HomeMy WebLinkAboutMINUTES - 06202006 - C.25 2�
SEL
TO: BOARD OF SUPERVISORS, AS GOVERNING Contra�"�� ���=�'
BOARD OF THE FLOOD CONTROL&WATER
CONSERVATION DISTRICT SI'- h Costa
FROM: MAURICE M. SHIU, CHIEF ENGINEER
------
°ocoax �~� County
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DATE: June 20, 2006
SUBJECT: APPROVE contract with Matt Bolender, in the amount of$56,000 for the period July 1, 2006 through
June 30, 2007, Countywide. (California Integrated Waste Management Board's Used Oil Recycling
Grant Program Funds) (All Districts) Project No. 7519 6x7632
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDED ACTION:
APPROVE and AUTHORIZE the Chief Engineer,Flood Control and Water Conservation District,or designee,on
behalf of the Contra Costa Clean Water Program, to execute a contract with Matt Bolender in the amount not to
exceed$56,000 for consulting services for the Used Oil Recycling Block Grant Program,for the period July 1,2006
through June 30, 2007 Countywide (California Integrated Waste Management Board's Used Oil Recycling Grant
Program Funds) (All Districts) Project No. 7519 6x7632
�7
CONTINUED ON ATTACHMENT: ❑x SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR REOQVMMENDATION OARD CO TT
APPROVE OTHER
a
SIGNATURE(S): /
ACTION OF BOAR N V G4/'»IC-0 APPROVED AS RECOMMENDED OTHER
VOTE OF SUPERVISORS: I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT
COPY OF AN ACTION TAKEN AND ENTERED ON
UNANIMOUS(ABSENT O'T'7MINUTES OF THE BOARD OF SUPERVISORS ON THE
AYES: NOES: DATE SHOWN.
ABSENT: ABSTAIN:
Contact:
G:\NPDES\BO_Res_Contracts_Agmt\Bolender\06 07\130 06_07.doc ATTESTED V
JOHN CULLEN,CLERK OF THE BOARD OF
SUPERVISORS
cc:
BY: ,DEPUTY
. SUBJECT: APPROVE contract with Matt Boiender, in the amount of$56,000 for the period July 1, 2006
through June 30, 2007, Countywide. (California Integrated Waste Management Board's Used
Oil Recycling Grant Program Funds) (All Districts)Project No. 7519 6x7632
DATE: June 20, 2006
PAGE: 2 of 2
FISCAL IMPACT:
None. Paid for by the California Integrated Waste Management Board's Used Oil Recycling Grant Program Funds.
REASONS FOR RECOMMENDATION AND BACKGROUND:
The Contra Costa Clean Water Program has been receiving funds from the California Integrated Waste Management
Board's Used Oil Recycling Block Grant Program for the past several years. The purpose of the grant is to provide
funds to the cities and County to implement used oil collection programs that encourage recycling or appropriate
disposal of used oil.The three primary activities during the past several years have been the certification of used oil
recycling centers, a school education program targeted to elementary and high school students and a public
education program promoting used oil-recycling activities to the general public. The response to the Program has
been positive and the activities will be continued in the 2006/2007 fiscal year.
The grant will total approximately$94,508 during the 12-month period commencing July 1,2006 and ending June
30, 2007. The consultant will be primarily responsible for implementing all grant program activities. The
Management Committee of the Contra Costa Clean Water Program has unanimously recommended the Board of
Supervisors continue its contract with Matthew Bolender due to his past exemplary performance.
CONSEQUENCES OF NEGATIVE ACTION:
Should the Board of Supervisors fail to approve this consulting services agreement, funding for public
educational programs will be lost.
CONSULTING SERVICES AGREEMENT
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1. Special Conditions. These Special Conditions are incorporated below by reference.
