HomeMy WebLinkAboutPhil Backlund Personal Services Agreement Sept 2021Personal Services Agreement
THIS AGREEMENT is entered into between KITTITAS COUNTY (hereinafter "the County'f or "Kittitas County"), a
political subdivision of the State of Washington, and
Name:
Address:
Project Contact:
Telephone #:
Email:
Phil Backlund
24L8 Wheaton Court
Ellensburg, WA 98926
Phil Backlund
509-3L2-93r7
Philip.Backlund@cwu.edu
(hereinafter "Contractor")
This Agreement is comprised of:
Attachment A - Scope of Work
Attachment B - Compensation
Attachment C - General Conditions
Attachment D - lnsurance
Attachment E - Retirement Status Form (signature required)
Attachment F - Contractor W-9 (must be completed and returned to the County for payment)
Copiesof which are attached hereto and incorporated herein bythis reference as if fullysetforth
The term of this Agreement shall commence on the 1st day of July,2O2L and shall be completed no later than
June 30, 2022, unless terminated or modified as provided elsewhere in this Agreement.
County's Address:
Kittitas County
205 W. 5th Avenue, Suite L08
Ellensburg, WA 98926
County Project Manager:
Name: Cory Wright
Title: Commissioner
Telephone #: 509-962-7508
Email: cory.wright@co.kittitas.wa.us
Page 1 of 18
PERSONAL SERVICES AGREEMENT
Contractor acknowledges and by signing this Agreement agrees that the lndemnification provisions set forth in
paragraphs 7 (lndependent Contractor),9 (Taxes), 15 (Defense and lndemnityAgreement), 21(Patent/Copyright
lnfringement) and 24 (Confidentiality), are totally and fully part of this Agreement and have been mutually
negotiated by the parties.
lN WITNESS WHEREOF, the parties have executed this Agreement this 7th day of September ,202L
APPROVED:
CONTRACTOR:
Phil Backlund
KITTITAS COU NTY, WASH I NGTON
Board of County Commissioners
Brett Wachsmith, Chairman
Laura Osiadacz, Vice Chair
Cory Wright, Commissioner
ATTEST:
n Clerk of the Board, Julie Kjorsvik
n Rdministrative Supervisor, Mandy Buchholz
n Rdministrative Assistant, Taylor Crouch
CONTRACT HAS BEEN APPROVED AS TO FORM BY
KITTITAS COUNTY DEPUTY PROSECUTING ATTORNEY
Sign re
Date Signed i,u,, 7 a ,2021\j
Page 2 of 18
PERSONAL SERVICES AGREEM ENT
ATTACHMENT ''A''
SCOPE OF WORK
Contractor shall provide ongoing consultation services on BoCC strategic plan development, implementation and
refinement.
Contractor to provide the following
One weekly 1-hour meeting with BOCC to determine plan component progress, identify additional needs and
troubleshoot issues related to plan implementation
Administration, implementation and weekly maintenance of Traction@ Tools software suite supporting work
necessary to execute strategic plan elements
One quarterly 4-hour strategic plan review workshop to refine plan elements, assess individual progress towards
plan elements and, if necessary, amend strategic plan elements.
a
a
a
Page 3 of 18
PERSONAL SERVICES AGREEMENT
ATTACHMENT.'B''
COMPENSATION
The County shall pay the Contractor the following compensation, which shall be invoiced to the County on the first of
each month after services are provided:
o $zOoO/month for services provided
. $tqg/month for reimbursement of Traction Tools license fee
o $tSO0 per quarterly workshop which will be payable upon submission of an invoice detailing the expense
lnvoices may be submitted to:
Julie Kjorsvik
205 West 5th Avenue, Suite L08
Ellensburg, WA 98926
iulie.kiorsvik@co.kittitas.wa.us
Page 4 of 18
t.
