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Amendment No. 1 to the Agreement with Miami-Dade County
2 O I a - 2.9 24-s A, THE CITY OF MIAMI BEACH IDENTIFICATION ASSISTANCE PROGRAM CONTRACT#: PC-1617-ID-2 AMENDMENT#1 OF THE AGREEMENT BETWEEN MIAMI-DADE COUNTY AND THE CITY OF MIAMI BEACH IDENTIFICATION ASSISTANCE PROGRAM CONTRACT#: PC-1617-ID-2 HIS AMENDMENT #1 OF THE AGREEMENT (the "Agreement Amendment #1") is made as of PlarUIQ► 2S,747 by and between Miami-Dade County, through the Miami-Dade County Homeless Trust (the "County') and The City of Miami Beach, (the "Provider), a recipient of grant funds to serve homeless individuals. WITNESSETH: WHEREAS, on January 19, 2016, the County and the Provider entered into a Grant Agreement ("Agreement") which provides funding for the provision of emergency housing and supportive services to homeless individuals and families in Miami-Dade County. WHEREAS,the Agreement provides for certain rights and responsibilities of the County; and WHEREAS,the Agreement allows for amendments and extensions at the sole discretion of the County; and WHEREAS, the County is desirous of extending and amending the Agreement for one (1) additional year pursuant to the terms of the Agreement; NOW, THEREFORE, BE IT RESOLVED, for and consideration of the mutual agreements between the County and the Provider, which are set forth in this Amendment#1 of the Agreement,the receipt and sufficiency )of which are acknowledged,the County and the Provider amend this Agreement as follows: ? ARTICLE I—Recitals The foregoing recitals are true and correct and constitute a part of this Amendment#1 of the Agreement. ARTICLE II—Amendments The Agreement is hereby amended as follows: Article 2 is replaced as follows: ARTICLE 2. AMOUNT PAYABLE. Subject to available funds, the maximum amount payable for services rendered under this contract shall not exceed: IDENTIFICATION ASSISTANCE PROGRAM $ 25,000.00 THE CITY OF MIAMI BEACH ' IDENTIFICATION ASSISTANCE PROGRAM CONTRACT#: PC-1617-ID-2 Both parties agree that should available Miami-Dade County funding be reduced, the amount payable under this Contract may be proportionately reduced at the sole discretion and option of the County. All services undertaken by the Provider before the County's execution of this Contract shall be at the Provider's risk and expense. It is the responsibility of the Provider to maintain sufficient financial resources to meet the expenses incurred during the period between the provision of services and payment by the County. The County, at its sole discretion,may allow Provider an advance of N/A once the Provider has submitted an appropriate request and submitted an invoice in the form required by the County. Article 4 is replaced as follows: ARTICLE 4. BUDGET SUMMARY The Provider agrees that all expenditures or costs shall be made in accordance with the revised 2016-2017 Budget,which is attached hereto and incorporated herein as Attachment B. The parties agree that the Provider may, with the County's prior written approval, revise the line item budget, and such revision shall not require an amendment to this Contract. Pursuant to Board of Miami-Dade County Commissioners' Resolution Number R-630-13, the Provider will submit a detailed project budget, and sources and uses statement as Attachment B, which shall be sufficiently detailed to show (i) the total project cost, (ii) the amount of funds to be used for administrative and overhead costs, (iii) whether the County funds will be 'gap' funds meaning that they would be the last remaining funds needed to ensure funding for the total project cost,(iv) any profit to be made by the Provider, and(v)the amount of funds devoted toward the provision of the desired services or activities. The County Mayor or Mayor's designee may make unannounced, on-site visits during normal working hours to the Provider's headquarters and any location or site where the services contracted for under this Agreement are performed. Article 5 is replaced as follows: ARTICLE 5. EFFECTIVE TERM Both parties agree that the Effective Term of this Contract shall continue to commence on October 1,2016 and terminate at the close of business on September 30,2017. Contingent on the existence of sufficient funding, the provider's performance and the approval of the County may be extended for one (1) additional one(1)year term, at the County's sole discretion. 2 THE CITY OF MIAMI BEACH IDENTIFICATION ASSISTANCE PROGRAM CONTRACT#: PC-1617-ID-2 Article 10 is replaced as follows: ARTICLE 10. CIVIL RIGHTS The Provider agrees to abide by Chapter 11A of the Code of Miami-Dade County ("County Code"), as amended, which prohibits discrimination in employment, housing and public accommodations on the basis of race, color, religion, color, sex, familial status, marital status, sexual orientation, pregnancy, age, ancestry, national origin, disability, gender identity, gender expression or actual or perceived status as a victim of domestic violence, dating violence or stalking; Title VII of the Civil Rights Act of 1968, as amended, which prohibits discrimination in employment and public accommodation; the Age Discrimination Act of 1975, 42 U.S.C. 0.101, as amended, which prohibits discrimination in employment because of age; the Rehabilitation Act of 1973, 29 U.S.C. §794, as amended, which prohibits discrimination on the basis of disability; the Americans with Disabilities Act, 42 U.S.C. §12101 et seq., which prohibits discrimination in employment and public accommodations because of disability; the Federal Transit Act, 49 U.S.C. §1612, as amended; and the Fair Housing Act, 42 U.S.C. §3601 et seq. It is expressly understood that the Provider must submit an affidavit attesting that it is not in violation of the Acts. If the Provider or any owner, subsidiary, or other firm affiliated with or related to the Provider is found by the responsible enforcement agency, the Courts or the County to be in violation of these acts,the County will conduct no further business with the Provider. Any contract entered into based upon a false affidavit shall be voidable by the County. If the Provider violates any of the Acts during the term of any contract the Provider has with the County, such contract shall be voidable by the County, even if the Provider was not in violation at the time it submitted its affidavit. The Provider agrees that it is in compliance with the Domestic Violence Leave, codified as § 11A-60 et seq. of the Miami-Dade County Code, which requires an employer, who in the regular course of business has fifty (50) or more employees working in Miami-Dade County for each working day during each of twenty (20) or more calendar work weeks to provide domestic violence leave to its employees. Failure to comply with this local law may be grounds for voiding or terminating this Contract or for commencement of debarment proceedings against Provider. ARTICLE III—Ratification of the Agreement Other than expressly modified or amended herein, all other terms and conditions of the Agreement shall remain in full force and effect. SIGNATURES APPEAR ON THE FOLLOWING PAGE 3 , THE CITY OF MIAMI BEACH"' " IDENTIFICATION ASSISTANCE PROGRAM CONTRACT#: PC-1617-ID-2 IN WITNESS WHEREOF, the parties have caused this four (4) page Amendment#1 of the Agreement to be executed by their respective and duly authorized officers the day and year first above written. THE CITY 0 MIAMI :EACH MIAMI-DADE COUNTY, By. ( .il _0- By. / ( ' Name: ] 1..4I M i--• MoRAt-.ES Name: w0'Ao ,t 61,4kriCe Title: CITY MANAGER Title: ` IV� � Date: 2. ( 3 (17 Date: O1 1 7 • Attest: -, 2 I-) Attest: HARVEY RUVIN, Clerk • ithoriz- '-rso OR Notary Board of County Commissioners Public Print Name: Pir.,, 400 1--74-F...L.. Gil-r"rnc►.� By: Title: Print Name: � .„,, w► 066 s � � Corporate Seal ORNoIal/$tanW ,< o'er ,, ,_ ,.\--:;:.,_'i : Y , 10 _„. ii-^ 117 7 i) ••• ORID X41 T 1/ .` ..o.. This A reement is approved as to form and legal sufficiency. See memorandum dated /I/ PP g i y/ • . APPROVED AS TO FORM & LANGUAGE -y4...F9OR EXE UTION City Attorney Date 4 NV— THE CITY OF MIAMI BEACH IDENTIFICATION ASSISTANCE GRANT GRANT#: PC-1617-ID-2 ATTACHMENT A,SCOPE OF SERVICES THE CITY OF MIAMI BEACH IDENTIFICATION ASSISTANCE PROGRAM GRANT#: PC-1617-ID-2 The provider agrees to provide identification assistance services to 300 homeless persons in Miami-Dade County. The following services must be provided under this Agreement: ■ Identification document replacement services for homeless persons in Miami-Dade County. Documents to be replaced include,but are not limited to: 1. Florida Identification Cards 2. Birth Certificates 3. Marriage Certificates 4. School Records 5. Court Documents(judgements, orders,related documents) 6. Lawful Permanent Resident Cards 7. Naturalization Certificates 8. Florida Driver's Licenses Note: The costs of replacing the documents specified above may be funded via this grant or where applicable fee waivers may be obtained via the appropriate source. • Staff shall deliver identification services to homeless individuals. • Staff shall maintain a regular working schedule, as may be modified from time to time as mutually agreed upon in writing, with an intake specialist/case worker providing services. Staffing will be provided primarily in the Miami Beach Office of Homeless Programs located at 555 17a'Street,Miami Beach, Florida. • Provide referral services for community-based resources including but not limited to: legal and medical services, food, employment,vocational training and clothing. • Provide follow-up and tracking of each person assisted to determine outcome measures. PERFORMANCE MEASURES EXPECTED OUTCOMES INDICATORS 1. Homeless clients will be assessed 300 clients will be assessed. 2. Homeless clients will obtain vital personal 200 or 66% of homeless clients will obtain vital personal identification documents. identification documents. 3. Homeless clients will obtain official photo 150 or 50% of homeless clients will obtain official photo identification. identification. Cp O_ c Di D) NJ - Et_ 3 re fD "O n� r+ I� Di CD OJ C r3-r -O_ -S Q1 CrQ r3-r r3-r 70 3 3? CD fn O O N =? ,=r*tto CD c,7 Di N `<% N C.ct ,i. .-t. v 3 r.f. -Oi, in CTD 3 co CDD rr CD V) - D Di — CD N -' rn . rr n -o , N m CD rn = Di V CD 7' I-a "O a) 0 O cn N (10 CD Di 3 0 CD -S VF ill. i/? i!)- 7J CP 0 C CD vl rr CD Q N I--, I-, -n ill O -P C O V UJ 0 3 O O O 0 I? O 0 0 0 = O b b b DO O 0 0 0 0_ c.) d OCD in 3 CD rt CD C n °J n)H. 0 0 O N 3 n ;-% CD O N n C C -0 S 3 "O o C CD CD -% 3 N in '+ -O C O CD in 70 -S rr CD -. fD v 111 CD r+ cooX = m N D 3 rt r+ * CU el m C S CD (D 3 `n N CD 3 rt CO CO C O. ao to rt 1 ATTACHMENT F Miami-Dade County Homeless Trust Monthly Payment Request NAME OF AGENCY: The City of Miami Beach SERVICE PERIOD: TO NAME OF GRANT: Identification Assistance Program GRANT NUMBER: PC-1617-ID-2 TOTAL AWARD AMOUNT: $ 25,000.00 AMOUNT OF FUNDS REQUESTED THIS MONTH: $ AMOUNT OF FUNDS RECEIVED TO DATE: $ BALANCE REMAINING ON GRANT: $ 25,000.00 (following payment of this request) Signature of Executive Director or Date Agency Authorized Representative Printed Name of Executive Director or Authorized Agency Representative r ATTACHMENT L MIAMI-DADE COUNTY HOMELESS TRUST ANNUAL ACTUAL EXPENDITURE REPORT CITY OF MIAMI BEACH HOMELESS ASSISTANCE PROGRAM IDENTIFICATION ASSISTANCE PROGRAM—GRANT NUMBER PC-1617-ID-2 OCTOBER 1,2016 —SEPTEMBER 30,2017 Name of Agency: THE CITY OF MIAMI BEACH $ 25,000.00 Month of Services Amount Paid October 2016 November 2016 December 2016 January 2017 February 2017 March 2017 April 2017 May 2017 June 2017 July-2017 August 2017 September 2017 Total Requested $ 0.00 Balance Remaining $ 25,000.00 Executive Director Signature or Authorized Agency Representative Signature Executive Director or Authorized Agency Representative-Printed Name Signature Date Miami-Dade County's Affidavits and Declarations M IAM I-DADS COUNTY Miami-Dade County requires each party desiring to enter into a contract with Miami-Dade County to; (1) sign an affidavit as to certain matters and (2) make a declaration as to certain other matters. This form contains both an Affidavit form for matters requiring the entity to sign under oath and a Declaration form for matters requiring only an affirmation or declaration for other matters. Each section of this form must be read, and initialed indicating acceptance and/or compliance with the County's policy related to the particular affidavit. For affidavit sections that you do not believe are applicable to your organization,please indicate this by placing"x" in the box next to N/A. ALL SECTIONS MUST BE COMPLETED THE FOLLOWING MATTERS REQUIRE THE ENTITY TO SIGN AN AFFIDAVIT UNDER OATH: STATE OF( Ft,-OR i t,A ) COUNTY OF (MtiAMI - DA DE ) COUNTRY OF((_, A ) Before me the undersigned authority appeared (Print Name), 1 M M y i_.. iviORA LeS who is personally known to me or who has provided as identification and who did swear to the following: That he or she is the duly authorized representative of(Name of Entity) C UT"/ OF M i AMI E3EAC,i-i (Address of Entity) i`40O Coioiv ra-r'ic v CE:i-I-TER. ( RIVE- Post Office addresses are not acre table. Jr' 9- 00oo - 3 Z Federal Employment Identification Number c.cry ® ' MI AM t eEA CH (hereinafter referred to as the contracting "entity"), and that he or she is the entity's (Sole Proprietor)(Partner)(President or Other Authorized Officer) C urY MANAGCk That he or she has full authority to make this affidavit, and that the information given herein and the documents attached hereto are true and correct; and That he or she says as follows: 1 Miami-Dade County's Affidavits and Declarations 1. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT(SECTION 2-8.1 Pertains Li OF THE COUNTY CODE) N/A If the contract or business transaction is with a corporation,the full legal name and business address shall be provided for each officer and director and each stockholder who holds directly or indirectly five percent(5%) or more of the corporation's stock. If the contract or business transaction is with a partnership,the foregoing information shall be provided for each partner. If the contract or business transaction is with a trust,the full legal name and address shall be provided for each trustee andeach beneficiary. The foregoing requirements shall not pertain to contracts with publicly traded corporations or to contracts with the United States or any department or agency thereof,the State or any political subdivision or agency thereof or any municipality of this State. All such names and address are outlined below:Post Office addresses are not acceptable. (Full Legal Name,Address,%Ownership) (Full Legal Name,Address,%Ownership) (Full Legal Name,Address,%Ownership) (Full Legal Name,Address,%Ownership) The full legal names and business address of any other individual(other than subcontractors,material person, suppliers,laborers, or lenders) who have,or will have, any interest(legal, equitable beneficial or otherwise) in the contract or business transaction with Miami Dade County are: Post office addresses are not acceptable Any person who willfully fails to disclose the infoi uiation required herein, or who knowingly discloses false. information in this regard,shall be punished by a fine of up to five hundred dollars ($500.00) or imprisonment in jail for up to sixty(60) days or both. 1 Miami-Dade .County's Affidavits and Declarations 2. MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT(COUNTY. ORDINANCE 90-133,AMENDING SECTION 2.8-1;SUBSECTION(d)(2) OF THE Pertains ) COUNTY CODE) N/A D Except where precluded by Federal or State laws or regulations,each contract or business transaction or renewal thereof which involves the expenditure of then thousand dollars ($10,000) or more shall require the entity contracting or transaction business to disclose the following information. The foregoing disclosure requirements do not apply to contracts with the United States or any department or agency thereof,the State or any political subdivision or agency thereof or any municipality of this State. Does your firm have a collective bargaining agreement with its employees? Yes D No Does your firm provide paid health care benefits for its employees?`J Yes D No Provide a current breakdown(number of persons) of your firm's work force and ownership (below): White: Males 2q Females 1 Black: Males 265 Females 162. Hispanic: Males s i t Females 3 V Asian: Males i Females 5 American Native: Males 2 Females Q Aleut(Eskimo): Males es? Females is Miami-Dade County's Affidavits and Declarations 3. MIAMI-DADE COUNTY AFFIRMATIVE ACTION/ NONDISCRIMINATION OF EMPLOYMENT,PROMOTION AND Pertains PROCUREMENT PRACTICES(COUNTY ORDINANCE 98-30 CODIFIED N/A O AT 2-8.L5 OF THE COUNTY CODE) Pursuant to Miami-Dade County's Ordinance No.98-30,Section 2-8.1.5,entities with annual gross revenue in excess of$5,000,000 seeking to contract with the County shall,as a condition of receiving a County contract,have: 1) a written affil illative action plan which sets forth the procedures the entity utilizes to assure that it does not discriminate in its employment and promotion practices and 2) a written procurement policy which sets forth the procedures the entity utilizes to assure that it does not discriminate against minority and women-owned businesses in its own procurement of goods,supplies and services.Such affirmative action plans and procurement policies shall provide for periodic review to determine their effectiveness in assuring the entity does not discriminate in its employment,promotion and procurement practices.The foregoing,not withstanding,corporate entities whose board of directors are representative of the population make-up of the nation shall be presumed to have non-discriminatory employment and procurement policies,and shall not be required to have a written affirmative action plan and procurement policy in order to receive a County contract.The foregoing presumption maybe rebutted.The requirements of this section maybe waived upon written recommendation of the County Manager that it is in the best interest of the County to do so and approval of the County Commission by majority vote of the members present. Based on the above,please complete the affidavit as directed and return the completed affidavit along with a cover letter on your company's letterhead,listing the company's address,phone , and fax numbers,and any required documents,to:Miami-Dade County,Department of Procurement Management Affirmative Action Plan Unit 111 NW 1st Street, 13th Floor Miami,FL 33128 Yes No ❑ My company has an affirmative action plan and procurement policy and is available for review. My company has annual gross revenues in excess of$5,000,000. Yes it No ❑ Therefore, our company's affirmative action plan and procurement policy is available for review. Yes D No OBJ My company has annual gross revenues less than$5,000,000. If at any time the Miami Dade County has reason to believe that any person or firm has willfully and knowingly provided incorrect information or made false statements,the County may refer the matter to the State Attorney's Office and/or other investigative agencies.The County may initiate debarment and/or pursue other remedies in accordance with Miami-Dade County policy and/or applicable federal,state and local laws. 4. MIAMI-DADE COUNTY CRIMINAL RECORD AFFIDAVIT Pertains 6 (SECTION 2-8.6 OF THE COUNTY CODE) N/A ❑ The individual or entity entering into a contract or receiving funding from Miami-Dade County ❑has ❑has not, as of the date of this affidavit,been convicted of a felony during the past ten(10)years. An officer,director, or executive officer of the entity entering into a contract or receiving funding from Miami-Dade County 0 has tl has not as of the date of this affidavit been convicted of a felony during the past ten (10)years. Miami-Dade County's Affidavits and Declarations 5. PUBLIC ENTITY CRIMES AFFIDAVIT(SECTION Pertains k 287.133(3)(a),FLORIDA STATUTES) N/A D The individual or entity entering into a contract or receiving funding from Miami-Dade County understands the following: That a"public entity crime"as defined in Paragraph 287.133 (1) (g) Florida Statutes,means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state of the United States of America,including but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state of the United States of America and involving antitrust,fraud,theft,bribery, collusion,racketeering, conspiracy,or material misrepresentation. That"Convicted" or"conviction"as defined in Paragraph 287.133 (1) (b) Florida Statutes means a finding of guilt or a conviction of a public entity crime,with or without an adjudication of guilt,in any federal state trial court of record relating to charges brought by indictment or information after July 1,1989,as a result of a jury verdict,non- jury trial,or entry of plea of guilty or nolo contendere. That an"affiliate" as defined in Paragraph 287.133 (1) (a) Florida Statutes means a) a predecessor or successor of a person convicted of a public entity crime; or b) an entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term"affiliate"includes those officers, directors, executives,partners,shareholders, employees,members,and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person,or pooling of equipment or income among persons when not for fair market value under an arm's length agreement,shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. That a"person"as defined in Paragraph 287.133 (1) (e) Florida Statutes means any natural person or entity organized under the laws of any state or of the United States of America with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity,or which otherwise transacts or applies to transact business with a public entity. The term"person" includes those officers, directors, executives,partners,shareholders,employees,members and agents who are active in the management of an entity. Based on information and belief,the statement as marked below,is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies by applying the individual initials near the box). Q�1 Neither the entity submitting this sworn statement nor any of its officers,directors, executives,pal Miers, shareholders, employees,members or agents who are active in the management of the entity,nor an affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months. D The entity submitting this sworn statement or one or more of its officers,directors,executives,partners, shareholders, employees,members or agents who are active in the management of the entity,or an affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months; and D yes an additional statement is applicable or D no an additional statement is not applicable. D The entity submitting this sworn statement, or one or more of its officers,directors, executives,partners, shareholders,employees,members, or agents who are active in the management of the entity has been charged with and convicted of a public entity crime within the past 36 months. However,there have been subsequent proceedings before a Hearing Officer of the State of Florida,Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the"Convicted Vendor List". The individual or entity entering into a contract or receiving funding from Miami-Dade County understands that he or she is required to inform the public entity prior to entering into a contract in excess of the threshold amount provided in Section 287.017 Florida Statues for Category 2 of any change in the information contained in this form. Miami-Dade County's Affidavits and Declarations 6.MIAMI-DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT pertains (County Ordinance No.142-91 codified as Section 11A-29 et. N/A seq of the County Code) That in compliance with Ordinance No. 142-91 of the Code of Miami-Dade County, Florida,an employer with fifty (50) or more employees working in Dade County for each working day during each of twenty(20) or more calendar work weeks,shall provide the following information in compliance with all items in the aforementioned ordinance: An employee who has worked for the above firm at least one (1)year shall be entitled to ninety(90) days of family leave during any twenty-four(24)month period,for medical reasons,for the birth or adoption of a child,or for the care of a`child,spouse or other close relative who has a serious health condition without risk of termination of employment or employer retaliation. The foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof, or the State of Florida or any political subdivision or agency thereof. It shall,however,pertain to municipalities of this State. 7. MIAMI-DADE COUNTY DISABILITY NONDISCRIMINATION Pertains VD AFFIDAVIT (County Resolution R-385-95) N/A O That the above named firm,corporation or organization is in compliance with and agrees to continue to comply with, and assure that any subcontractor, or third party contractor under this project complies with all applicable requirements of the laws listed below including,but not limited to;those provisions pertaining to employment, provision of programs and services,transportation,communications,access to facilities,renovations,and new construction in the following laws:The Americans with Disabilities Act of 1990 (ADA),Pub.L. 101-336, 104 Stat. 327,42 U.S.C. 12101-12213 and 47 U.S. C.Sections 225 and 611 including Title I,Employment;Title II,Public Services; Title III, Public Accommodation and Services Operated by Private Entities; Title IV,Telecommunications; and Title V,Miscellaneous Provisions:The Rehabilitation Act of 1973, 29 U.S.C.Section 794:The Federal Transit Act,as amended 49 U.S.C.Section 1612:The Fair Housing Act as amended,42 U.S.C.Section 3601-3631.The foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof, or the State or any political subdivision or agency thereof or any municipality of this State. 