(a) Public Agency: Contra Costa County Flood Control &Water Conservation District on behalf of the
Contra Costa Clean Water Program
(b) Consultant's Name&Address: Matthew Bolender
968 Rolling Woods Way
Concord, CA 94521
(c) Project Name, Number, & Location: Used Oil Recycling Block Grant—Twelfth Cycle—Project. No. 7519 6x7632
(d) Effective Date: 07/01/06 (e) Payment Limit(s): $56,000
(f) Completion Date(s): 06/30/07
2. Signatures. These signatures attest the parties'agreement hereto:
PUBLIC AGENCY CON TANT
By: Maurice M. Shiu
Public Works Director/ By:
Chief Engineer, or Designee (Denate officia capacit in the business Type of Business:
(sole proprietorship, government agency, partnership, corporation, etc.)
If Corporation, State of Incorporation:
By: By:
(Designate official capacity in the business)
Note to Consultant: For corporations, the contract must be signed by two officers. The first signature must be that of the
chairman of the board, president, or vice-president; the second signature must be that of the secretary, assistant secretary,
chief financial officer,or assistant treasurer. (Civ. Code,Sec. 1190 and Corps. Code. Sec.313.)The acknowledgment below
must be signed by a Notary Public.
CERTIFICATE OF ACKNOWLEDGMENT
State of California )
ss.
County of )
On the date written below, before me, t undersigned Notary Public, sonally appeared the person(s)signing above for
Consultant,personally known to me(or prove o me on the basis of tisfactory evidence)to be the person(s)whose name(s)
is/are subscribed to the within instrument and nowledged me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their sig ture on the instrument the person(s), or the entity upon behalf of
which the person(s)acted, executed the instrument.
WITNESS my hand and official seal.
Dated:
Notary Public
(Notary's Seal)
3. . . Parties. Effective on the above date,the above-named Public Agency and Consultant mutually agree and promise as
follows:
4. Employment. Public Agency hereby employs Consultant, and Consultant accepts such employment,to perform the
professional services described herein, upon the terms and in consideration of the payments stated herein.
5. Scope of Service. Scope of service shall be as described in Appendix A, attached hereto and made a part hereof by
this reference.
6. Report Disclosure Section.Any document or written report prepared hereunder by Consultant,or a subcontractor,for
Public Agency shall contain, in a separate section, the numbers and dollar amounts of this contract and all sub-
contracts relating to the preparation of such document or written report, provided that the payment limit specified in
Sec. 1(e)exceeds$5,000.When multiple documents or written reports are the subject or products of this agreement,
the disclosure section may also contain a statement indicating that the total contract amount represents compensation
for multiple documents or written reports.
7. Insurance. Consultant shall, at no cost to Public Agency, obtain and maintain during the term hereof: (a)Workers'
Compensation Insurance pursuant to state law; (b) Professional Liability Insurance with minimum coverage of
$ 1,000,000 and a maximum deductible of$ 100,0001;and,(c)Comprehensive General Liability Insurance,including
blanket contractual(or contractual liability)coverage, broad form property damage coverage,and coverage for owned
and non-owned vehicles,with a minimum combined single limit coverage of$1,000,000 for all damages due to bodily
injury,sickness or disease,or death to any person,and damage to property, including the loss of use thereof,arising
out of each accident or occurrence, and naming Public Agency, Contra Costa County, City of Antioch, City of
Brentwood,City of Clayton,City of Concord,Town of Danville,City of EI Cerrito,City of Hercules,City of Lafayette,City
of Martinez,Town of Moraga, City of Oakley, City of Orinda, City of Pinole, City of Pittsburg,City of Pleasant Hill,City
of Richmond, City of San Pablo, City of San Ramon, City of Walnut Creek, its/their governing bodies, officers and
employees as additional insureds. Consultant shall promptly furnish to Public Agency certificates of insurance
evidencing such coverage and requiring 30 days' written notice to Public Agency of policy lapse, cancellation or
material change in coverage.
