSSA otflcs or g€t thb form onlln€ et
pu,u. $S,4. gnrr. You ffrarr elso gsuhG form Uy ca! iinO 1 -80fl . ? ?2. I i tl,
Use Form W.7; Appllcstlon for IRS thdiviCuelTaxpayqr idenrithetion
NUffb€r, to aFply for en lTlN, or Form S$.4, Appliiation for EmFldr,r\€r
ld€ntilication Number. toapptyforan ElN. Yo! can apij!{oren EIN
anlin€ by ac*€.gsing ths lRg.vl,sheit€ et 1{4t,u.A"s.gov/&Jsi,'ress€s and
clhking on Enploysr ldsntiticetion Nrimber (BNl und€tgHnihg e
Businsss..Go 1o.u^vl,u-,rsgEy/F6rfis to vh!'i. downloed, or print Form
W.l Ard/6i Fom SS-+, Or, liQu can go ro *vnv,i'3.gEv/6iderForinr to
Fbo€ an orclsr snd hs,!i€ Fbrm W-? endf.or Sg-+ meiledto Vou within 10
business days.
It you aie a.ek€d ro complel€ Fotm W.9 But do nrit haW e TlN. eppv
ftr a TIN and wriis "AFpliad Far" in tis $Face for lh€ JIN; sign end dat€
ths torm, End giv€ it to thd ldqu€s1€i. Fof. int€resl arid dlviCa nd
paym€nE, endc€rlain psymsnts mads \.iith rssp€cl to rqadily tradable
in,E{iumant$, oiifi€rally },oii Will haw S.0 deys lo gst a TIN and giw it ro
ths r€qu€st€r befon you er€ subFct.to backuplrrithholding on
paym€nls. The 6{.day ruh do€s not apply to cther typss ol Faymsil,E.
You will be sublrct to beckup withholdifiq on 4ll.such payiilsnts until
you proviJe yourTlN 10 tis r€qu€stsr.
l.loto; Ent€ring .ApFli€d For" me anb that you haue akaady applied lor a
1lN or that you int€nd to epplv tor on€ s{lpn.
Ceutlonr.A disrqgerded U€. snlity thst has a.lorelgn or*n€r must us€
th€ apFropr6ts Form W-€.
Fart ll. Cerlilication
To€6leblish toth€ wlthholding aqintthatl(DU €r€ aLl..s. psr$on. or
r€sidsntali€n, stgtt Form'W.6. You may bs rsqu€stsdlostln byth€
withholdinE eg€-nt s,ush il itsfi 1 . +, or s bslc)r# ifldketss.oth€rwis€,
tui.e ioirit eccounl cinly th€ person whos€ TIN ie ehc,\rin in Pen I
.shsuld.si!n lwh€n r€quirsq, ln th€ ces of e di.slggeided€nt ity, th€
psrson identilh'd on line t must sblr. Exdmpt fegs€6 .Eds E'refiFr psye€
codg serhor.
Slf,nelulg lEqullsmoms, ComFlst€ ths a€fiificetbn as indicatsd in
it€nc 1 through 5 bsleil/,
lrom
abo,!ta
Frymem ht
an.d divids
El-I p{yment Alsnipt(or,,,
AllsiBm s*cspt
Ih h+
an
th€y
.s;ils.s of
l rn..s Forr,l 10Sg-MISe, i,lieceltaneous lficorils, and its instruetions.
2 tlov,'ewr. the followino Blvm€nts mad€ to e corooration end
rsportebl€ on Form 10So-lilSC srs not €x€mpr tiom beckup
withholding: mediceland heehh cerc payirr€nts. attorn€ys' f€€s,. gtoss
pcceeds pad to an sttorn€y r€portabls undsr ssction 6.045(4, end
paym€nts lor.g€rviiss Fad by a fcdsrel€xscuti\i€ ag€ncy.
&don f rom FATCA rcpordng code, The lolbvring ccdes iCentify
FeJr's€s thet ar€ €x€mF! from r€poning undsi FATCA. Th€ss codsE
eFply to psrsons submittin's this form fi3r eccounts meintAinsd outsids
qf th€'lJnit€d Slel€e bV c€rtain tordign linanchl in,slitution$. Th€r€for€, if
you ers onV submin.ing thb torrn.for en account lou hold in.rh€ Unh€d
Stat€s, lr,ou ff'ay leer/€.lhiilisld blenk. Cdnsultwilh th€ p€rson
l€qu€sting thi.sform if you.ate unc€rtein if th€ fiBencht irciitution is
su bjsct to th€s€ r€qu irs rrr€ ntE. A rsqu€st€ r mey indicet€ that a code is
not r€quirsd bV FroviCing ) cu wirh e Form W.g luith "Not Applicabl€" lor
eny similAr indicet'ron) writtsn or print€d ctn th€ lins fcir e FATCA
oeemption code.