8.MIAMI-DADE COUNTY REGARDING DELINQUENT AND CURRENTLY DUE Pertains FEES OR TAXES(Sec.2-8.1(c) of the County Code) N/A O Except for small purchase orders and sole source contracts,that above named firm, corporation,organization or individual desiring to transact business or enter into a contract with the County verifies that all delinquent and currently due fees or taxes--including but not limited to real and property taxes,utility taxes and occupational licenses--which are collected in the normal course by the Dade County Tax Collector as well as Dade County issued parking tickets for vehicles registered in the name of the firm, corporation,organization or individual have been paid: Miami-Dade County's Affidavits and Declarations 9. CURRENT ON ALL COUNTY CONTRACTS,LOANS AND OTHER OBLIGATIONS Pertains 1K N/A The individual entity seeking to transact business with the County is current in all its obligations to the County and is not otherwise in default of any contract,promissory note or other loan document with the County or any of its agencies or instrumentalities. 10. DOMESTIC VIOLENCE LEAVE (Resolution 185-00; 99-5 Codified At 11A- Pertains ] 60 Et.Seq.of the Miami-Dade County Code). N/A The firm desiring to do business with the County is in compliance with Domestic Leave Ordinance,Ordinance 99- 5,codified at 11A-60 et.seq.of the Miami Dade County Code,which requires an employer which has in the regular course of business fifty(50) or more employees working in Miami-Dade County for each working day during each of twenty(20) or more calendar work weeks in the current or proceeding calendar years,to provide Domestic Violence Leave to its employees. 11. MIAMI-DADE COUNTY EMPLOYMENT DRUG-FREE WORKPLACE AFFIDAVIT (County Ordinance No.92-15 codified as Section 2- Pertains 8.12 of the County Code) N/A That in compliance with Ordinance No.92-15 of the Code of Miami-Dade County,Florida,the above named person or entity is providing a drug-free workplace.A written statement to each employee shall inform the employee about: 1. danger of drug abuse in the workplace; 2. the firm's policy of maintaining a drug-free environment at all workplaces; 3. availability of drug counseling,rehabilitation and employee assistance programs; 4._ penalties that may be imposed upon employees for drug abuse violations. The person or entity shall also require an employee to sign a statement, as a condition of employment that the employee will abide by the terms and notify the employer of any criminal drug conviction occurring no later than five (5) days after receiving notice of such conviction and impose appropriate personnel action against the employee up to and including termination. Compliance with Ordinance No. 92-15 maybe waived if the special characteristics of the product or service offered by the person or entity make it necessary for the operation of the County or for the health,safety,welfare economic benefits and well-being of the public.Contracts involving funding which is provided in whole or in part by the United States or the State of Florida shall be exempted from the provisions of this ordinance in those instances where those provisions are in conflict with the requirements of those governmental entities. Miami-Dade County's Affidavits and Declarations 12. ATTESTATION REGARDING DUE AND PROPER ACKNOWLEDGEMENT OF Pertains ►A COUNTY FUNDING SUPPORT N/A ❑ By initialing this subsection and accepting County funds,the above named firm, corporation, organization or individual agrees to abide by the grant contract requirement to recognize and acknowledge Miami-Dade County's grant support in a manner commensurate with all contributors and sponsors of its activities at comparable dollar levels. 13.MIAMI-DADE COUNTY RESOLUTION NO.R-630-13 REQUIRING A DETAILED PROJECT BUDGET,SOURCES AND USES STATEMENT,CERTIFICATIONS AS Pertains ❑ TO PAST DEFAULTS ON AGREEMENTS WITH NON-COUNTY FUNDING N/A `C SOURCES,AND DUE DILIGENCE CHECK Pursuant to Miami-Dade County Resolution No.R-630-13,requiring a detailed project budget,sources and uses statement,certifications as to past defaults on agreements with non-county funding sources and due diligence check prior to the County Mayor or County Mayor's designee recommending a commitment of Miami-Dade County funds to Social Services,Economic Development, Community Development, and Affordable Housing Agencies and Providers. The undersigned entity certifies,to the best of his or her knowledge and belief,that: 1. Within the past five (5)years,neither the Agency nor its directors,partners,principals,members or board members: (1) have been sued by a funding source for breach of contract or failure to perform obligations under a contract; (ii) have been cited by a funding source for non-compliance or default under a contract; (iii) have been a defendant in a lawsuit based upon a contract with a funding source. Please list any matters which prohibit the Agency from making the certifications required and explain how the matters are being resolved(use separate sheet if necessary): 14.MIAMI-DADE COUNTY RESOLUTION No.R-478-12 NOT TO USE PRODUCTS Pertains OR FOODS CONTAINING"PINK SLIME" N/A ❑ Pursuant to Miami-Dade County Resolution No.R-478-12,the undersigned certifies,not to use meat products containing"Pink Slime"in food provided or served as part any food program;urging all who provide food services or operate a food program to immediately discontinue using meat products containing"pink slime"in food provided or served in these programs. Miami-Dade County's Affidavits and Declarations 15.MIAMI-DADE COUNTY REQUIRED LOBBYIST REGISTRATION FOR ORAL Pertains PRESENTATION Section 2-11.1(i)(2) CONFLICT OF INTEREST AND CODE OF ETHICS ORDINANCE All lobbyists shall register with the Clerk of the Board of County Commissioners within five (5)business days of being retained as a lobbyist or before engaging in any lobbying activities,whichever shall come first.Every person required to so register shall: 1.Register on forms prepared by the Clerk; 2.State under oath his or her name,business address and the name and business address of each person or entity which has employed said registrant to lobby.If the lobbyist represents a corporation,the corporation shall also be identified.Without limiting the foregoing,the lobbyist shall also identify all persons holding, directly or indirectly, a five(5) percent or more ownership interest in such corporation,partnership, or trust.Registration of all lobbyists shall be required prior to January 15 of each year and each person who withdraws as a lobbyist for a particular client shall file an appropriate notice of withdrawal. 3.Prior to conducting any lobbying,all principals must file a form with the Clerk of the Board of County Commissioners,signed by the principal or the principal's representative,stating that the lobbyist is authorized to represent the principal.Failure of a principal to file the form required by the preceding sentence may be considered in the evaluation of a bid or proposal as evidence that a proposer or bidder is not a responsible contractor.Each principal shall file a form with the Clerk of the Board at the point in time at which a lobbyist is no longer authorized to represent the principal. By initialing here,the principals or principal's representative have filed with the Clerk of the Board of County Commissioners stating that a lobbyist is authorized to represent the principal. 4.Any public officer, employee or appointee who only appears in his or her official capacity shall not be required to register as a lobbyist. 5.Any person who only appears in his or her individual capacity for the purpose of self-representation without compensation or reimbursement,whether direct,indirect or contingent,to express support of or opposition to any item,shall not be required to register as a lobbyist. 6.Any person who only appears as a representative of a not-for-profit corporation or entity(such as a charitable organization, or a trade association or trade union),without special compensation or reimbursement for the appearance,whether direct,indirect or contingent,to express support of or opposition to any item, shall register with the Clerk as required by the Ordinance subsection,but,upon request,shall not be required to pay any registration fees. The Clerk of the Board of County Commissioners shall notify the Commission on Ethics and Public Trust of the failure of a lobbyist or principal to file a report and/or pay the assessed fines after notification. A lobbyist or principal may appeal a fine and may request a hearing before the Commission on Ethics and Public Trust.A request for a hearing on the fine must be filed with the Commission on Ethics and Public Trust within fifteen(15) calendar days of receipt of the notification of the failure to file the required disclosure form.The Commission on Ethics and Public Trust shall have the authority to waive the fine,in whole or part,based on good cause shown.The Commission on Ethics and Public Trust shall have the authority to adopt rules of procedure regarding appeals from the Clerk of the Board of County Commissioners. • Except as otherwise provided in subsection of the Ordinance,the validity of any action or determination of the Board of County Commissioners or County personnel,board or committee shall not be affected by the failure of any person to comply with the provisions of this subsection(s). (Ord.No. 00-19,§ 1, 2-8-00; Ord.No. 01-93, § 1,5-22- 01; Ord. No. 01-162, § 1, 10-23-01;'Ord.No:03-107,§ 1, 5-6-03) Miami-Dade County's Affidavits and Declarations M1AMI DA©E COUNTY I have carefully read this entire ten (10) page document entitled, "Miami-Dade County's Affidavits and Declarations" and agree to; (1) sign an affidavit as to certain matters and(2) make a declaration as to certain other matters. This form contains both an Affidavit form for matters requiring the entity to sign under oath,and a Declaration foiin for matters requiring only an affirmation or declaration for other matters. Each section of this form must be read,and initialed indicating acceptance and/or compliance with the County's policy related to the particular affidavit. For affidavit sections that you do not believe are applicable to your organization,please indicate this by placing"x"in the box next to N/A. BY BY SIGNING AND NOTARIZING THIS PAGE YOU ARE ATTESTING TO AFFIDAVITS 145 MIAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE By: l 2-/isin P-A-FADIL ener•4-A '" �% q % .,2. 1 / 20 Signatur:' of Witness or Secretary Se \\ s `e , mc Signa of Affi. it '' e "`-� ler.a a► ployer Identification Number tifv(DRP ORATED r✓i I L, MORALES , r Pl- n MI s, g, Ac1-1 Printed 1 e of Aunt and Name‘O. "°, O)Z tit�h.,� " n �'+:, -7 ,`l'O d �- "°`fit" ,..�_.7 'Ll!: 1- Fly', i 400 iVae=NT1 C)Ni C:I:N i E "4 ,s Address of Agency SUBSCRIBED AND SWORN TO (or affirmed) before me this 1 day of F-40007, 20 17 He/She is personally,;, s own to me or has presented as identification. Type of identification Air ' gnature of Notary Serial Number Print or Stamp Name of Notary Expiration Date B Notary Public—State of 4/®re'cf 0� "P LIUACARDILLO *? 0.-.,, •:,,: MY COMMISSION#FF 155322 ''°r - EXPIRES:August 27,2018 }� r�j�A )��� [\ ��o .'•r 4° Bonded Thru Nota Public Underwriters Cozen of a Notary Seal tiler Form ■■-9 Request for Taxpayer Give Form to the (Rev.December2014) Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. Internal Revenue Service 1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank. G 1-r4 OF MIAMI 3I ACI-I 2 Business name/disregarded entity name,if different from above m m °- 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to ° ❑IndividuaVsole proprietor or ❑ C Corporation ❑S Corporation ❑ Partnership ❑Trust/estate certain entities,not individuals;see instructions on page 3): a o single-member LLC Exempt payee code(if any) ;,_, ❑Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership))• o ? Note.Fora single-member LLC that is disregarded,do not check LLC;check the appropriate box in the line above for Exemption from FATCA reporting i• n the tax classification of the single-member owner. code(if any) 4 V .14,Other(see instructions)I• (Applies to accounts mainfained outside the U.S.) = 5 Address(number,street,and apt.or suite no.) Requester's name and address(optional) U . ENT I c714 c riE( 1:>k 6 City,state,and ZIP code m Cl) 7 List account number(s)here(optional) Part I Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid I Social security number backup withholding.For individuals,this is generally your social security number(SSI .However,for a resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other - - entities,it is your employer identification number(FIN).If you do not have a number,see How to get a TIN on page 3. or Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identification number guidelines on whose number to enter. • 59 t 2 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 abandonm nt of secured prope ,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interes nd dividends,you re not required to sign the certification,but you must provide your correct TIN.See the instructions on page 3.. Sign re of Hre u.s.person).