8. Payment. Public Agency shall pay Consultant for professional services performed at the rates shown in Appendix B
attached hereto,which include all overhead and incidental expenses,for which no additional compensation shall be
allowed. Notwithstanding the foregoing, those incidental expenses specifically itemized in Appendix B shall be
reimbursable by Public Agency to Consultant,provided that Consultant submits copies of receipts and,if applicable,a
detailed mileage log to Public Agency. In no event shall the total amount paid to Consultant exceed the payment
limit(s)specified in Sec. 1(e)without prior written approval of the Public Agency.Consultant's billing statements shall
be submitted at convenient intervals approved by Public Agency and shall list,for each item of services,the employee
categories, hours and rates. Public Agency will pay consultant in accordance with the requirements of Civil Code
Section 3320 as applicable.
9. Status. The Consultant is an independent contractor, and shall not be considered an employee of Public Agency.
10. Time for Completion. Unless the time is extended in writing by Public Agency,Consultant shall complete all services
covered by this Agreement no later than the Completion Date(s) listed above.
11. Record Retention and Auditinci. Except for materials and records delivered to Public Agency,Consultant shall retain all
materials and records prepared or obtained in the performance of this Agreement, including financial records,for a
period of at least five years after Consultant's receipt of the final payment under this Agreement. Upon request by
Public Agency,at no additional charge,Consultant shall promptly make such records available to Public Agency,or to
authorized representatives of the state and federal governments,at a convenient location within Contra Costa County
designated by Public Agency, and without restriction or limitation on their use.
12. Documentation. Consultant shall prepare and deliver to Public Agency at no additional charge,the items described in
Appendix A to document the performance of this Agreement and shall furnish to Public Agency such information as is
necessary to enable Public Agency to monitor the performance of this Agreement.
1 Not required
13._ Ownership of Documents.All materials and records of a finished nature, such as final plans, specifications, reports,
and maps,prepared or obtained in the performance of this Agreement,shall be delivered to and become the property
of Public Agency. All materials of a preliminary nature, such as survey notes, sketches, preliminary plans,
computations and other data, prepared or obtained in the performance of this Agreement, shall be made available,
upon request, to Public Agency at no additional charge and without restriction or limitation on their use.
14. Extra Work. Any work or services in addition to the work or services described in Appendix A shall be performed by
Consultant according to the rates or charges listed in Appendix B. In the event that no rate or charge is listed for a
particular type of extra work, Consultant shall be paid for the extra work at a rate to be mutually agreed on prior to
commencement of the extra work. In no event shall Consultant be entitled to compensation for extra work unless a
written authorization or change order describing the work and payment terms has been executed by Public Agency
prior to the commencement of the work.
15. Payment Retention. Public Agency shall retain ten percent(10%)of the monies due the Consultant as security for the
fulfillment of this Agreement.After the Consultant has completed all work under this Agreement,submitted final billing,
and the Public Agency has found the work to be accurate,the Public Agency will pay all withheld funds.Public Agency
will pay withheld funds in accordance with the requirements of Civil Code Section 3320 as applicable.A retention will
not be withheld for any"on-call"work.
16. Termination by Public Agency.At its option, Public Agency shall have the right to terminate this Agreement at any time
by written notice to Consultant,whether or not Consultant is then in default. Upon such termination,Consultant shall,
without delay, deliver to Public Agency all materials and records prepared or obtained in the performance of this
Agreement, and shall be paid, without duplication, all amounts due for the services rendered up to the date of
termination.
17. Abandonment by Consultant. In the event the Consultant ceases performing services under this Agreement or
otherwise abandons the project prior to completing all of the services described in this Agreement, Consultant shall,
without delay, deliver to Public Agency all materials and records prepared or obtained in the performance of this
Agreement, and shall be paid for the reasonable value of the services performed up to the time of cessation or
abandonment, less a deduction for any damages or additional expenses which Public Agency incurs as a result of
such cessation or abandonment.