PERSONAL SERVICES AGREEM ENT
ATTACHMENT ''C"
GENERAL CONDITIONS
Scope of Contractor's Services: Contractoroagrees to provide to the County services and any materials
set forth in the project narrative identified in Attachment "A" during the Agreement period. No material,
labor, or facilities will be furnished by the County, unless otherwise provided for in the Agreement.
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 codes and ordinances.
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
4.7 "Additional lnsured's" means the County, its successors and assigns, and the respective directors,
ofiicers, employees, agents and representatives of the County and its successors and assigns.
4.2 "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.
4.3 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.
d ment for Contractor Payment to the Contractor for services rendered under
this Agreement shall be as set forth in Attachment "8". Where Attachment "B" requires payments by
the County, payment shall be based upon billings, supported unless otherwise provided in Attachment
"B", bv documentation of units of work actually performed and amounts earned, including where
appropriate, the total number of hours for the month and the total dollar payment requested. Unless
specifically stated in Attachment "8" 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.
THE COUNTY WILt NOT PROCESS PAYMENT FOR SERVICES RENDERED UNDER THIS AGREEMENT UNTII THE CONTRACTOR
suBMtTs A coMPIETED W-9 (SEE ATTACHMENT "F")
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 "B".
2.
3
5.
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PERSONAL SERVICES AGREEM ENT
6 Assignment and Subcontracting: 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.
7. lndependent Contractor: The Contractor's services shall be furnished b y 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 independent
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 Emplovment: 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.
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 indemnify 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 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.
Regulations and Requirement: This Agreement shall be subject to all laws, rules and regulations of the
United States of America, and State of Washington, and politicalsubdivisions of the State of Washington,
and to any other provisions set forth herein or in the Attachments.
9
L0
Page 5 of 18
PERSONAL SERVICES AGREEMENT
It. Risht to Review: This contract is su bject 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.
t2. Modifications:
Iz.L Either party may request changes in the Agreement. Any and all agreed modifications shall be in
writing, signed by each of the parties.
L2.2 The County may, at any time, by written notice thereof to Contractor ("Change Notice") make
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.
12.3 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.
I2.4 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 Notice that does not set forth any acceptable adjustment,
submit to the County a written statement setting forth any adjustment claimed.
L2.5 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.
Termination for Default: lf the Contractor defaults by failing to perform any of the obligations of the
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.
13.
Page 7 of 18
PERSONAL SERVICES AGREEMENT
lf a notice of termination for default has been issued and it is later determined for any 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.
74.Termination for P blic Conveni 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.
L5. Defense & lndemn The Contractor agrees to and shall defend, indemnify 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, when 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 bythe sole 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.
L6.lndustrial lnsurance 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 indemnify, 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.
L7 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.
Withholdins Pavment: 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
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Page 8 of 18
PERSONAL SERVICES AGREEM ENT
may, upon written notice, withhold all monies due and payable to Contractor, without penalty, until such
failure to perform is cured or otherwise adjudicated.
19. Future Non-Allocation 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'
20 Contractor Co mitments. Warranties and oresentations: The Contractor re presents and warrants to
the County as follows
20.L The Contractor is duly incorporated, validly existing and in good standing under the laws of the
State of Washington, and has all requisite corporate power and authority to enter into and to
perform its obligations under this Agreement.
20.2 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.
20.3 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.
20.4 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.
20.5 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.
20.6 The Contractor certifies that that it is not presently debarred, suspended, proposed for
debarment, declared ineligible or voluntarily excluded from covered transactions by any Federal
department or agency.
20.7 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.
Page 9 of 18
PERSONAL SERVICES AGREEMENT
21. Patent/Coovrisht lnfrin gement: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:
21'.L Contractor shall be notified promptly in writing by County of any notice of such claim
21.2 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 claim of infringement is made,
provided no reduction in performance or loss results to the County.
22. Disputes:
22.t 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 County 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.
22.2 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 additional time claimed to be
additional.
22.3. 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.
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.
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Page 10 of 18
24.