- Date ot, 113/I7 General Instructions •Form 1098(home mortgage interest),1098-E(student loan interest),1098-T (tuition) Section references are to the Internal Reven e Code unless otherwise noted. •Form 1099-C(canceled debt) Future developments.Information about d elopments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property) as legislation enacted after we release it)is at www.irs.gov/fw9. Use Form W-9 only if you are a U.S.person(including a resident alien),to Purpose of Form provide your correct TIN. An individual or entity(Form W-9 requester)who is required to file an information If you do not return Form W-9 to the requester with a TIN,you might be subject return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What is backup withholding?on page 2. which may be your social security number(SSN),individual taxpayer identification By signing the filled-out form,you: number(ITIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number identification number(EIN) to report on an information return the amount paid to to be issued), you,or other amount reportable on an information return.Examples of information returns include,but are not limited to,the following: 2.Certify that you are not subject to backup withholding,or •Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding if you are a U.S.exempt payee.If •Form 1099-DIV(dividends,Including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your allocable share of any partnership income from a U.S.trade or business is not subject to the •Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and •Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on •Form 1099-S(proceeds from real estate transactions) page 2 for further information. •Form 1099-K(merchant card and third party network transactions) Cat.No.10231X Form W-9(Rev.12-2014) • Y ' I , Form W-9(Rev.12-2014) Page 2 Note.If you are a U.S.person and a requester gives you a form other than Form 3.The IRS tells the requester that you furnished an incorrect TIN, W-9 to request your TIN,you must use the requester's form if it is substantially 4.The IRS tells you that you are subject to backup withholding because you did similar to this Form W-9. not report all your interest and dividends on your tax return(for reportable interest Definition of a U.S.person.For federal tax purposes,you are considered a U.S. and dividends only),or person if you are: 5.You do not certify to the requester that you are not subject to backup •An individual who is a U.S.citizen or U.S.resident alien; withholding under 4 above(for reportable interest and dividend accounts opened •A partnership,corporation,company,or association created or organized in the after 1983 only). United States or under the laws of the United States; Certain payees and payments are exempt from backup withholding.See Exempt •An estate(other than a foreign estate);or payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information. •A domestic trust(as defined in Regulations section 301.7701-7). Also see Special rules for partnerships above. Special rules for partnerships.Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section What is FATCA reporting? 1446 on any foreign partners'share of effectively connected taxable income from The Foreign Account Tax Compliance Act(FATCA)requires a participating foreign such rulesbusiness.dFurther,cionin4 certain casesapartnership a Form W-9 has not been received,ad, financial nstitution to report all United States account holders that are specified the i nunder and pa the require a p6 withholdingto presume e ort a partner Is United States persons.Certain payees are exempt from FATCA reporting.See foreign person,and pay the section 1446 tax.Therefore,if you are a U.S.person that is a partner in a partnership conducting a trade or business in the Exemption from FATCA reporting code on page 3 and the Instructions for the United States,provide Form W-9 to the partnership to establish your U.S.status Requester of Form W-9 for more information. and avoid section 1446 withholding on your share of partnership income. Updating Your Information In the cases below,the following person must give Form W-9 to the partnership for purposes of establishing its U.S.status and avoiding withholding on its You must provide updated information to any person to whom you claimed to be allocable share of net income from the partnership conducting a trade or business an exempt payee if you are no longer an exempt payee and anticipate receiving in the United States: reportable payments in the future from this person.For example,you may need to •In the case of a disregarded entity with a U.S.owner,the U.S.owner of the provide updated information if you are a C corporation that elects to be an S disregarded entity and not the entity; corporation,or if you no longer are tax exempt.In.addition,you must furnish a new Form W-9 if the name or TIN changes for the account;for example,if the grantor •In the case of a grantor trust with a U.S.grantor or other U.S.owner,generally, of a grantor trust dies. the U.S.grantor or other U.S.owner of the grantor trust and not the trust;and •In the case of a U.S.trust(other than a grantor trust),the U.S.trust(other than a Penalties , grantor trust)and not the beneficiaries of the trust. . Failure to furnish TIN.If you fail to furnish your correct TIN to a requester,you are Foreign person.If you are a foreign person or the U.S.branch of a foreign bank subject to a penalty of$50 for each such failure unless your failure is due to that has elected to be treated as a U.S.person,do not use Form W-9.Instead,use reasonable cause and not to willful neglect. the appropriate Form W-8 or Form 8233(see Publication 515,Withholding of Tax Civil penalty for false information with respect to withholding.If you make a on Nonresident Aliens and Foreign Entities). false statement with no reasonable basis that results in no backup withholding, Nonresident alien who becomes a resident alien.Generally,only a nonresident you are subject to a$500 penalty. alien individual may use the terms of a tax treaty to reduce or eliminate U.S.tax on Criminal penalty for falsifying information.Willfully falsifying certifications or certain types of income.However,most tax treaties contain a provision known as affirmations may subject you to criminal penalties including fines and/or a"saving clause."Exceptions specified in the saving clause may permit an imprisonment. exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S.resident alien for tax purposes. Misuse of TINs.If the requester discloses or uses TINS in violation of federal law, the requester may be subject to civil and criminal penalties. If 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 Specific Instructions of income,you must attach a statement to Form W-9 that specifies the following p five items: 1.The treaty country.Generally,this must be the same treaty under which you Line 1 claimed exemption from tax as a nonresident alien. You must enter one of the following on this line;do not leave this line blank.The 2.The treaty article addressing the income, name should match the name on your tax return. 3.The article number(or location)in the tax treaty that contains the saving If this Form W-9 is for a joint account,list first,and then circle,the name of the clause and its exceptions. person or entity whose number you entered In Part I of Form W-9. 4.The type and amount of income that qualifies for the exemption from tax a. Individual.Generally,enter the name shown on your tax return.If you have changed your last name without informing the Social Security Administration(SSA) 5.Sufficient facts to justify the exemption from tax under the terms of the treaty of the name change,enter your first name,the last name as shown on your social article. security card,and your new last name. Example.Article 20 of the U.S.-China income tax treaty allows an exemption Note.ITIN applicant:Enter your individual name as it was entered on your Form from tax for scholarship income received bye Chinese student temporarily present W-7 application,line 1a.This should also be the same as the name you entered on in the United States.Under U.S.law,this student will become a resident alien for the Form 1040/1040A/1040EZ you filed with your application. tax purposes if his or her stay in the United States exceeds 5 calendar years. b. Sole or single-member LLC.Enter name as However,paragraph 2 of the first Protocol,to the-U.S.-China treaty(dated April 30, b. on your proprietor104oor sline 1.You may your individualyour name trade, 1984)allows the provisions of Article 20 to continue to apply even after the shownshong business 10s /1 40A/1(DBA)040Eme onn line 2. 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 c. Partnership,LLC that is not a single-member LLC,C Corporation,or S relying on this exception to claim an exemption from tax on his or her scholarship Corporation.Enter the entity's name as shown on the entity's tax return on line 1 or fellowship income would attach to Form W-9 a statement that includes the and any business,trade,or DBA name on line 2. information described above to support that exemption. d. Other entities.Enter your name as shown on required U.S.federal tax If you are a nonresident alien or a foreign entity,give the requester the documents on line1.This name should match the name shown on the charter or appropriate completed Form W-8 or Form 8233. other legal document creating the entity.You may enter any business,trade,or DBA name on line 2. Backup Withholding e. Disregarded entity.For U.S.federal tax purposes,an entity that is What is backup withholding?Persons making certain payments to you must disregarded as an entity separate from its owner is treated as a"disregarded under certain conditions withhold and pay to the IRS 28%of such payments.This entity." See Regulations section 301.7701-2(c)(2)(iii).Enter the owner's name on is called"backup withholding." Payments that may be subject to backup line 1.The name of the entity entered on line 1 should never be a disregarded withholding include interest,tax-exempt interest,dividends,broker and barter entity.The name on line 1 should be the name shown on the income tax return on exchange transactions,rents,royalties,nonemployee pay,payments made in which the income should be reported.For example,if a foreign LLC that is treated settlement of payment card and third party network transactions,and certain as a disregarded entity for U.S.federal tax purposes has a single owner that is a payments from fishing boat operators.Real estate transactions are not subject to U.S.person,the U.S.owner's name is required to be provided on line 1.If the backup withholding. direct owner of the entity is also a disregarded entity,enter the first owner that is You will not be subject to backup withholding on payments you receive if you not disregarded for federal tax purposes.Enter the disregarded entity's name on give the requesteryour correct TIN,make the proper certifications,and report all line 2,"Business name/disregarded entity name."If the owner of the disregarded q P P entity is a foreign person,the owner must complete an appropriate Form W-B your taxable interest and dividends on your tax return. instead of a Form W-9. This is the case even if the foreign person has a U.S.TIN. 