18. Breach. In the event that Consultant fails to perform any of the services described in this Agreement or otherwise
breaches this Agreement, Public Agency shall have the right to pursue all remedies provided by law or equity.Any
disputes relating to the performance of this Agreement shall not be subject to non-judicial arbitration. Any litigation
involving this Agreement or relating to the work shall be brought in Contra Costa County, and Consultant hereby
waives the removal provisions of Code of Civil Procedure Section 394.
19. Compliance with Laws. In performing this Agreement, Consultant shall comply with all applicable laws, statutes,
ordinances, rules and regulations,whether federal, state, or local in origin. This includes compliance with prevailing
wage rates and their payment in accordance with California Labor Code, Section 1775.
20. Assignment. This Agreement shall not be assignable or transferable in whole or in part by Consultant, whether
voluntarily,by operation of law or otherwise;provided,however,that Consultant shall have the right to sub-contract that
portion of the services for which Consultant does not have the facilities to perform so long as Consultant notifies Public
Agency of such subcontracting prior to execution of this Agreement.Any other purported assignment,transfer or sub-
contracting shall be void.
21 Subcontracting.All subcontracts exceeding$25,000 in cost shall contain all of the required provisions of this contract.
Consultant will pay each subconsultant in accordance with the requirements of Civil Code Section 3321 as applicable.
22. Endorsement on Plans.Consultant shall endorse all plans,specifications,estimates,reports and other items described
in Appendix A prior to delivering them to Public Agency,and where appropriate, indicate his/her registration number.
23. Patents and Copyrights.The issuance of a patent or copyright to Consultant or any other person shall not affect Public
Agency's rights to the materials and records prepared or obtained in the performance of this Agreement.Public Agency
reserves a license to use such materials and records without restriction or limitation, and Public Agency shall not be
required to pay any additional fee or royalty for such materials or records.The license reserved by Public Agency shall
continue for a period of fifty years from the date of execution of this Agreement,unless extended by operation of law or
otherwise.
24. Indemnification. Consultant shall indemnify, defend, save, protect, and hold harmless Public Agency, its governing
body, officers, employees, representatives, and agents ("Indemnitees") from any and all demands, losses, claims,
costs,suits,liabilities,and expenses for any damage, injury,or death(collectively"Liability")arising directly or indirectly
from or connected with the services provided hereunder which is caused,or claimed or alleged to be caused,in whole
or in part, by the negligence or willful misconduct of Consultant, its officers, employees, agents, contractors,
subconsultants, or any persons under its direction or control and shall make good to and reimburse Indemnitees for
any expenditures, including reasonable attorneys' fees and costs, the Indemnitees may make by reason of such
matters and , if requested by any of the Indemnitees, shall defend any such suits at the sole cost and expense of
Consultant. Consultant's obligations under this section shall exist regardless of concurrent negligence or willful
misconduct on the part of the Public Agency or any other person; provided, however, that Consultant shall not be
required to indemnify Indemnitees for the proportion of liability a court determines is attributable to the negligence or
willful misconduct of the Public Agency, its governing body,officers,or employees. This indemnification clause shall
survive the termination or expiration of this Agreement.
25. Heirs,Successors and Assigns. Except as provided otherwise in Section 20 above,this Agreement shall inure to the
benefit of and bind the heirs, successors, executors, personal representatives, and assigns of the parties.
26. Public Endorsements. Consultant shall not in its capacity as a Consultant with Public Agency publicly endorse or
oppose the use of any particular brand name or commercial product without the prior approval of the Public Agency's
governing board. In its Public Agency Consultant capacity, Consultant shall not publicly attribute qualities or lack of
qualities to a particular brand name or commercial product in the absence of a well-established and widely accepted
scientific basis for such claims or without the prior approval of the Public Agency's governing board. In its Public
Agency Consultant capacity,Consultant shall not participate or appear in any commercially-produced advertisements
designed to promote a particular brand name or commercial product, even if Consultant is not publicly endorsing a
product,as long as the Consultant's presence in the advertisement can reasonably be interpreted as an endorsement
of the product by or on behalf of Public Agency. Notwithstanding the foregoing,Consultant may express its views on
products to other Consultants, the Public Agency's governing board, its officers, or others who may be authorized by
the Public Agency's governing board or by law to receive such views.