A-An orgenizetion exempt from iax under ssction sOJ (al or any
individual r€tir€m€nt Flan a.e dstin€d in section t i01 htt3 ?l
B-Th€ Unh€d Stet€s or any of its agenc i€s qr instrumsntelitiss
q -A .s{At€. th€ Sbtr'tcr of Cal0nbh, + U..$. commonwbalth dr
pos€sgrion: or eny $1 thsir political subdiv isions or instrum€nleliti€s
D-A corporetion the sto{k of r#hich b reguhrtyrraded on on€ or
ltDrs €steblish€d securitiss merk€ts, aE.d€€cribsd in Fie{uletbns
seiticn t.t+rz-t1c;p11i1
E-A corporation that is a msmb€r ol the same expanded ettiliet€d
glou p q.s a corpsretion d€sc rib€d in Fsg u t4lions .psction 1, 1a?2. 1 Fl [1] tl
F-A d€aler in s€cuillis,s. comtn€diti€s. or d€rivativ€ flnenciel
instrume nts {including not ionel Frinc ipal coniracts. f utu r€s, folMerds tiild 6ptions]lhit i! r€gisr€rCd e"s$u{h und€r th€.lalus of'the United
Stat€s or eny .gtet€
G -A reale$ate in,iestment trust
H-A requhte{ in\.sstm€nt com Fe.ny es dsilned in s€ction 8sl or en
€nrty'r€gists r€d sl 4lltim€s durin{ th€ t€x.y€sr u ndsi th€ lnwistment
Compeny Acr of 194.fl
l-A common trust,ftnd as dsfined in ssction S8+{el
J-A bank es d€finad in secticn s8i
K-A b'roker
L- A trust exempt frorr tex under s€ction SS4 or d€.sc ribed in s€ction
{a+{e}[1)
Professional Services Agreement
Page24
tu.nrW€iFlsv, le$rsl P"ss 5
1, lileFE€t, dlvldend, end barter excliange sccbufiis dpan{#
betol€ 1$&{ €nd broker eccount€ coneldei€d ectlva durino 1963,
You must givs yourcoff€ct TlN, but you do not haw to .sign th€
cFrtification.
I lntere*t, dlvldencl, broke r, snd barter ecchaffie sccounls
operfed qft6i l$de dr*t bfok€r socbunt* con*Hercd lnectlre durhd
1S63, You. m ust sign lhe certificatbn or bac kup withholdtng vrill appF.-lf
)pu erg .Eubjsct lo backuF l(ithholding end you srs m€rsly proliijing
lour coff.€ct TIN t0 th.s r€qusst€r, yo! must,cross out it€m 2 in th€.
csnifibathn bqtor€ signing th€ forrn.
f HEgl €6fsf€ iramactlons. You must sign thc c€nif icetion. You rile.r'
cross oul h€m 2 ot th€ c€rtification.
+ Other peymenls, You mlst Sivs your cor€ct TlN. but you ds not
hale io s&jn fi€ c€nification unhss you hev€ b€€n notif iddlhar you
hsve Fr€viously gimn an incorEctTlN. *Stherpeymsntg't inclu*i
paym€nts msde in th€ cours€ ot th€ ldqu€stsi's trad€ or busin€ss fof
r€ nts, royaltiss, g{rc{Ls [oth€r then bi lh tor m€rc hendh€l, rn€d hel and
hselth cer€ dlrvicei fincluding paymsntE to corporationsl, paym€ntq to
a non€m Fl{I/ae for servicss, Faymsnls mad€ in ,sttl€m€nt of payment
cerd 4rid thhd Fefly mhirbrk liansection.s, paym€nts !o ienAin fishinq
boel cr€w n€mbsrs snd fishermen. and gross pfttc€€ds paid to
attolneys [inc I udin g peyft € nts to csrForation.€I.
f niloilOrage lnreredl pald byyou, ecqulsltlon or abandonm6ntflf
aecurcd piopefly, csncolladonof debrr, quellfled tulrlsn Fro0rempeymefit€ lunder rectlon 5!9], ABLE sccouilts luirder secrlon 52sAi,
lRA, Cor€rdell eBA, Arclror MSA or HSA r,oiltrlbuions or
dbrrlbutlonf, hnd peffilondl€triburloffi. You must giw yourcorr€ct
TlN, brit you do not har/e to iigfi ths csrtificatioB.