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 Part II instructions on page 3 for details), 1 ' Form W-9(Rev.12-2014) Page 3 Line 2 'However,the following payments made to a corporation and reportable on Form If you have a business name,trade name,DBA name,or disregarded entity name, 1099-MISC are not exempt from backup withholding:medical and health care you may enter it on line 2. payments,attorneys'fees,gross proceeds paid to an attorney reportable under section 6045(f),and payments for services paid by a federal executive agency. Line 3 Exemption from FATCA reporting code.The following codes identify payees Check the appropriate box in line 3 for the U.S.federal tax classification of the that are exempt from reporting under FATCA.These codes apply to persons person whose name is entered on line 1.Check only one box in line 3. submitting this form for accounts maintained outside of the United States by Limited Liability Company(LLC).If the name online 1 is an LLC treated as a certain foreign financial institutions.Therefore,if you are only submitting this form partnership for U.S.federal tax purposes,check the"Limited Liability Company" for s account you perholson requestingithe United States,you may leave thisan field blank. box and enter"P"in the space provided.If the LLC has filed Form 8832 or 2553 to Consult ui with the ec to these this form ryou are un n 'rf tee a anciol be taxed as a corporation,check the"Limited Liability Company"box and in the trequir id suprot to requirements.witaFrmAre with "Nr may indicateible"(or a code is space provided enter"C"for C corporation or"5"for S corporation.If it is a not similar indicedation) by providing you with a Form W-9 with"Not Applicable"exemption code.any single-member LLC that is a disregarded entity,do not check the"Limited Liability indication)written or printed on the line for a FATCA Company"box;instead check the first box in line 3"Individual/sole proprietor or A—An organization exempt from tax under section 501(a)or any individual single-member LLC." retirement plan as defined in section 7701(a)(37) Line 4, Exemptions B—The United States or any of its agencies or instrumentalities If you are exempt from backup withholding andlor FATCA reporting,enter in the C—A state,the District of Columbia,a U.S.commonwealth or possession,or anyof their political subdivisions or instrumentalities appropriate space in fine 4 any code(s)that may apply to you. Exempt payee code. D—A corporation the stock of which Is regularly traded on one or more established securities markets,as described in Regulations section • Generally,individuals(including sole proprietors)are not exempt from backup 1.1472-1(c)(1)() withholding. E—A corporation that is a member of the same expanded affiliated group as a • Except as provided below,corporations are exempt from backup withholding corporation described in Regulations section 1.1472-1(c)(1)(i) for certain payments,including interest and dividends. F—A dealer in securities,commodities,or derivative financial instruments. • Corporations are not exempt from backup withholding for payments made in (including notional principal contracts,futures,forwards,and options)that is settlement of payment card or third party network transactions. registered as such under the laws of the United States or any state • Corporations are not exempt from backup withholding with respect to attorneys' G—A real estate investment trust fees or gross proceeds-paid to attorneys,and corporations that provide medical or H—A regulated Investment company as defined in section 851 or an en health care services are not exempt with respect to payments reportable on Form registered at all times during the tax year under the Investment Company Ac of 1099-MISC. 1940 The following codes identify fy payees that are exempt from backup withholding. I—A common trust fund as defined in section 584(a) Enter the appropriate code in the space in line 4. 1—An organization exempt from tax under section 501(a),any IRA,or a J—A bank as defined in section 581 custodial account under section 403(b)(7)if.the account satisfies the requirements K—A broker of section 4010)(2) L—A trust exempt from tax under section 664 or described in section 4947(a)(1) 2—The United States or any of its agencies or instrumentalities M—A tax exempt trust under a section 403(b)plan or section 457(g)plan • 3—A state,the District of Columbia,a U.S.commonwealth or possession,or Note.You may wish to consult with the financial institution requesting this form to any of their political subdivisions or instrumentalities determine whether the FATCA code and/or exempt payee code should be 4—A foreign government or any of its political subdivisions,agencies,or completed. instrumentalities Line 5 5—A corporation 6—A dealer in securities or commodities required to register in the United Enter your address(number,street,and apartment or suite number).This is where States,the District of Columbia,or a U,S.commonwealth or possession the requester of this Form W-9 will mail your information returns. 7—A futures commission merchant registered with the Commodity Futures Line 6 Trading Commission Enter your city,state,and ZIP code. 8—A real estate investment trust 9—An entity registered at all times during the tax year under the Investment Part I.Taxpayer identification Number(TIN) Company Act of 1940 Enter your TIN in the appropriate box.If you are a resident alien and you do not 10—A common trust fund operated by a bank under section 584(a) have and are not eligible to get en SSN,your TIN is your IRS individual taxpayer 11—A financial institution identification number(ITIN).Enter it in the social security number box.If you do not have an ITIN,see How to get a TIN below. 12—A middleman known in the investment community as a nominee or If you are a sole proprietor and you have an EIN,you may enter either your SSN custodian or EIN.However,the IRS prefers that you use your SSN. 13—A trust exempt from tax under section 664 or described in section 4947 If you are a single-member LLC that is disregarded as an entity separate from its The following chart shows types of payments that may be exempt from backup owner(see Limited Liability Company(LLC)on this page),enter the owner's SSN withholding.The chart applies to the exempt payees listed above,1 through 13. (or EIN,if the owner has one).Do not enter the disregarded entity's EIN.If the LLC is classified as a corporation or partnership,enter the entity's EIN. IF the payment is for... THEN the payment is exempt for... Note.See the chart on page 4 for further clarification of name and TIN combinations. Interest and dividend payments All exempt payees except How to get a TIN.If you do not have a TIN,apply for one immediately.To apply for 7 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 Broker transactions Exempt payees 1 through 4 and 6 calling 1-800-772-1213.Use Form W-7,Application for IRS Individual Taxpayer through 11 and all C corporations.S Identification Number,to apply for an ITIN,or Form SS-4,Application for Employer corporations must not enter an exempt Identification Number,to apply for an EIN.You can apply for an EIN online by payee code because they are exempt accessing the IRS website at www.irs.gov/businesses and clicking on Employer only for sales of noncovered securities Identification Number(EIN)under Starting a Business.You can get Forms W-7 and acquired prior to 2012. SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676). Barter exchange transactions and Exempt payees 1 through 4 If you are asked to complete Form W-9 but do not have a TIN,apply for a TIN patronage dividends and write"Applied For"in the space for the TIN,sign and date the form, and give it to the requester.For interest and dividend payments,and certain payments made Payments over$600 required to be Generally,exempt payees with respect to readily tradable instruments,generally you will have 60 days to get reported and direct sales over$5,0001 1 through 52 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 Payments made in settlement of Exempt payees 1 through 4 subject to backup withholding on all such payments until you provide your TIN to payment card or third party network the requester. transactions Note.Entering"Applied For"means that you have already applied for a TIN or that 1 See Form 1099-MISC,Miscellaneous Income,and its instructions. 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. , I . Page 4 Form W-9(Rev.12-2014) • Part II.Certification 3You 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 SIN(if you To establish to the withholding agent that you are a U.S.person,or resident alien, have one),but the IRS encourages you to use your SSN. sign Form W-9.You may be requested to sign by the withholding agent even if °List first and circle the name of the trust,estate,or pension trust.(Do not furnish the TIN of the items 1,4,or 5 below indicate otherwise.. personal representative or trustee unless the legal entity itself Is not designated in the account For a joint account,only the person whose TIN is shown in Part I should sign .hole.)Also see o ciSpeciasal rules s for pa nem VJ s 9 to on pag e2 of trust. (when required).In the case of a disregarded entity,the person identified on line 1 must sign.Exempt payees,see Exempt payee code earlier. Note.If no name is circled when more than orfe name is listed,the number will be Signature requirements.Complete the certification as indicated in items 1 considered to be that of the first name listed. through 5 below. Secure Your Tax Records from Identity Theft 1.Interest,dividend,and barter exchange accounts opened before 1984 Identitytheft occurs when someone uses your personal information such as your and broker accounts do considered active during 1983.You must give your name, SN,or other identifying information,without your permission,to commit correct TIN,but you not have to sign the certification. cation. fraud or other crimes.An identity thief may use your SSN to get a job or may file a 2.Interest,dividend,broker,and barter exchange accounts opened after tax return using your SSN to receive a refund. 1983 and broker accounts considered inactive during 1983.You must sign the To reduce your risk certification or backup withholding will apply.If you are subject to backup withholding and you are merely providing your correct TIN to the requester,you •Protect your SSN, must cross out item 2 in the certification before signing the form. •Ensure your employer is protecting your SSN,and 3.Real estate transactions.You must sign the certification.You may cross out •Be careful when choosing a tax preparers. item 2 ofh r payments.nYou If your tax records are affected by identity theft and you receive a notice from the4 Other lehave give your idh correct TIN,but your vdo notlhave to sign the IRS,respond right away to the name and phone number printed on the IRS certification unless you have been notified that you have previously given an notice or letter. incorrect TIN."Other payments"include payments'made in the course of the requester's trade or business for rents,royalties,goods(other than bills for If your tax records are not currently affected by identity theft but you think you merchandise),medical and health care services(including payments to are at risk due to a lost or stolen purse or wallet,questionable credit card activity corporations),payments to a nonemployee for services,payments made in or credit report,contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit settlement of payment card and third party network transactions,payments to Form 14039. certain fishing boat crew members and fishermen,and gross proceeds paid to For more information,see Publication 4535,Identity Theft Prevention and Victim attorneys(including payments to corporations). Assistance. 5.Mortgage interest paid by you,acquisition or abandonment of secured Victims of identity theft who are experiencing economic harm or a system property,cancellation of debt,qualified tuition program payments(under problem,or are seeking help in resolving tax problems that have not been resolved section 529),IRA,Coverdell ESA,Archer MBA or HSA contributions or through normal channels,may be eligible for Taxpayer Advocate Service(TAS) pension and pension distributions.You must give your correct TIN,but you assistance.You can reach TAS by calling the TAS toll-free case intake line at do not have to sign the certification. 1-877,777-4778 or TTY/TDD 1-800-829-4059. What Name and Number To Give the Requester. Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business For this type of account: Give name and SSN of: 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 t Individual The individual into surrendering private information that will be used for identity theft. 