27. Project Personnel. In performing the services under this Agreement, Consultant shall use the personnel listed in
Appendix C, attached hereto and made a part hereof by this reference. Changes in project personnel may only be
made with Public Agency's written consent,and Consultant shall notify Public Agency in writing at least thirty(30)days
in advance of any proposed change. Any person proposed as a replacement shall possess training,experience and
credentials comparable to those of the person being replaced.
28. Disadvantaged Business Enterprise(DBE)Requirements(Federal aidproiects only). Consultant shall comply with all
applicable provisions of 49 CFR, Parts 23 and 26, and the County's Disadvantaged Business Enterprise (DBE)
Program, which are incorporated into this Agreement by reference. In addition, in performing services under this
Agreement,Consultant shall utilize all DBEs listed in Consultant's written response to the Public Agency's request for
qualifications or request for proposal and shall pay to the listed DBEs the estimated amounts listed in Appendix B
attached to this Agreement. The Consultant shall not substitute a listed DBE at any time or decrease the amount to be
paid to a listed DBE without the advance, written consent of the Public Agency. If a listed DBE is proposed to be
replaced, Consultant shall make a good faith effort to replace the original DBE with another DBE and shall submit to
Public Agency written documentation of such effort.
29. Federal Cost Principles and Procedures (Federal aid projects only). Consultant shall comply with the following
provisions,which are incorporated into this Agreement by reference:(a)the cost principles for allow ability of individual
items of costs set forth in 48 CFR, Chapter 1, Part 31: (b)the administrative procedures set forth in 49 CFR,Part 18;
and (c) the administrative procedures for non-profit organizations set forth in OMB Circular A-110, if applicable to
Consultant. In the event that payment is made to Consultant for any costs that are determined by subsequent audit to
be unallowable under 48 CFR, Chapter 1, Part 31, Consultant shall refund the payment to Public Agency within 30
days of written request from Public Agency. Should Consultant fail to do so, and should the Public Agency file legal
action to recover the refund, Consultant shall reimburse the Public Agency for all attorney's fees, costs, and other
expenses incurred by Public Agency in connection with such action.
Attachments:Appendix A,Appendix B,Appendix C
Form approved by County Counsel(11/00)
G:\GrpData\NPDES\BO_Res_Contracts_Agmt\Bolender\06 07\CSA 06 07.doc
APPENDIX "A"
CONTRA COSTA CLEAN WATER PROGRAM (Program)
SCOPE OF WORK (FY 2006/2007)
Individual tasks will be initiated by Matthew Bolender (Consultant) only upon receipt of
written pre-approval by the Program Manager. The schedule for completion of tasks will .
also be agreed upon before work is initiated.
Consultant will perform the following tasks:
1. Administrative tasks including: the weekly review of labor and other direct costs
charged to the contract, review and approval of monthly invoices, filing and
communicating with the Program on progress, schedule, and budget.
2. Over the course of the year, certify a minimum of seven (7) used oil collection
centers as defined by the California Integrated Waste Management Board's
(CIWMB) rules and regulations, and perform sixty (60) site visits to verify compliance
at existing certified used oil collection centers. This task shall include telephone
solicitation, direct personnel solicitation, the filing of forms for certification as a used
oil collection center, and coordination with CIWMB personnel regarding
reimbursement expenses.
3. Coordinate a minimum of thirty-five (35) school presentations featuring the "Mr.
Funnelhead" character. The target audience is specifically elementary school
children. Consultant will coordinate all activities necessary to provide these
presentations including the necessary equipment (sound equipment, lights, music,
special effects, etc.) create or repair Mr. Funnelhead costumes, produce educational
material, coordinate actors for- the presentations, the development of the
presentation, the promotion of the Mr. Funnelhead magnet contest for students, and
other duties as needed to provide the school presentation.