PERSONAL SERVICES AGREEM ENT
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 upon the prior written consent of the Kittitas County Prosecuting Attorney or
an order entered by a court after having acquired jurisdiction over the County. Contractor shall
immediately give to the County notice of any judicial proceedings seeking disclosure of such information'
Contractor shall indemnify 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.
Notice: Except as iet 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, the County Project Manager (listed on page L of this Agreement) and
to the Kittitas County Board of County Commissioners, 205 W 5th 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.
26 Severabilitv: 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.
27. Miscellaneous:
27.r The County'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.
27.2 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.
27.3 The rights and remedies of the County 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 County by any other
provisions of this Agreement, by any of Contractor's Support or by law.
27 .4 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.
25.
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28
PERSONAL SERVICES AGREEM ENT
29
Waiver: 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.
Survival: The provisions of paragraphs 7, g, I!, !3, L4, !5, L6, 17 , 18, !9, 20, 2L, 22, 23, 24,28, 30, and
31, shall survive, notwithstanding the termination or invalidity of this Agreement for any reason'
30. Nondisc mination
30.1 The County is an equal opportunity employer.
30.2 Nondiscrimination in Emplovment: 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.
30.3 Nondiscrimin ion 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.
30.4 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.
3I Prevailing Wage: 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.L2 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.
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PERSONAL SERVICES AGREEM ENT
Contractor verifies that it meets the requirements set forth in RCW 39.04.350 by certifying that either
the Contractor has received training on prevailing wage and public works requirements or that the
Contractor is exempt from this training because they have completed three or more public works
projects and have had a valid Washington business license for three or more years.
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'
32.Time is of Essence: Time is of the essence in the performance of this contract unless a more specific time
period is set forth elsewhere in this Agreement.
33. Construction: This Agreement has been mutually reviewed and negotiated bythe parties and should be
given a fair and reasonable interpretation and should not be construed less favorably against either
party.
34.Standard of Care: The Contractor shall perform its duties hereunder in a manner consistent with that
degree of care and skill ordinarily exercised by members of the same profession as Contract currently
practicing under similar circumstances. The Contractor shall, without additional compensation, correct
those services not meeting such a standard.
35 Asreement Not for Benefit of Third Parties: This Agreement is entered into solely for the benefit of the
parties hereto and vests no rights in, or is it enforceable by, any third parties.
Page 13 of 18
PERSONAL SERVICES AGREEM ENT
ATTACHMENT ''D,'
INSURANCE
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.
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-L5 WAC.
The Contractor shall provide proof of insurance for:
X Commercial General Liabilitv lnsurance.' coveralli;ffiIrlll'lil;.nce
per project
o $2,000,000 general aggregate
o $1,000,000 products & completed operations aggregate
o $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
r Sixty (60) days written notice from Contractor to the County of cancellation of the
insurance policy.
Commercial Automobile Liabilitv I nsurance
. 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:
o $1-,000,000 combined single limit
' Thirty (30) days written notice from Contractor to the County of cancellation of the
insurance policy.
Excess or Umbrella Liabilitv.
The Contractor shall provide Excess or Umbrella Liability coverage at limits of S1,000,000
per occurrence and annual aggregate. This Excess or Umbrella Liability coverage shall
Page 14 of 18
PERSONAL SERVICES AGREEM ENT
I
apply, at a minimum, to both the Commercial General and Auto lnsurance policy
coverage.
This requirement may be satisfied instead through the Contractor's primary Commercial
General and Automobile Liability coverage, or any combination thereof.
X Workers' Compensation.
. Workers' Compensation in amounts required by law.
Stop Gap/Emplovers Liabilitv.
. Coverage limits not less than:
o $1,000,000 each accident
o $1,000,000 disease - policy limit
o $1,000,000 disease - each employee
. Thirty (30) days written notice from Contractor to the County of cancellation of the
insurance policy.