2.Two or more individuals(joint The actual owner of the account or, The IRS does not initiate contacts with taxpayers via emails.Also,the IRS does account) if combined funds,the first not request personal detailed information through email or ask taxpayers for the individual on the account' PIN numbers,passwords,or similar secret access information for their credit card, 3.Custodian account of a minor The minor' bank,or other financial accounts. (Uniform Gift to Minors Act) If you receive an unsolicited email claiming to be from the IRS,forward this 4.a.The usual revocable savings The grantor-trustee' message to phishing@irs.gov.You may also report misuse of the IRS name,logo, or other IRS property to the Treasury Inspector General for Tax Administration b.tr ustSo-called r also trustee) (fIGTA)at 1-800-366-4484.You can.forward suspicious emails to the Federal t a egtrusttrust account that is The actual owner' Trade Commission at:spam@uce.gov or contact them at www.ftc.gov/idtheft or sote legal or valid trust under 1-877-IDTHEFT(1-877-438-4338). state law 5.Sole proprietorship or disregarded The owner' Visit IRS.gov to team more about identity theft and how to reduce your risk. entity owned by an individual 6.Grantor trust filing under Optional The grantor" Privacy Act Notice Form 1099 Filing Method 1(see Section 6109 of the Internal Revenue Code requires you to provide your correct Regulations section 1.671-4(b)(2)() TIN to persons(including federal agencies)who are required to file information (A)) returns with the IRS to report interest,dividends,or certain other income paid to For this type of account: Give name and EIN of: you;mortgage interest you paid;the acquisition or abandonment of secured 7.Disregarded entity not owned by an The owner property;the cancellation of debt;or contributions you made to an IRA,Archer MSA,or HSA.The person collecting this form uses the information on the form to individual file information retums with the IRS,reporting the above information.Routine uses 8.A valid trust,estate,or pension trust Legal entity' of this information include giving it to the Department of Justice for civil and 9.Corporation or LLC electing The corporation criminal litigation and to cities,states,the District of Columbia,and U.S. corporate status on Form 8832 or commonwealths and possessions for use in administering their laws.The Form 2553 information also may be disclosed to other countries under a treaty,to federal and 10.Association,club,religious, The organization state agencies to enforce civil and criminal laws,or to federal law enforcement and charitable,educational,or other tax- 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 exempt organization withhold a percentage of taxable interest,dividend,and certain other payments to 11.Partnership or multi-member LLC The partnership a payee who does not give aTIN to the payer.Certain penalties may also apply for 12.A broker or registered nominee The broker or nominee providing false or fraudulent information. 13.Account with the Department of The public entity Agriculture in the name of a public entity(such as a state or local government,school district,or prison)that receives agricultural program payments 14.Grantor trust filing under the Form The trust 1041 Filing Method or the Optional Form 1099 Filing Method 2(see Regulations section 1.671-4(b)(2)O (B)) 'List first and circle the name of the person whose number you furnish.If only one person on a joint account has an SSN,that person's number must be furnished. 'Circle the minor's name and furnish the minor's SSN. Miami-Dade County's Affidavits and Declarations 15.MIAMI-DADE COUNTY REQUIRED LOBBYIST REGISTRATION FOR ORAL Pertains PRESENTATION Section 2-11.1(i)(2) CONFLICT OF INTEREST AND CODE N/A OF ETHICS ORDINANCE All lobbyists shall register with the Clerk of the Board of County Commissioners within five (5) business days of being retained as a lobbyist or before engaging in any lobbying activities,whichever shall come first.Every person required to so register shall: 1. Register on forms prepared by the Clerk; 2.State under oath his or her name,business address and the name and business address of each person or entity which has employed said registrant to lobby.If the lobbyist represents a corporation,the corporation shall also be identified.Without limiting the foregoing,the lobbyist shall also identify all persons holding,directly or indirectly, a five (5) percent or more ownership interest in such corporation,partnership, or trust.Registration of all lobbyists shall be required prior to January 15 of each year and each person who withdraws as a lobbyist for a particular client shall file an appropriate notice of withdrawal. 3.Prior to conducting any lobbying,all principals must file a form with the Clerk of the Board of County Commissioners,signed by the principal or the principal's representative,stating that the lobbyist is authorized to represent the principal.Failure of a principal to file the form required by the preceding sentence may be considered in the evaluation of a bid or proposal as evidence that a proposer or bidder is not a responsible contractor.Each principal shall file a form with the Clerk of the Board at the point in time at which a lobbyist is no longer authorized to represent the principal. By initialing here,the principals or principal's representative have filed with the Clerk of the Board of County Commissioners stating that a lobbyist is authorized to represent the principal. 4.Any public officer, employee or appointee who only appears in his or her official capacity shall not be required to register as a lobbyist. 5.Any person who only appears in his or her individual capacity for the purpose of self-representation without compensation or reimbursement,whether direct,indirect or contingent,to express support of or opposition to any item,shall not be required to register as a lobbyist. 6.Any person who only appears as a representative of a not-for-profit corporation or entity(such as a charitable organization, or a trade association or trade union),without special compensation or reimbursement for the appearance,whether direct,indirect or contingent,to express support of or opposition to any item,shall register with the Clerk as required by the Ordinance subsection,but,upon request,shall not be required to pay any registration fees. The Clerk of the Board of County Commissioners shall notify the Commission on Ethics and Public Trust of the failure of a lobbyist or principal to file a report and/or pay the assessed fines after notification. A lobbyist or principal may appeal a fine and may request a hearing before the Commission on Ethics and Public Trust.A request for a hearing on the fine must be filed with the Commission on Ethics and Public Trust within fifteen (15) calendar days of receipt of the notification of the failure to file the required disclosure form.The Commission on Ethics and Public Trust shall have the authority to waive the fine,in whole or part,based on good cause shown.The Commission on Ethics and Public Trust shall have the authority to adopt rules of procedure regarding appeals from the Clerk of the Board of County Commissioners. Except as otherwise provided in subsection of the Ordinance,the validity of any action or determination of the Board of County Commissioners or County personnel,board or committee shall not be affected by the failure of any person to comply with the provisions of this subsection(s). (Ord.No. 00-19, § 1, 2-8-00; Ord.No. 01-93, § 1, 5-22- 01; Ord. No. 01-162, § 1, 10-23-01; Ord.No. 03-107,-§ 1,5-6-03) Miami-Dade County's Affidavits and Declarations MIAMI-DADS COUNTY I have carefully read this entire ten (10) page document entitled, "Miami-Dade County's Affidavits and Declarations" and agree to; (1) sign an affidavit as to certain matters and (2) make a declaration as to certain other matters. This form contains both an Affidavit form for matters requiring the entity to sign under oathand a Declaration form for matters requiring only an affirmation or declaration for other matters. Each section of this form must be read,and initialed indicating acceptance and/or compliance with the County's policy related to the particular affidavit. For affidavit sections that you do not believe are applicable to your organization,please indicate this by placing"x"in the box next to N/A. BY SIGNING AND NOTARIZING THIS PAGE YOU ARE ATTESTING TO AFFIDAVITS 1-15 MIAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE By: .4111111( 215-� t7 � •� • �'' l 5— , 20 /-7 S.gnatur a`: of Witness ...V' 4 :t0 Signa 1' of Aff., t A s 10c,0V\ Or` es er ployer Identification Number '4r4 J I r.'I i Y MORAL-CS Printed Name of Affiant and Name of.Agenc I N VEN r i®N GEN r Fz __.1:›R a V C Address of Agency SUBSCRIBED AND SWORN TO (or affirmed) before me this If day of Febr Uar,!20 / 7 He/She is personally known to me or has presented as identification. Type of identification S gnature of otary Serial Number Print or Stamp Name of Notary Expiration Date ,a.:r.... WACARDILLO Notary Public—State of �1 tSY I �� 4 MY COMMISSION#FF 155322 r,�a :47 EXPIRES:August 27,2018 ;pF�4Q�• Bonded Thru Notary Public Underwriters County of 14661144.;-N4 Notary Seal Form W.9 Request for Taxpayer Give Form to the (Rev.December2014) Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. Internal Revenue Service 1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank. CITY OF MIAMI e.)C..14 c\i 2 Business name/disregarded entity name,if different from above m m 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to ° ❑Individual/soleproprietor orot anst actions c single-member LC ❑ C Corporation ❑ S Corporation ❑ Partnership ❑Trust/estate certain onsion,on page 3):individuals;see M. c ElLimited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)► Exempt payee code(if any) g disregarded, Exemption from FATCA reporting `o 2 Note.For a single-member LLC that is do not check LLC;check the appropriate box in the line above for 5 y the tax classification of the single-member owner. code(if any) c O. t, Other(see instructions)► (Applies to accounts maintained outside the U.S.) ?E. 5 Address(number,street,and apt.or suite no.) Requester's name and address(optional) rn 14co NivEjv r i ON cC-1 zg c iv'E ° 6 City,state,and ZIP code n MiAM1 eitsAc -t� 1=-[. 3- iact 7 List account number(s)here(optional) Part I Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number backup withholding.For individuals,this is generally your social security number(SSN).However,for a resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other entities,it is your employer identification number(EIN).If you do not have a number,see How to get a TIN on page 3. or Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identification number guidelines on whose number to enter. 59 G oOo 3 - 2 Eau 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 abandonme • of secured prope ,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest. d dividends,you.re not required to sign the certification,but you must provide your correct TIN.See the instructions on page 3. Sign Signature of A Here U.S.person - Date► Z. I /12 General Instructions I •Form 1098 Thome mortgage interest),1098-E(student loan interest),1098-T (tuition) Section references are to the Internal Revenu- ode unless otherwise noted. •Form 1099-C(canceled debt) Future developments.Information about dev-•pments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property) as legislation enacted after we release it)is at www.irs.gov/fw9. Use Form W-9 only if you are a U.S.person(including a resident alien),to Purpose of Form provide your correct TIN. An individual or entity(Form W-9 requester)who is required to file an information If you do not return Form W-9 to the requester with a TIN,you might be subject return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What is backup withholding?on page 2. which may be your social security number(SSN),individual taxpayer identification By signing the filled-out form,you: number(ITIN),adoption taxpayer identification number(ATIN),or employer identification number(EIN),to report on an information return the amount paid to 1.Certify that the TIN you are giving is correct(or you are waiting for a number you,or other amount reportable on an information return.Examples of information to be issued), returns include,but are not limited to,the following: 2.Certify that you are not subject to backup withholding,or •Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding if you are a U.S.exempt payee.If •Form 1099-DIV(dividends,including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your allocable share of any partnership income from a U.S.trade or business is not subject to the •Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and •Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on •Form 1099-S(proceeds from real estate transactions) page 2 for further information. •Form 1099-K(merchant card and third party network transactions) Cat.No.10231X Form W-9(Rev.12-2014) Form W-9(Rev.12-2014) Page 2 Note.If you are a U.S.person and a requester gives you a form other than Form 3.The IRS tells the requester that you furnished an incorrect TIN, W-9 to request your TIN,you must use the requester's form if it is substantially 4.The IRS tells you that you are subject to backup withholding because you did similar to this Form W-9. not report all your interest and dividends on your tax return(for reportable interest Definition of a U.S.person.For federal tax purposes,you are considered a U.S. and dividends only),or person if you are: 5.You do not certify to the requester that you are not subject to backup •An individual who is a U.S.citizen or U.S.resident alien; withholding under 4 above(for reportable interest and dividend accounts opened •A partnership,corporation,company,or association created or organized in the after 1983 only). United States or under the laws of the United States; Certain payees and payments are exempt from backup withholding.See Exempt •An estate(other than a foreign estate);or payee code on page 3 and the separate Instructions for the Requester of Form 9 W-9 for more information. •A domestic trust(as defined in Regulations section 301.7701-7). Also see Special rules for partnerships above. Special rules for partnerships.Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section What is FATCA reporting? 1446 on any foreign partners'share of effectively connected taxable income from such business.Further,in certain cases where a Form W-9 has not been received, The Foreign Account Tax Compliance Act(FATCA)requires a participating foreign the rules under section 1446 require a partnership to presume that a partner is a financial institution to report all United States account holders that are specified foreign person,and pay the section 1446 withholding tax.Therefore,if you are a United States persons.Certain payees are exempt from FATCA reporting.See U.S.person that is a partner in a partnership conducting a trade or business in the Exemption from FATCA reporting code on page 3 and the Instructions for the United States,provide Form W-9 to the partnership to establish your U.S.status Requester of Form W-9 for more information. and avoid section 1446 withholding on your share of partnership income. Updating Your Information In the cases below,the following person must give Form W-9 to the partnership for purposes of establishing its U.S.status and avoiding withholding on its' You must provide updated information to any person to whom you claimed to be allocable share of net income from the partnership conducting a trade or business an exempt payee if you are no longer an exempt payee and anticipate receiving in the United States: 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 •In the case of a disregarded entity with a U.S.owner,the U.S.owner of the corporation,or if you no longer are tax exempt.In addition,you must furnish a new disregarded entity and not the entity; Form W-9 if the name or TIN changes for the account;for example,if the grantor •In the case of a grantor trust with a U.S.grantor or other U.S.owner,generally, of a grantor trust dies. the U.S.grantor or other U.S.owner of the grantor trust and not the trust;and •In the case of a U.S.trust(other than a grantor trust),the U.S.trust(other than a Penalties grantor trust)and not the beneficiaries of the trust. Failure to furnish TIN.If you fail to furnish your correct TIN to a requester,you are Foreign person.If you are a foreign person or the U.S.branch of a foreign bank subject to a penalty of$50 for each such failure unless your failure is due to that has elected to be treated as a U.S.person,do not use Form W-9.Instead,use reasonable cause and not to willful neglect. the appropriate Form W-8 or Form 8233(see Publication 515,Withholding of Tax Civil penalty for false information with respect to withholding.If you make a on Nonresident Aliens and Foreign Entities). false statement with no reasonable basis that results in no backup withholding, Nonresident alien who becomes a resident alien.Generally,only a nonresident you are subject to a$500 penalty. alien individual may use the terms of a tax treaty to reduce or eliminate U.S.tax on Criminal penalty for falsifying information.Willfully falsifying certifications or certain types of income.However,most tax treaties contain a provision known as affirmations may subject you to criminal penalties including fines and/or a"saving clause."Exceptions specified in the saving clause may permit an imprisonment. exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S.resident alien for tax purposes. Misuse of TINs.If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties. If 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 Specific Instructions of income,you must attach a statement to Form W-9 that specifies the following p five items: Line 1 1.The treaty country.Generally,this must be the same treaty under which you claimed exemption from tax as a nonresident alien. You must enter one of the following on this line;do not leave this line blank.The 2.The treaty article addressing the income. name should match the name on your tax return. 3.The article number(or location)in the tax treaty that contains the saving If this Form W-9 is for a joint account,list first,and then circle,the name of the 'clause and its exceptions, person or entity whose number you entered in Part I of Form W-9. 4.The type and amount of income that qualifies for the exemption from tax. a. Individual.Generally,enter the name shown on your tax return.If you have changed your last name without informing the Social Security Administration(SSA) 5.Sufficient facts to justify the exemption from tax under the terms of the treaty of the name change,enter your first name,the last name as shown on your social article. security card,and your new last name. Example.Article 20 of the U.S.-China income tax treaty allows an exemption Note.ITIN applicant:Enter your individual name as it was entered on your Form from tax for scholarship income received by a Chinese student temporarily present W_7 application,line la.This should also be the same as the name you entered on in the United States.Under U.S.law,this student will become a resident alien for the Form 1040/1040A/1040EZ you filed with your application. tax purposes if his or her stay in the United States exceeds 5 calendar years. b. Sole proprietor or LLC. your individual name as However,paragraph 2 of the first Protocol to the U.S.-China treaty(dated April 30, shown. on your 104or or ssingle-member on line 1.You Enteryy enter your business,atrade, 1984)allows the provisions of Article 20 to continue to apply even after the or"doing your 10business /1 40A/1 name on line 2. 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 c. Partnership,LLC that is not a single-member LLC,C Corporation,or S relying on this exception to claim an exemption from tax on his or her scholarship Corporation.Enter the entity's name as shown on the entity's tax return on line 1 or fellowship income would attach to Form W-9 a statement that includes the and any business,trade,or DBA name on line 2. information described above to support that exemption. d. Other entities.Enter your name as shown on required U.S.federal tax If you are a nonresident alien or a foreign entity,give the requester the documents on line 1.This name should match the name shown on the charter or appropriate completed Form W-8 or Form 8233. other legal document creating the entity.You may enter any business,trade,or DBA name on line 2. Backup Withholding e. Disregarded entity.For U.S.federal tax purposes,an entity that is What is backup withholding?Persons making certain payments to you must disregarded as an entity separate from its owner is treated as a"disregarded under certain conditions withhold and pay to the IRS 28%of such payments.This entity." See Regulations section 301.7701-2(c)(2)(iii).Enter the owner's name on is called"backup withholding." Payments that may be subject to backup line 1.The name of the entity entered on line 1 should never be a disregarded withholding include interest,tax-exempt interest,dividends,broker and barter entity.The name on line 1 should be the name shown on the income tax return on exchange transactions,rents,royalties,nonemployee pay,payments made in which the income should be reported.For example,if a foreign LLC that is treated settlement of payment card and third party network transactions,and certain as a disregarded entity for U.S.federal tax purposes has a single owner that is a payments from fishing boat operators.Real estate transactions are not subject to U.S.person,the U.S.owner's name is required to be provided on line 1.If the backup withholding. direct owner of the entity is also a disregarded entity,enter the first owner that is on You will not be subject to backup withholding on payments you receive if you not 2d,"Businessined for mfee pisral tax rdepurd entity Enter the disregarded of they's name e line 2, name/disregarded name."If the owner disregarded give the requester your correct TIN,make the proper certifications,and report all entity is a foreign person,the owner must complete an appropriate Form W-8 your taxable interest and dividends on your tax retum. instead of a Form W-9. This is the case even if the foreign person has a U.S.TIN. 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 Part II instructions on page 3 for details), Form W-9(Rev.12-2014) Page 3 Line 2 :However,the following payments made to a corporation and reportable on Form If you have a business name,trade name,DBA name,or disregarded entity name, 1099-MISC are not exempt from backup withholding:medical and health care you may enter it on line 2. payments,attorneys'fees,gross proceeds paid to an attorney reportable under Line 3 section 6045(f),and payments for services paid by a federal executive agency. Exemption from FATCA reporting code.The following codes identify payees Check the appropriate box in line 3 for the U.S.federal tax classification of the that are exempt from reporting under FATCA.These codes apply to persons person whose name is entered on line 1.Check only one box in line 3. submitting this form for accounts maintained outside of the United States by Limited Liability Company(LLC).If the name on line 1 is an LLC treated as a certain foreign financial institutions.Therefore,if you are only submitting this form partnership for U.S.federal tax purposes,check the"Limited Liability Company" for s account you hold inrequestinge United States,you may leave thisn if theh blank. box and enter"P"in the space provided.If the LLC has filed Form 8832 or 2553 to Consult it with the ec to t se requirements. eqthismform if you are indicate if that be taxed as a corporation,check the"Limited Liability Company"box and in the institution is bysuprovidingof to these rwith a Form A W-9 with"NotNr may lic ble"(or a code is space provided enter"C"for C corporation or"S"for S corporation.If it is a not required by you with a Form with Applicable"(or any single-member LLC that is a disregarded entity,do not check the"Limited Liability similar indication)written or printed on the line for a FATCA exemption code. Company"box;instead check the first box in line 3"Individual/sole proprietor or A—An organization exempt from tax under section 501(a)or any individual single-member LLC." retirement plan as defined in section 7701(a)(37) Line 4, Exemptions B—The United States or any of its agencies or instrumentalities If you are exempt from backup withholding and/or FATCA reporting,enter in the C—A state,the District of Columbia,a U.S.commonwealth or possession,or any of their political subdivisions or instrumentalities appropriate space In line 4 any code(s)that may apply to you. Exempt payee code. D—A corporation the stock of which is regularly traded on one or more established securities markets,as described in Regulations section • Generally,individuals(including sole proprietors)are not exempt from backup 1.1472-1(c)(1)(i) withholding. E—A corporation that is a member of the same expanded affiliated group as a • Except as provided below,corporations are exempt from backup withholding corporation described in Regulations section 1.1472-1(c)(1)(i) for certain payments,including interest and dividends. F—A dealer in securities,commodities,or derivative financial instruments • Corporations are not exempt from backup withholding for payments made in (including notional principal contracts,futures,forwards,and options)that is settlement of payment card or third party network transactions. registered as such under the laws of the United States or any state • Corporations are not exempt from backup withholding with respect to attorneys' G—A real estate investment trust 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 H—A regulated investment company as defined in section 851 or an entity 1099-MISC. registered at all times during the tax year under the Investment Company Act of 1940 The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4. I—A common trust fund as defined in section 584(a) 1—An organization exempt from tax under section 501(a),any IRA,or a J—A bank as defined in section 581 custodial account under section 403(b)(7)if the account satisfies the requirements K—A broker of section 401(f)(2) L—A trust exempt from tax under section 664 or described in section 4947(a)(1) 2—The United States or any of its agencies or instrumentalities M—A tax exempt trust under a section 403(b)plan or section 457(g)plan 3—A state,the District of Columbia,a U.S.commonwealth or possession,or Note.You may wish to consult with the financial institution requesting this form to any of their political subdivisions or instrumentalities determine whether the FATCA code and/or exempt payee code should be 4—A foreign government or any of its political subdivisions,agencies,or completed. instrumentalities 5—A corporation Line 5 6—A dealer in securities or commodities required to register in the United Enter your address(number,street,and apartment or suite number).This is where States,the District of Columbia,or a U.S.commonwealth or possession the requester of this Form W-9 will mail your information returns. 