2018 Contract David Van Loon AGREEMENT BETWEEN
THE MONROE COUNTY VALUE ADJUSTMENT BOARD
And
DAVID VAN LOON, ESQUIRE
For
SPECIAL MAGISTRATE SERVICES
This Agreement is made and entered into, on the date last below written, by and between
the MONROE COUNTY VALUE ADJUSTMENT BOARD, 500 Whitehead Street, Key West,
FL 33040 (hereinafter referred to as "VAB "), and the individual identified and executing this
Agreement as the undersigned (hereinafter referred to as "Contractor ").
1. RECITALS.
1.1 The VAB requires the services of one or more individuals to act as a Special
Magistrate for the purpose of taking testimony and receiving evidence at the hearings, as
provided by Chapter 194, Florida Statutes, and Rule 12D -9, Florida Administrative Code
(F.A.C.), and making recommended findings of fact and conclusions of law to the VAB.
1.2 Contractor desires to provide such services to the VAB as an independent contractor.
1.3 Contractor certifies that Contractor possesses the minimum qualifications required by
Section 194.035, Florida Statutes, and Rules 12D -9.010 and 12D- 9.012, F.A.C., to provide
services as a Special Magistrate.
1.4 In consideration of the mutual terms and conditions, promises, covenants and
payment hereinafter set forth, the VAB and Contractor enter into this Agreement as set forth
herein.
2. SERVICES.
2.1 Contractor shall perform professional services to the VAB as a Special Magistrate.
Contractor's services shall include, but not be limited to, the following:
2.1.1 Taking testimony at hearings provided pursuant to Chapter 194, Florida
Statutes and Rule 12D -9, F.A.C.
2.1.2 Receiving evidence into the hearing record.
2.1.3 Ruling of objections made during the hearing by either of the parties to the
hearing.
2.1.4 Making recommended findings of fact and conclusions of law to the VAB.
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2.1.5 Preparing and submitting such reports and other documents as the VAB or
the Clerk of the VAB may from time to time require.
2.2 Contractor shall be responsible for complying with all federal, state and local rules,
regulations, statutes, laws or ordinances, regarding payment for his or her services under this
Agreement, and any reporting requirements thereunder.
2.3 During any hours Contractor provides services to the VAB, Contractor shall devote
his full time and effort to the services being performed for the VAB. Contractor shall truthfully
and accurately maintain all records and make such reports as the VAB may require.
2.4 Contractor agrees that this contract for Special Magistrate services is not exclusive to
Contractor, and that the VAB may, and probably will, enter into agreements with other
contractors to perform Special Magistrate services for the VAB. Further, Contractor agrees that
this Agreement does not require the VAB to request any particular services of the contractor.
2.5 Upon receipt of the docket for hearing, the contractor shall review the petitioners'
names and addresses for a potential conflict of interest. If a potential conflict of interest exists,
the contractor shall immediately notify the Clerk of the VAB who shall reassign the case to
another Special Magistrate.
2.6 The contractor shall receive and retain all exhibits presented during a hearing, and
shall transmit the record along with the original copy of the recommended order to the Clerk of
the VAB, pursuant to Rule 12D- 9.025(7).
3. FEES.
3.1 The VAB shall pay Contractor at the rate of One Hundred Fifty dollars ($150.00) per
hour for Contractor's services under this Agreement. Billable time shall commence at the
scheduled start of a hearing or at the time of the Contractor's arrival and set -up, whichever is
later, and shall end at conclusion of the hearing, except as noted in paragraphs 3.3 and 3.6,
below. For each day that the Contractor is scheduled to serve as a Special Magistrate, there shall
be a minimum payment due to the Contractor of $225.00. In the event a scheduled hearing date
is cancelled in its entirety, there shall be a payment due to the Contractor of $225.00. There is no
half -day cancellation fee.
3.2 Except as provided herein, no travel expenses or travel time shall be paid for travel to
and from hearing sites, nor shall ordinary office supplies consumed in the course of the
Contractor's services be reimbursed. The VAB shall pay for the Contractor's mileage, at the rate
established in the Monroe County Code of Ordinances, for travel to and from hearing sites that
are outside of the Contractor's home district. Upon the execution of this Agreement, the
Contractor shall notify the Clerk of the VAB of his or her home district (i.e. Lower Keys, Middle
Keys, and Upper Keys). Mileage will not be reimbursed for travel within a district.
3.2.1 The VAB shall pay reasonable travel expenses to a Contractor who is located
outside of Monroe County when a Special Magistrate who is located in Monroe County is not
Page
selected or is selected but is not available to perform the services set forth in this Agreement.
See the attached Monroe County Clerk of Court Expense Reimbursement Requirements.
3.3. If a Contractor does not render a recommended decision at hearing, therefore
requiring additional time for research and preparation of the recommended decision, then there is
a presumption that the Contractor shall require up to two hours of additional billable hours to
complete the work and VAB's obligation to pay shall be capped at two hours of billable time. If
the Contractor anticipates that the required time will exceed two hours, then the Contractor must
obtain written permission for specified additional time from the VAB Attorney.