Contractor shall furnish to the County a Certificate of lnsurance with Endorsement as evidence that policies
providing insurance required by this Agreement are in full force and effect, and name the County as additional
insured, excluding i) Workers Compensation and ii) Commercial Automobile Liability, where County will not be
named additional insured. Contractor hereby waives all rights of recourse 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 lnsurance with Endorsement, properly
completed and in the amount required, is attached hereto.
Page 15 of 18
ATTACH NT ''E"
RETTREMENT STATUS FORM (STGNATURE REQUTRED)-COUNTY RETAINS THIS FORM
ALL CONTRACTORS, SERVTCES CONTRACTORS, AND INDEPENDENT CONTRACTORS MUST COMPTETE AND SIGN
sEcTlON 1: CONTRACTOR COMPLETES THIS SECTION:
Did you retire from one of the State of Washington Retirement Systems?
Did you retire before age 65 using the 2008 early retirement factors (ERF)?
Will you be receiving direct compensation for these services?
Will you be receiving indirect compensation for these services?
CoNTRACTOR (Full of ntractor as in DRS filings-Please Print):
Signature:Last Four Digits of Social Security No.
Yes .k'No
Yes -ti 'No
;Y'ves - No
- Yes }1t{o
lr^-*./
Date:r'?t,/t4eL.''7 .':
,?c./---,-/ /
'/SECTION 2: COUNTY 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?
-
Yes
-
No
lf yes, which system and plan?
_ Teacher's Retirement System (TRS)
-
Plan L
-
Plan 2
-
Plan 3
_ School Employees' Retirement System (SERS) _ Plan 2 _ Plan 3
_ Public Employees' Retirement Systems (PERS) _ Plan 1- _ Plan 2 _ Plan 3
_ Public Safety Employees' Retirement System (PSERS) _ Plan 2
_ Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) _ Plan l- _ Plan 2
_ Washington State Patrol Retirement System (WSPRS) _ Plan 1- _ Plan 2
_ Judicial Retirement System (JRS)
2. ls the Contractor a retiree of a Washington State Retirement System?
3. Did the Contractor retire before age 65 using the 2008 ERF?
I have verified the information above using MRV or by contacting DRS
COUNTY REPRESENTATIVE (Please Print):
Date:
Yes
Yes
No
No
Signature
COUNTY RETAINS THIS FORM
Page 16 of 18
PERSONAL SERVICES AG REEM ENT
ATTACHMENT "F''
Form W-9
Request for Taxpayer ldentification Number and Certification
SAMPLE FORM ON NEXT PAGE
Please to go to https://www.irs.eov/pub/irs-pdf/fw9'pdf to
complete the current version of Form W-9 (as released by the
IRS), then submit the completed form with this Agreement.
Page 17 of 18
PERSONAL SERVICES AGREEM ENT
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Page 18 of 18
Request for Taxpayer
Identification Number and Certification
JI-Go to www.irs.gov/FormW9 for instructions and the latest information.
1is 'line; do not leave this line b lank.
C'i a, 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the g> following seven boxes.
§ 1'5:r Individual/sole proprietor or
ai � r single-member LLC
D C Corporation D S Corporation D Partnership D Trust/estate
Cl. 0 Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) � ___ _ �� D
� 2 Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check
£ 1'.1 LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
._ -another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
c..g is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Give Form to the
requester. Do not
send to the IRS.
4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
Exempt payee code (if any) ----
Exemption from FATCA reporting
code (if any)
·c:; D Other (see Instructions) .... (Applies lo accaunls maintained outside Iha U.S.) t% l----5'=A"'d..,.d-'-
'8-s-'s-(:....n_um-be;.;:. .. r..;...;.st:..; .. rei.;.;:._e.:.:1t "-'a-n""d_a_�-,7-.o-r-su"",l.,..ttee----,-Jo-.)-S_e_e""l -ns_t_ru _c..,.tlo_n_s_. -------------r-=:R-eq_u_es_te-r',--s_n_a _m_e_a._n-:d -a-:d-,dr-e-ss---,-(o-p-:ti -on-a--::1) _____ _
J 1 lf Ill U)lfe'/t,1,-, &-t (_ I 6 City, state, and ZJP code
:.... �t 11>-/) {12
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Social security number
or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to·enter.