7—A futures commission merchant registered with the Commodity Futures Line 6 Trading Commission Enterour city,ty,state,and ZIP code. 8—A real estate investment trust 9—An entity registered at all times during the tax year under the Investment Part I.Taxpayer Identification Number(TIN) Company Act of 1940 Enter your TIN in the appropriate box.If you are a resident alien and you do not 10—A common trust fund operated by a bank under section 584(a) have and are not eligible to get an SSN,your TIN is your IRS individual taxpayer 11—A financial institution identification number(ITIN).Enter it in the social security number box.If you do not have an ITIN,see How to get a TIN below. 12—A middleman known in the investment community as a nominee or If you are a sole proprietor and you have an EIN,you may enter either your SSN custodian or EIN.However,the IRS prefers that you use your SSN. 13—A trust exempt from tax under section 664 or described in section 4947 If you area single-member LLC that is disregarded as an entity separate from its The following chart shows types of payments that may be exempt from backup owner(see Limited Liability Company(LLC)on this page),enter the owner's SSN withholding.The chart applies to the exempt payees listed above,1 through 13. (or EIN,if the owner has one).Do not enter the disregarded entity's EIN.If the LLC is classified as a corporation or partnership,enter the entity's EIN. IF the payment is for... THEN the payment is exempt for... Note.See the chart on page 4 for further clarification of name and TIN combinations. Interest and dividend payments All exempt payees except Flow to get a TIN.If you do not have a TIN,apply for one immediately.To apply for 7 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 Broker transactions Exempt payees 1 through 4 and 6 calling 1-800-772-1213.Use Form W-7,Application for IRS Individual Taxpayer through 11 and all C corporations.S Identification Number,to apply for an!TIN,or Form SS-4,Application for Employer corporations must not enter an exempt Identification Number,to apply for an EIN.You can apply for an EIN online by payee code because they are exempt accessing the IRS website at www.irs.gov/businesses and clicking on Employer only for sales of noncovered securities Identification Number(EIN)under Starting a Business.You can get Forms W-7 and acquired prior to 2012. SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676). Barter exchange transactions and Exempt payees 1 through 4 If you are asked to complete Form W-9 but do not have a TIN,apply for a TIN patronage dividends and write"Applied For"in the space for the TIN,sign and date the form,and give it to the requester.For interest and dividend payments,and certain payments made Payments over$600 required to be Generally,exempt payees with respect to readily tradable instruments,generally you will have 60 days to get reported and direct sales over$5,0001 1 through 52 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 Payments made in settlement of Exempt payees 1 through 4 subject to backup withholding on all such payments until you provide your TIN to payment card or third party network the requester. transactions Note.Entering"Applied For"means that you have already applied for a TIN or that I See Form 1099-MISC,Miscellaneous Income,and its instructions, 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. • Form W-9(Rev.12-2014) Page 4 Part II.Certification '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 To establish to the withholding agent that you are a U.S.person,or resident alien, have one),but the IRS encourages you to use your SSN. sign Form W-9.You may be requested to sign by the withholding agent even if a Ust first and circle the name of the trust,estate,or pension trust.(Do not furnish the TIN of the items 1,4,or 5 below indicate otherwise. personal representative or trustee unless the legal entity itself is not designated in the account For a joint account,only the person whose TIN is shown in Part I should sign title.)Also see Special rules for partnerships on page 2. (when required).In the case of a disregarded entity,the person identified on line 1 *Note.Grantor also must provide a Form W-9 to trustee of trust. must sign.Exempt payees,see Exempt payee code earlier. Note.If no name is circled when more than one name is listed,the number will be Signature requirements.Complete the certification as indicated in items 1 considered to be that of the first name listed. through 5 below. Secure Your Tax Records from Identity Theft 1.Interest,dividend,and barter exchange accounts opened before 1984 and broker accounts considered active during 1983.You must give your Identity theft occurs when someone uses your personal information such as your correct TIN,but you do not have to sign the certification. 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 2.Interest,dividend,broker,and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983.You must sign the tax return using your SSN to receive a refund. certification or backup withholding will apply.If you are subject to backup To reduce your risk: withholding and you are merely providing your correct TIN to the requester,you •Protect your SSN, must cross out item 2 in the certification before signing the form. •Ensure your employer is protecting your SSN,and 3.Real estate transactions.You must sign the certification.You may cross out •Be careful when choosing a tax preparer. item 2 of the certification. If your tax records are affected by identity theft and you receive a notice from 4.Other payments.You must give your notified correcthaTIN,but your vdo notslhave to sign the IRS,respond right away to the name and phone number printed on the IRS the certification unless you have been that you have previously given an notice or letter. incorrect TIN."Other payments"include payments made in the course of the requester's trade or business for rents,royalties,goods(other than bills for If your tax records are not currently affected by identity theft but you think you merchandise),medical and health care services(including payments to are at risk due to a lost or stolen purse or wallet,questionable credit card activity corporations),payments to a nonemployee for services,payments made in or credit report,contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit settlement of payment card and third party network transactions,payments to Form 14039. certain fishing boat crew members and fishermen,and gross proceeds paid to For more information,see Publication 4535,Identity Theft Prevention and Victim attorneys(including payments to corporations). Assistance. 5.Mortgage interest paid by you,acquisition or abandonment of secured Victims of identity theft who are experiencing economic harm or a system property,cancellation of debt,qualified tuition program payments(under problem,or are seeking help in resolving tax problems that have not been resolved section 529),IRA,Coverdell ESA,Archer MSA or HSA contributions or through normal channels,may be eligible for Taxpayer Advocate Service(TAS) pension and pension distributions.You must give your correct TIN,but you assistance.You can reach TAS by calling the TAS toll-free case intake line at do not have to sign the certification. 1-877-777-4778 or TTY/TDD 1-800-829-4059. What Name and Number To Give the Requester Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business For this type of account: Give name and SSN of: 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 1.Individual The individual into surrendering private information that will be used for identity theft. 2.Two or more individuals(joint The actual owner of the account or, The IRS does not initiate contacts with taxpayers via emails.Also,the IRS does account) if combined funds,the first not request personal detailed information through email or ask taxpayers for the individual on the account' PIN numbers,passwords,or similar secret access information for their credit card, 3.Custodian account of a minor The minor' ' bank,or other financial accounts. (Uniform Gift to Minors Act) If you receive an unsolicited email claiming to be from the IRS,forward this 4.a.The usual revocable savings The grantor-trustee' message to phishing@irs.gov.You may also report misuse of the IRS name,logo, trust(grantor is also trustee) or other IRS property to the Treasury Inspector General for Tax Administration b.So-called trust account that is The actual owner' (fIGTA)at 1-800-366-4484.You can forward suspicious emails to the Federal not a legal or valid trust under Trade Commission at:spam@uce.gov or contact them at www.ftc.gov/idtheft or state law 1-877-IDTHEFT(1-877-438-4338). 5.Sole proprietorship or disregarded The owner' Visit IRS.gov to learn more about identity theft and how to reduce your risk. entity owned by an individual 6.Grantor trust filing under Optional The grantor* Privacy Act Notice Form 1099 Filing Method 1(see Section 6109 of the Internal Revenue Code requires you to provide your correct Regulations section 1.671-4(b)(2)(i) TIN to persons(including federal agencies)who are required to file information (A)) returns with the IRS to report interest,dividends,or certain other income paid to For this type of account: Give name and EIN of: you;mortgage interest you paid;the acquisition or abandonment of secured 7.Disregarded entity not owned by an The owner property;the cancellation of debt;or contributions you made to an IRA,Archer individual MSA,or HSA.The person collecting this form uses the information on the form to 8.A valid trust,estate,or pension trust Legal entity` file information returns with the IRS,reporting the above information.Routine uses of this information include giving it to the Department of Justice for civil and 9.Corporation or LLC electing The corporation criminal litigation and to cities,states,the District of Columbia,and U.S. corporate status on Form 8832 orcommonwealths and possessions for use in administering their laws.The • Form 2553information also may be disclosed to other countries under a treaty,to federal and 10.Association,club,religious, The organization state agencies to enforce civil and criminal laws,or to federal law enforcement and charitable,educational,or other tax- intelligence agencies to combat terrorism.You must provide your TIN whether or exempt organization 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 11.Partnership or multi-member LLC The partnership a payee who does not give a TIN to the payer.Certain penalties may also apply for 12.A broker or registered nominee The broker or nominee providing false or fraudulent information. 13.Account with the Department of The public entity Agriculture in the name of a public entity(such as a state or local government,school district,or prison)that receives agricultural program payments 14.Grantor trust filing under the Form The trust 1041 Filing Method or the Optional Form 1099 Filing Method 2(see Regulations section 1.671-4(b)(2)(i) (B)) 'List first and circle the name of the person whose number you furnish.If only one person on a joint account has an SSN,that person's number must be furnished. a Circle the minor's name and furnish the minor's SSN.