4. Coordinate thirty-seven (37) public municipal events utilizing the "Mr. Funnelhead"
character. Consultant will develop and produce educational materials promoting the
recycling of used motor oil. This task will include the production of English/Spanish
coloring books, purchase of crayons, develop newspaper advertisements for
certified oil collection centers, and other materials promoting recycled used oil.
5. Produce two (2) public service announcements (1-30 second and 1-60 second) and
other pertinent videos and cause them to be aired on community access and
premium cable television channels.
G:\NPDES\BO_Res_contracts_Agmt\Bolender\06 0MOW Append A.doc
6. Update and maintain pertinent information and centers within the
www.funnelhead.com website.
7. Submit summary report of UOBG activities and materials for Annual Report to
Program by August 1, 2007.
G:\NPDES\BO—Res—Contracts_Agmt\Bolender\06 07\SOW_Append A.doc
APPENDIX "B"
RATES AND CHARGES:
LABOR - $27.50 per hour
MILEAGE - $44.5 per mile, not to exceed a cost of
$3,5000
OUT OF POCKET EXPENSES* - Actual charges, not to exceed a cost of
$4,500
* All costs shall be directly related to the establishment, maintenance or enhancement of
local or regional used oil collection centers and must be incurred from July 1, 2006 to June
30, 2007.
APPENDIX "C"
Personnel — Matt Bolender, Project Manager
G:\NPDESIBO_Res_Contracts_Agmt\Bolender\06 07\Append B-C.doc
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
STATE OF CALIFORNIA
COUNTY OF CONTRA COSTA
On June 6, 2006, beforeLISA A. DALZIEL, Notary Public, personally appeared
4y�aAlfiQlo 1;�cS QQ1V ef-m- - - personally
known to me to be the person whose name is subscribed to the within instrument and
acknowledged to me that he executed the same in his authorized capacity, and that by his
signature on the instrument the person, or the entity upon behalf of which the person
acted, executed the instrument.
WITNESS my hand and official seal.
LISA A.DALZIEL
Commission# 1377110 Z ;
ZNotary Public - California
Contra Costa County 4t��4 11
*My Comm.bores Sep 28,2006
Signature of Notary Public
j
------------------------
Contra Costa County Number
Standard Form M-1
Revised 2002
QUESTIONNAIRE FOR DETERMINING
INDEPENDENT CONTRACTOR STATUS AND PAYMENT METHOD
All new or renewed independent contractors that do not meet IRS or other legal criteria for
independent contractor status must be paid through the payroll system so that employment,
disability and Social Security taxes can be withheld by the County. Please complete the
following questionnaire for each self-employed individual with whom you intend to contract.
(Note: this form does not apply to contracts with corporations, temporary help agencies,
partnerships or established businesses with Taxpayer Identification numbers).
For completion by Department Head or Authorized Designee.
Yes No
1. Do 1, as the employer,have the right to control the hours, ❑ Er
place and manner of, and means by which the work will be done?
2. Am I setting the independent contractor's hours? ❑ []�
3. Is the independent contractor restricted from providing ❑ [�
services to other businesses or entities while working for the
County?
4. Do 1 or other departments have employee(s)with similar ❑ [T
duties as the independent contractor?
5. Does the County supply assistants to the independent ❑
contractor?
;p
6. '1Does the County furnish training, tools, equipment or place of ❑
work to the independent contractor?
7. Is the individual prohibited from subcontracting out his or her ❑ [�
services (as opposed to performing them personally)?
A "yes" answer to any of the above questions will require paying the contractor through
the payroll system.
CONTRACTOR APPROVAL: PREPARED BY.
I certify that the answers to the above questions e A
accurately reflect my anticipated X /{/(
workin relatio ip with the County.