I Employer Identification number
Certification
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.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4.The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA}, and generally, payments
other than interest and dividends, you ar:e not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. /'l ,, ,, /
General lnstructio s
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
•Form 1099-INT (interest earned or paid)
Cat. No. 10231X
•Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
•Form 1099-8 (stock or mutual fund sales and certain other
transactions by brokers)
•Form 1099-S (proceeds from real estate transactions}
•Form 1099-K (merchant card and third party network transactions)
•Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
•Form 1099-C (canceled debt)
•Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Form W-9 (Rev. 10-2018)
Form W-9 (Rev. 1 0-2018)eage2
By signing the filled-out form, you:
1. Cenify 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. exbmpt
payee. lf applicable, you are also certifying that as a U.S. person, your
allocable share of any parlnership income from a U.S. trade or business
is not subject to the withholding tax on foreign partners' share of
effeciively connected income, and
4. Cedify that FATCA code(s) entered on this form (if any) indicating
that you are exempt from the FATCA reporting, is correct. See Whaf ls
FATCA repofting, later, for further information.
Note: lf you are a U.S. person and a requester gives you a form other
than Form W-9 to request your TlN, you must use the requester's form if
it is substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
. An individual who is a U.S. citizen or U.S. resident alien;
. A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States;
. An estate (other than a foreign estate); or
. A domestic trust (as defined in Regulations section 301 .7701-7).
Special rules for pannerships. 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 cedain 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 1 446 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.
ln 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.
. ln the case of a disregarded entity with a U.S. owner, the U.S. owner
ofthe disregarded entity and not the entity;
o ln 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
. ln the case of a U.S. trust (other than a grantor trust), the U.S. kust
(other than a grantor trust) and not the beneficiaries of the trust.
Foreign person. lf 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. lnstead, use the appropriate Form W-8 or Form 8233 (see
Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
Nonresident alien who becomes a resident alien. Generally, only a
nonresident alien individual may use the terms of a tax treaty to reduce
or eliminate U.S. tax on certain types of income. However, most tax
treaties contain a provision known as a "saving clause." Exceptions
specified in the saving clause may permit an exemption from tax to
continue for cedain types of income even after the payee has otherwise
become a U.S. resident alien for tax purposes.
lf you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an exemption
from U.S. tax on certain types of income, you must attach a statement
to Form W-9 that specifies the following five items.
'1 . The treaty country. Generally, this must be the same treaty under
which you claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the
saving clause and its exceptions.
4. The type and amount of income that qualifies for the exemption
from tax.
5. Sufficient facts to justify the exemption from tax under the terms of
the treaiy article.
Example. Article 20 of the U.S.-China income tax treaty allows an
exemption from tax for scholarship income received by a Chinese
student temporarily present in the United States. Under U.S. law, this
student will become a resident alien for tax purposes if his or her stay in
the United States exceeds 5 calendar years. However, paragraph 2 of
the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows
the provisions of Article 20 to continue to apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of the first
protocol) and is relying on this exception to claim an exemption from tax
on his or her scholarship or fellowship income would attach to Form
W-9 a statement that includes the information described above to
support that exemption.
lf 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%;o ot such
payments.
subject to
dividends,
This is called "backup withholding." Payments that may be
backup withholding include interest, tax-exempt interest,
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 TlN, make the proper
certifications, and report all your taxable interest and dividends on your
tax return.
Payments you receive will be subject to backup withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the instructions for
Part ll for details),
3. The IRS tells the requester that you furnished an incorrect TlN,
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 1 983 only).
Cedain payees and payments are exempt from backup withholding.
See Exempt payee code, later, and the separate lnstructions for the
Requester of Form W-9 for more information.
Also see Special rules for partnerships, earlier.