What Name and Number To Give the Fequesler
For
nth
Fdhodture In tfF rianrB ofa pilbtc
Fldty € rch # a {tatF ai ts8l
gsi€lnf,rBnt, sclEel detlsl, or
pft sori} lhat Foqvgg agns/tunl
p rtlglaf,l pay ntBnis
l5- Grarior lruetihf, I rnder the Farm
l04l F'lr f, I Helicd sr tnEOfi oll{l
Forrn r0O0 Frl' ng lleltod I
ffiton I A7t-4(
namd EIN ofr
qBp*df,rcit TIE oubl,tr Bo ty
TIE lru6t
t,
FDrThE of sccouilt;GIv€ neme ettd 5€H otr
TtF
TIE actrsl s.JrErci{lhB ffiufit or, rl
cOdlbrn€d fufids. tlEfrrgt rfdrkrdual on
tr€ irtountl
E{*h rEadel of llE nr{ourtt
Tte nrm/
Trc gtantol-t.nt*'
TrB amua uvrmr'
Trp sfnerj
TtE glentof
daaftsl
I*g* enatl{
IIF Erooreloh
TIF o(gsftraton
ThF. partrpr€ht
TIF uret€rqtEnriffi
I Llstiir.stendchclq the name olth€ psr.son whcas numb€ryo! furnlsh.
ItonvOn€ Fsrson on a jilintaccount hdsan $SN, thel psrson'.s numbsf
filust b€ furnish€d.
: Circls ths minorrs name and furnish th€ minor's.S$N.
! You must sha'v/ iiour. indlviduel nam€ and vou mav elso €nt€r vour
busino.ss or DBA iamg on th€ "Busin€-ss neine/dirrbgarded cntity"
nems.lln€. You may Us€ dith€r l'sur.SsN or EIN [if you hevs on€], but th€
lR$encouraqesrlqu to use your $.SN.
{ Llgt tirst end ckcls the name of th€ trust, €stat€. or trsnsion trust. tD+
nol lurnish th€ TIN ofth€ p€rscnal r€Fr€.s€ntatiw ot trusl€€ unlq.ss ih€
lsgelsntiry ih{ilf ir notdssidnet€d in the eccount titl€.1 Alsos€s Speeial
riJ,bs.fal p|lr0lefshiilq sarlis r.
lNct$ Th€ grantor also m ust provld€ e Form W-g to trust€€ ol lrust,
Itlole; lf no nem€ GciFrlsdr#hsn mors than cn€ nam€ E listsd, th€
null1bar will b0 considsred to bs thal of ths f irEt nane li+ed.
Secure Your Tax Hecords From ldentity Theft
ldantity thett cccurs whe n somqons usss your p{rsonal lnlormetion
€uc h ,as you r fi enis. $Slr,l, or 6ther ids ntif yin g intormethfl , without you r
Fsrml4slon, to commit faud or oth€r crim€s. An ldanthy thkf rnay use
your ggN to g€t e lob or m4V fih a tsx rstlrn usi[{ lrlour$SN lo rscsivs
a rsfund.
To reduce your rigkr
' Frotect your SgM.
; Ensurs your smphryer k protecting pur 93N, and
. Ee carslul when chcosing a ar Freper€r.
!!yourtix rscdriJgers affect€d try lienthyth€ftandyou r,scgiw a
notic€ ffom th€ lRg, fqspond ihht ewer to thE name and phone number
print€d $n th€ IRS fiotic€ or htt€r,
ll yourtax rscord,E aje not cur€nt[/ eff€cted by ldentitg thelt but.you
think yeu ar€ et fEk due to a hst or giolsn Furbe df well€l, qqsslionablil
credit card aciivity or crsdil r€ Fort, contect th€ IRS ld€ntity Th€it Hotiine
st 1 .800.909.44S0 or .!1lbmil Form 14419.
F5r mdr€ infoimetion. s6e Fub. 5fl27, ld6ntity Th€ft lntormation lor
Texpeyers.
Victims of identhythsft who are experkncing economic herm or a
systemk Frabls#, orer€.ss€king h€lp in r€solving tax problsms$at
helE not bsen'r€soh€d through.normel channsls, may bs.€l'E ibh for.:
Taxpaysr Adlgcats $orvice ffASI "ssistarrce. You cari'r€ach TAS h/
celling ths TAS tall.freecaE€ intek€ lins et {.9??.7??.-+??8 oTTTYfTDD
1 "8fl0.829.4.05s.
Frolect yo urueli f ro m cusp lcloul €melld o r phlshl ng echem€*,
Fhi$hing isthe creatian end use of'emailgnd u*bsitesdesigned to.
nimic lsgitimat€ busin€qs smsils end luqbsitss. Th€ mosl common act
i,s,s€nding en emeil to e ussrlatssly chiming to be en €s'tabihh€d
lcgitimsts €nt€rprEs in an att€mptto scgm ih€ u€€i intosurbndsring
prlvet€ informstion that will b€ ussd for iJsntit/ thAft.