REVIEWED AND APPROVED BY:
Con actor's signature
epartment ead or Auth 'ze esignee
X �Pi12��?�
Contractor's Name (printed)
Form M-1 (Page 1 of 1)
Form w-9 Request for Taxpayer Give form to the
+ -(Rev.January 2002) Identification Number and Certification requester, Do not
Department of the Treasury send to the IRS.
intemal Revenue Service
.,) Name
_=L Bu iness name,if different from above
d y
Individual/ Exem
P t from backu
P
Check appropriate box: Sole proprietor El Corporation ❑ Partnership ❑ Other ► ___________________ ❑ withholding
02
a y
Add r (number,stWend,a t.or suite o.) s1//J� Requester's name and address(optional)
U L115z)
City,state.and ZIP code
d
4
N
List account number(s)here(optional)
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. For individuals, this is your social security number(SSN). Social security number
However, for a resident alien, sole proprietor,or disregarded entity, see the Part I instructions on 6 _
page 2. For other entities, it is your employer identification number(EIN). If you do not have a number, 134
f d Vi
see How to get a TIN on page 2, or
Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number Employer identification number
to enter.
Certification
Under penalties of perjury, 1 certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or(b) I have not been notified by the Internal
Revenue Service(IRS)that 1 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. 1 am a U.S. person(including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends,you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 2.)
Sign Signature
liere U.S. pers _1,_
Date ► rj
Purpose of For What is backup withholding?Persons making 5. You do not certify to the requester that you
certain payments to you must under certain are not subject to backup withholding under 4
A person who is required to file an information conditions withhold and pay to the IRS 30%of above(for reportable interest and dividend
return with the IRS must get your correct such payments after December 31, 2001 (29% accounts opened after 1983 only).
taxpayer
iticomeati d to number
r TIN)to report, for after December 31, 2003).This is called "backup Certain payees and payments are exempt
example, P Y withholding."Payments that may be subject to from backu withholding. See the instructions on
transactions, mortgage interest you paid, backup withholding include interest, dividends, p
page 2 and the separate instructions for the
acquisition or abandonment of secured property, broker and barter exchange transactions, rents,
cancellation of debt,or contributions you made royalties, nonemployee pay, and certain Requester of Form W-9.
to an IRA. payments from fishing boat operators. Real Penalties
Use Form W-9 only if you are a U.S.person estate transactions are not subject to backup
(including a resident alien),to give your correct withholding. Failure to furnish TIN. If you fail to furnish your
TIN to the person requesting it (the requester) You will not be subject to backup withholding correct TIN to a requester,you are subject to a
and. when applicable, to: on payments you receive it you give the penalty of$50 for each such failure unless your
failure is due to reasonable cause and not to
1.Certify the TIN you are giving is correct(or requester your correct TIN, make the proper willful neglect.
ycu are waiting for a number to be issued), certifications, and report all your taxable interest
and dividends on your tax return. Civil penalty for false information with respect
2. Certify you are not subject to backup to withholding. If you make a false statement
withholding, or Payments you receive will be subject to with no reasonable basis that results in no
3.Claim exemption from backup withholding if backup withholding if: backup withholding,you are subject to a 5500,
you are a U.S. exempt payee. 1. You do not furnish your TIN to the penalty.
If you are a foreign person, use the requester, or Criminal penalty for falsifying information.
appropriate Form W-B. See Pub. 515, 2. You do not certify your TIN when required Willfully falsifying certifications or affirmations
Withholding of Tax on Nonresident Aliens and (see the Part II instructions on page 2 for may subject you to criminal penalties including
o,eign Entities. details), or fines and/or imprisonment.
Note: If a requester gives you a form other than 3.The IRS tells the requester that you Misuse of TINS. If the requester discloses or
Form W-9 to request your TIN,you must use the furnished an incorrect TIN, or uses TINS in violation of Federal Jaw, the
racuester's form if it is substantia!/ similar to this requester may be subject to civil and criminal
y 4, The IRS tells you that you are subject to
fo m w-9. penalties.
backup withholding because you did not report
all your interest and dividends on your tax return
(for reporable interest and dividends only), or
Cat. No.10231X Form W-9 (Rev. 1-2002)