What is FATCA Reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a
participating foreign financial institution to report all United States
account holders that are specified United States persons. Certain
payees are exempt from FATCA reporting. See Exemption from FATCA
repofting code, laler, and the lnstructions for the Requester of Form
W-9 for more information.
Updating Your lnformation
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. ln addition, you must furnish a new Form W-9 if
the name or TIN changes for the account; for example, if the grantor of a
grantor trust dies.
Penalties
Failure to furnish TlN. lf 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. lf 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. 1 0-2018)Page 3
Criminal penalty for falsifying information' Willfully falsifying
certifications or affirmations may subject you to criminal penalties
including fines and/or imprisonment.
Misuse of TlNs, lf the requester discloses or uses TlNs in violation of
federal law, the requester may be subiect to civil and criminal penalties.
Specific lnstructions
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'
lf this Form W-9 is for a joint account (other than an account
maintained by a foreign financial institution (FFl)), list first, and then
circle, the name of the person or entity whose number you entered in
Part I of Form W-9. lf 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. lndividual. Generally, enter the name shown on your tax return. lf
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: lTlN applicanti Enter your individual name as it was entered on
your Form W-7 application, line 1a. This should also be the same as the
name you entered on the Form 1040/10404/1040EZyou filed with your
application.
b. Sole proprietor or single-member LLC. Enter your individual
name as shown on your 1040/1040N104OE2 on line 1. You may enter
your business, trade, or "doing business as" (DBA) name on line 2.
c. Partnership, LLG that is not a single-member LLC' C
corporation, or S corporation. Enter the entity's name as shown on the
entity's tax return on line 1 and any business, trade, or DBA name on
line 2.
d. Other entities, Enter your name as shown on required U.S. federal
tax documents on line 1. This name should match the name shown on the
charter or other legal document creating the entity. You may enter any
business, trade, or DBA name on line 2.
e. Disregarded entity. For U.S. federal tax purposes, an entity that is
disregarded as an entity separate from its owner is treated as a
"disregarded entity." See Regulations section 301.7701-2(c)(2)(iii). Enter
the owner's name on line 1. The name of the entity entered on line 1
should never be a disregarded entity. The name on line 1 should be the
name shown on the income tax return on which the income should. be
reported. For example, if a foreign LLC that is treated as a disregarded
entity for U.S. federal tax purposes has a single owner that is a U.S.
person, the U.S. owner's name is required to be provided on line 1. lf
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." lf 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. TlN.
Line 2
lf 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.
Line 4, Exemptions
lf you are exempt from backup withholding and/or FATCA reporting,
enter in the appropriate space on line 4 any code(s) that may apply to
you.
Exempt payee code.
r Generally, individuals (including sole proprietors) are not exempt from
backup withholding.
. Except as provided below, corporations are exempt from backup
withholding for certain payments, including interest and dividends.
. Corporations are not exempt from backup withholding for payments
made in settlement of payment card or third party network transactions.
. Corporations are not exempt from backup withholding with respect to
attorneys' fees or gross proceeds paid to attorneys, and corporations
that provide medical or health care services are not exempt with respect
to payments reportable on Form 1099-M|SC.
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 lRA, or
a custodial account under section 403(bX7) if the account satisfies the
requirements of section 401(De)
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 commodiiies 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
lnvestment Company Act of 1940
10-A common trust fund operated by a bank under section 584(a)
1 1 -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
lF the entity/person on line 1 is
a(n) ...
THEN check the box for
. Corporation Corporation
. lndividual
. Sole proprietorship, or
. Single-member limited liability
company (LLC) owned bY an
individual and disregarded for U.S.
federal tax purposes.
lndividual/sole proprietor or single-
member LLC
. LLC treated as a padnership for
U.S. federal tax purposes,
o LLC that has filed Form 8832 or
2553 to be taxed as a 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.
Limited liability company and enter
the appropriate tax classif ication.