2 frjo qr ntore rndvrddals (tq fit
sE|oufit dtl€r lh4h en airo dnt
nnntarrxd by. an FFI
{ TriDor f,raB U.T. peEoffi
qom€E{odflt nrarit*rEd B an FF0
4: Ci€tldral acmunt sl * n\tfrl
iudftrnl 6ft to Mrrbra,!c9
g a. T16 'Jtual iEtoffibl€ saurEs trdt
{gJanbrrs €lso tfHl*)
b. S+aallEd iiuit'ataour|tthet is
4 lqtl or ldrd ttudt drdBf staie laVJ
A Sds pbprarior€h g o. dteGgd,d€d
€rtlt grarEd by enrrd't/rdlJ|,l
T,.Sltnlor trdt tl'ng lnd€r Oatonal
Forir U€6Fhrg MetH I Fes
El€gudtorB €*toft .l .g/r -d(blq0)
FDr thh ol
an
rrdvrdrral
4A lald trml, €sti.i6, or F€ffirgn trrEt
10. Coigoreton ar LLC dstrE
mrporatestetu on Fornr €842 or
Fornr't553
I t, Aglo(rsnbfl, ddn, ta'go'JE,
ChaitadB, edHioffl. or otlE. tilr-
s€nr0t oq+nraton
12. FafiffiEllp or fidt-f,ref,rbEr LLC
13. A blol(Fi ot €ltstE€d mtrrrF6
Professional Services Agreement
Page25
FbJfi !V-9 (FlFre. tG20rgl Pam 6
'The IRS do€s not inhiel€ conlacts wfth t€xFAy€rs vie €mail.e, Also, th€
lRgdo€s not r€qu€st persorial detEihd informetion thtough qmeilarerk
etrpayers iorthe plN numb€r.E. peesitrofds, or,gimilar ssc-rst qcc6ss
informatbn for th€ircr€dit card. bank, or oth€r linencial eccounts.
lf I$u rsc€irrE an un$olkit€dsmailcblming to be fram the lRg,
t$verd lhis msssag€ to pr}shl'1g@i,/,s.gcv. Ybu may also repon mi.quss
of the lRiS name, logo. or olh€r lRg propar.ty to th€ Tf€esury InsF€ctor
G€n€ralforTex Adminlstration rIIGTA! et l-8fl0.i158.44{4. You cen
brurard suspic ious i mail.e to th€ Fecli rel Trad6 Camm ission et
rparn@ilc€.grly cr ispoit th€m et tr,tr/rr.ltc.qsy/corfiptrifit you cen
contect th€ fTC at w',t4,v. flc. gsv/idths/t or 8 ? ? " l DTH E trT [g ? ?.4J8..t3381.
li IloU hew.F€n rh€ victim of id€ntity th{ft. isse $A,fi,(i"/denfityltelrgoy
end Fub. s02?.
Vish wnnu.rcgov.//AentityTh€ftto leErn more ebout idsntit/th€lt end
hc/r$ lo t€duc€ lioiji risk.
Privaey Act ltlollce
.g€clion ElCg otlhe lnt€r0al R{ri€nu€ Cods r€quir€s you to proviJe your
oorr€ct TIN to psrson.s {inCludjfig fqdsrsl aggnci€s} who are r€quiisd ro
lils inforffiation rst[rn€ with ths IRS to rspon int€isst; dividsnds. or
cartdn other incoms paidtoyou: nongeg€ int€r€styou peid: the
ecquisitbft or lbsndonm€nt of sccur€d propsnyi th€ mnc€llation of
dsbti oi conlributionslA)u mads to en lRA, ArclFr MSA. or HSA. The
psrson collsctin0 this fotm usss lh€ informatbn on ths form to f ils
informetiin r€turns with.th€ lB$. raporting _ths eto!,s inlorrnation,
Roulins usss ol lhis inlorrnalhn includs gfuing tt to th€ D€Fanm€nt of
JuSic€ for cMlland crimlnal lltigelion end to citi€s, .stet€s, lh€ Disvht ol
Columbir. end U.S. commonuisafthsend FoEs€.sshn.sfor us€ ln
adrfi iniq€ring th€ir taws. Th€ intormeliori dlso fuay bs di.eckresd to orhsr
countfi€s undor e tr€ev. to f€d€ralend slat€ ag€nchs taenforc€ civil
end crin inel laws. or to fsd€fel law €nloE€ment and int€lllg€ ncs
sq€nciss to corrlhst terrorbm, You must provtde $xur TIN wheth€r or
not i,a! aE r€quir€d to iil€ a te( r€turn. Und€r saction 34.08, paysrs
mu$ gansrally !'/ithhold e t €rclntags of tExebl€ int€r€st, divid€nd, end
oe neln oth€ r payments to a pay€€ who do€s not ghr€ e TIN to lhs peys r.
C'snein psnalllss may also eppV lor providinq feles or fraudulent
informati6n.
Professional Services Agreement
Page 26