3.3.1 The Contractor shall render his/her recommendation (findings and conclusions)
within seven (7) working days of the hearing; provided that, if the Contractor requires more time,
he /she shall obtain written permission for specified additional days from the VAB Attorney.
3.4 The Contractor understands and agrees that the VAB does not promise or guarantee
that the Contractor will be engaged to perform either a minimum or maximum amount of
services under this Agreement.
3.5 The Contractor understands and agrees that the time he or she must devote to Special
Magistrate training required by Rule 12D- 9.012, F.A.C., is not billable to or reimbursable by
VAB under this Agreement.
3.6 The Contractor shall cooperate with the VAB in any litigation or related matter that
might result from the Contractor's performance under this Agreement. Accordingly, the
Contractor shall be paid by VAB for such time at the rate established herein.
3.7 The Contractor understands and agrees that all bills paid pursuant to the terms of
Section 5 of this Agreement are subject to ratification by the VAB at a public meeting.
4. TERM/TERMINATION.
4.1 The term of this Agreement shall begin on the date last below written and shall
continue until the conclusion of the VAB hearings in the spring of 2019.
4.2 This Agreement may be terminated by either party, with or without cause, by written
notice to the other party of the intent to terminate. Such termination shall be effective
immediately upon receipt of such written notice of intent to terminate. No termination for cause
will be effective unless the defaulting party is first given ten (10) calendar days after receipt of
notice of intent to terminate in which to cure the cause for termination.
4.3 In the event of termination, Contractor shall be entitled to compensation for services
rendered and costs incurred through the effective date of termination. All finished or unfinished
documents prepared by Contractor shall become the property of the VAB and shall be delivered
by Contractor to the VAB immediately upon the effective date of termination.
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4.4 In the event of termination of this Agreement by the Contractor without cause,
Contractor shall be ineligible to be appointed as Special Magistrate to the VAB for a period of
five (5) years from the end of the calendar year in which such termination effected. This
provision shall survive the termination of this Agreement.
4.5 Contractor shall not represent any person or entity against either Monroe County or
the Monroe County School Board in a court case or administrative hearing at the time of
appointment. Any such representation that arises from the appointment through the final
meeting of the VAB will disqualify the Special Magistrate from any further hearings, and the
Clerk shall schedule another Special Magistrate to hear the matters scheduled for the disqualified
magistrate.
5. METHOD OF BILLING AND PAYMENT.
5.1 Contractor shall submit billings for payment of services actually rendered on a
monthly basis to the Clerk of the VAB for processing. Billings shall provide the nature of the
services performed.
5.1.1 Contractor shall maintain a record of his/her hours worked during and after the
close of a hearing when taking additional time to render a decision pursuant to Paragraph 3.3 of
this Agreement. Contractor shall provide the Clerk with detailed time records for each such case
taken after the close of a hearing.
5.2 Contractor acknowledges that each billing must be reviewed and approved by the
Clerk of the VAB or Clerk's designee. Should the Clerk of the VAB or the Clerk's designee
determine that the billing is not commensurate with services performed, work accomplished or
hours expended, Contractor shall adjust billing accordingly. Contractor shall be entitled to
payment of any portion of a billing not in dispute.
5.3 The VAB shall pay Contractor's billings in accordance with Section 218.70 through
218.79, Florida Statutes, the Florida Prompt Payment Act.
6. STANDARDS AND CORRECTIONS ERRORS.
6.1 Contractor shall perform or furnish to the VAB professional services in accordance
with the generally accepted standards of Contractor's profession or occupation and in accordance
with any laws, statutes, ordinances, codes, rules and regulations governing Contractor's services
hereunder.
6.2 Contractor shall, without additional compensation, correct and revise errors,
omissions, or other deficiencies in Contractor's work product, services, or materials arising from
the negligent act, error or omission of Contractor. The foregoing shall be construed as an
independent duty to correct rather than waiver of the VAB's rights under any applicable statute
of limitations. The review of, approval of, or payment for any of Contractor's work product,
services, or materials shall not be construed to operate as a waiver of any of the VAB's rights
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under this Agreement, or cause of action the VAB may have arising out of the performance of
this Agreement.
7. NO CONTINGENT FEES. Contractor certifies that Contractor has not employed or
retained any company or person, other than a bona fide employee working solely for Contractor,
to solicit or secure this Agreement and that Contractor has not paid or agreed to pay any person,
company, individual or firm, other than a bona fide employee working solely for Contractor, any
fee, commission, percentage, gift or other consideration contingent upon or resulting from the
award or making of this Agreement. For the breach or violation of this provision, the VAB shall
have the right to terminate the Agreement without liability at its discretion, to deduct from the
contract price, or otherwise recover, the full amount of such fee, commission, percentage, gift or
consideration.
8. NO ASSIGNMENT. This Agreement, or any interest herein, shall not be assigned,
transferred or otherwise encumbered, under any circumstances by Contractor without the prior
written consent of the VAB. Further, no portion of this Agreement may be performed by
subcontractors or sub - consultants without written notice to and approval of such action by the
VAB.