(P= Partnership; C= C corporation;
or S= S corporation)
. Partnership Partnership
o Trust/estate Trust/estate
Form W-9 (Rev. 10-2018)eage4
The following chart shows types of payments that may be exempt
from backup withholding. The chart applies to the exempt payees listed
above, l through 13.
lF the payment is for THEN the payment is exempt
for...
lnterest 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
patronage dividends
Exempt payees 1 through 4
Payments over $600 required to be
reported and direct sales over
$5,0001
Payments made in settlement of Exempt payees 1 through 4
payment card or third party
transactions
1 See Form 1099-MlSC, Miscellaneous lncome, and its instructions.
2 Ho*eu"r, the following payments made to a corporaiion and
reportable on Form 1099-MISC are not exempt from backup
withholding: medical and health care payments, attorneys'fees, gross
proceeds paid to an attorney reportable under selction 6045(0, and
payments for services paid by a federal executive agency.
Exemption from FATGA 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 {inancial 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 I.1 472-1 (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(cX1Xi)
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 lnvestment
Company Act of 1940
l-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
4e47(a)(1)
M-A tax exempt trust under a section 403(b) plan or section 457(9)
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. lf this address differs from the one the requester already has on
file, write NEW at the top. lf 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 l. Taxpayer ldentification Number (TIN)
Enter your TIN in the appropriate box. lf 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 (lTlN). Enter it in the social
security number box. lf you do not have an lTlN, see How to get a TIN
below.
lf you are a sole proprietor and you have an ElN, you may enter either
your SSN or ElN.
lf you are a single-member LLC that is disregarded as an entity
separate from its owner, enter the owner's SSN (or ElN, if the owner has
one). Do not enter the disregarded entity's ElN. lf the LLC is classified as
a corporation or partnership, enter the entity's ElN.
Note: See What Name and Number To Give the Requester, later, for
further clarification of name and TIN combinations.
How to get a TlN, lf you do not have a TlN, 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 lndividual Taxpayer ldentification
Number, to apply for an lTlN, or Form SS-4, Application for Employer
ldentification Number, to apply for an ElN. You can apply for an EIN
online by accessing the IRS website alwww.irs.gov/Bustnesses and
clicking on Employer ldentification Number (ElN) under Starting a
Business. Go to www.irs.govlForms to view, download, or print Form
W-7 and/or Form SS-4. Or, you can go lo www.irs.gov/OrderForms Io
place an order and have Form W-7 and/or SS-4 mailed to you within 10
business days.
lf you are asked to complete Form W-9 but do not have a TlN, apply
for a TIN and write "Applied For" in the space for the TlN, 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.
Noter 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 ll. 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). ln 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 cedification as indicated in
itemslthrough5below.
Generally, exempt payees
1 through 52
Form W-9 (Rev.10-2018)Page 5
1. lnterest, dividend, and barter exchange accounts opened
before 1984 and broker accounts considered active during 1983'
You must give your correct TlN, but you do not have to sign the
certification.
2. lnterest, dividend, broker, and barter exchange accounts
opened after 1983 and broker accounts considered inactive during
1983. You must sign the certification or backup withholding will apply. lf
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 cedification.
4. Other payments. You must give your correct TlN, but you do not
have to sign the certification unless you have been notified thai you
have previously given an incorrect TlN. "Other payments" include
payments made in the course of the requester's trade or business for
rents, royalties, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to
a nonemployee for services, payments made in settlement of payment
card and third party network transactions, payments to certain fishing
boat crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified tuition program
payments (under section 529), ABLE accounts (under section 529A)'
lRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct
TlN, 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:
For this type of account:Give name and EIN of:
14. Accouni with 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
1 5. Grantor trust filing under the Form
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
section 1.671-4(bX2)(iXB)
1 List first and circle the name of the person whose number you furnish.
lf only one person on a ioint account has an SSN, that person's number
must be furnished.
2 Circle the minor's name and furnish the minor's SSN.
3 You must show your individual name and you may also enter your
business or DBA name on the "Business name/disregarded entity"
name line. You may use either your SSN or EIN (if you have one), but the
IRS encourages you to use your SSN.
a 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 Specra/
rules for parlnershps, earlier.
*Note: The grantor also must provide a Form W-9 to trustee of trust.
Note: lf 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 ldentity Theft
ldentity theft occurs when someone uses your personal information
such as your name, SSN, or other identifying information, without your
permission, to commit fraud or other crimes. An identity thief may use
your SSN to get a job or may file a tax return using your SSN to receive
a refund.
To reduce your risk:
r Protect your SSN,
r Ensure your employer is protecting your SSN, and
e Be careful when choosing a tax preparer.
lf your tax records are affected by identity theft and you receive a
notice from the lRS, respond right away to the name and phone number
printed on the IRS notice or letter.
lf your tax records are not currently affected by identity theft but you
think you are at risk due to a lost or stolen purse or wallet, questionable
credit card activity or credit report, contact the IRS ldentity Theft Hotline
at 1 -800-908-4490 or submit Form 1 4039.
For more information, see Pub. 5027, ldentity Theft lnformation for
Taxpayers.
Victims of identity theft who are experiencing economic harm or a
systemic problem, or are seeking help in resolving tax problems that
have not been resolved through normal channels, may be eligible for
TaxpayerAdvocate Service [IAS) assistance. You can reach TAS by
calling the TAS toll-free case intake line al 1-877-777-4778 or ITYIIDD
1 -800-829-4059.
Protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of email and websites designed to
mimic legiiimate business emails and websites. The most common act
is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
private information that will be used for identity theft.
The trust
1. lndividual
2. Two or more individuals (oint
account) other than an account
maintained by an FFI
3. Two or more U.S. persons
(oint account maintained by an FFI)
4. Custodial account of a minor
(Uniform Gift to Mlnors Act)
5. a. The usual revocable savings trust
(grantor is also trustee)
b. So-called trust account that is not
a legal or valid trust under state law
6. Sole proprietorship or disregarded
entity owned by an individual
7. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Regulations section 1.671 -4(bX2Xi)
(A))
For this of accountl
8.not owned by an The owner
individual
9. A valid trust, estate, or pension trust
10. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
The individual
The actual owner of the account or, if
combined funds, the lirst individual on
the accountl
Each holder of the account
The minor2
The grantor-trusteel
The actual ownerl
-,3I ne owner
The grantor"
Give name and EIN of:
Legal entitya
The corporation
The organization
The partnership
11. Association, club, religious,
charitable, educational, or other tax-
exempt organization
12. Partnership or multi-member LLC
1 3. A broker or registered nominee The broker or nominee
Form W-9 (Rev. 10-2018)eage 6
The IRS does not initiate contacts with taxpayers via emails. Also' the
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers, passwords, or similar secret access
information for their credit card, bank, or other financial accounts.
lf you receive an unsolicited email claiming to be from the lRS,
forward this message to phishing@irs.9ov. You may also report misuse
of the IRS name, logo, or other IRS property to the Treasury lnspector
General for Tax Administration (IIGTA) at 1-800-366-4484' You can
forward suspicious emails to the Federal Trade Commission at
spam@uce.gov or report them at www.ftc.govlcomplaint' You can
contact the FTC al www.ft c. g ov / i dth eft or 87 7 -lDf H EFT (877-438-4338).
lf you have been the victim of identity theft, see www.ldentityTheft.gov
and Pub. 5027.
Visit www.ns.gov/ldentityTheft lo learn more about ideniity theft and
how to reduce your risk.
Privacy Act Notice
Section 61 09 of the lnternal 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 lRA, Archer MSA, or HSA. The
person collecting this form uses the information on the form to file
information returns with the lRS, reporting the above information.
Routine uses of this information include giving it to the Department of
Justice tor 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 enlorce 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
informaiion.