9. SEVERABILITY/NO WAIVERS. In the event any provision of this Agreement shall
be held invalid and unenforceable, the remaining provisions shall be valid and binding upon the
parties. One or more waivers by either party of any breach of any provision, term, condition or
covenant shall not be construed by the other party as a waiver of any subsequent breach.
10. GOVERNING LAW/VENUE. This Agreement shall be governed and construed in
accordance with Florida law. In the event litigation arises involving the parties in connection
with this Agreement, venue for litigation shall be in Monroe County, Florida.
11. INDEPENDENT CONTRACTOR STATUS. Contractor is an independent contractor
and is not an employee, servant, agent, partner or joint venture of the VAB or Monroe County or
the Monroe County School Board.
12. CERTIFICATIONS BY CONTRACTOR.
12.1 Contractor understands that Contractor need not be a resident of Monroe County.
12.2 Contractor understands that Contractor shall not serve as a Special Magistrate in the
same tax year in which he or she represents a person before the VAB, and that during the term of
this Agreement Contractor shall not undertake to represent or advise any taxpayer or petitioner
before the VAB.
12.3 Contractor certifies that Contractor is not an elected or appointed official or
employee of Monroe County or of the Monroe County School Board.
12.4 Contractor certifies that Contractor is not an elected or appointed official or
employee of a taxing jurisdiction.
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12.5 Contractor certifies that Contractor is not an elected or appointed official or
employee of the State of Florida.
12.6 Contractor certifies that Contractor possesses the following minimum qualifications
(CHECK ALL THAT APPLY):
[] Contractor is a member of The Florida Bar with no less than 5 years' experience in the
area of ad valorem taxation, and is qualified to hear petitions involving issues related to
exemptions and classifications.
[] Contractor is a state certified real estate appraiser with not less than 5 years' experience
in real property valuation, and is qualified to hear petitions involving issues regarding the
valuation of real estate.
[] Contractor is a member of a nationally recognized appraiser's organization with no less
than 5 years' experience in tangible personal property valuation, and is qualified to hear petition
involving issues regarding the valuation of tangible personal property.
13. PUBLIC RECORDS.
Contractor must comply with Florida public records laws, including but not limited to
Chapter 119, Florida Statutes and Section 24 of article I of the Constitution of Florida. The
County and Contractor shall allow and permit reasonable access to, and inspection of, all
documents, records, papers, letters or other "public record" materials in its possession or under
its control subject to the provisions of Chapter 119, Florida Statutes, and made or received by the
County and Contractor in conjunction with this contract and related to contract performance.
The County shall have the right to unilaterally cancel this contract upon violation of this
provision by the Contractor. Failure of the Contractor to abide by the terms of this provision
shall be deemed a material breach of this contract and the County may enforce the terms of this
provision in the form of a court proceeding and shall, as a prevailing party, be entitled to
reimbursement of all attorney's fees and costs associated with that proceeding. This provision
shall survive any termination or expiration of the contract.
The Contractor is encouraged to consult with its advisors about Florida Public Records
Law in order to comply with this provision.
Pursuant to F.S. 119.0701 and the terms and conditions of this contract, the Contractor is
required to:
(1) Keep and maintain public records that would be required by the County to perform
the service.
(2) Upon receipt from the County's custodian of records, provide the County with a
copy of the requested records or allow the records to be inspected or copied within a reasonable
time at a cost that does not exceed the cost provided in this chapter or as otherwise provided by
law.
(3) Ensure that public records that are exempt or confidential and exempt from public
records disclosure requirements are not disclosed except as authorized by law for the duration of
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the contract term and following completion of the contract if the contractor does not transfer the
records to the County.
(4) Upon completion of the contract, transfer, at no cost, to the County all public
records in possession of the Contractor or keep and maintain public records that would be
required by the County to perform the service. If the Contractor transfers all public records to the
County upon completion of the contract, the Contractor shall destroy any duplicate public
records that are exempt or confidential and exempt from public records disclosure requirements.
If the Contractor keeps and maintains public records upon completion of the contract, the
Contractor shall meet all applicable requirements for retaining public records. All records stored
electronically must be provided to the County, upon request from the County's custodian of
records, in a format that is compatible with the information technology systems of the County.
(5) A request to inspect or copy public records relating to a County contract must be
made directly to the County, but if the County does not possess the requested records, the County
shall immediately notify the Contractor of the request, and the Contractor must provide the
records to the County or allow the records to be inspected or copied within a reasonable time.
IF THE CONTRACTOR HAS QUESTIONS REGARDING THE
APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE .
CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING
TO THIS CONTRACT, CONTACT THE CUSTODIAN OF VAB PUBLIC
RECORDS, (Value Adjustment Clerk, Monroe County Clerk of Court, 500
Whitehead Sz Ste. 101, Key West, FL. 33040, (305)-292-3550,
VABCLERK a141onroe- Clerk. com):
; Attached to this agreement are the following.forms:
I . _W- 9.Request for Taxpayer Identification Number &..Certification
2. Travel Voucher
IN WITNESS WHEREOF, the parties hereto have caused the execution of these
premises as of the date written below,
CONTRACTOR: VALUE ADJUSTMENT BOARD
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Request for Taxpayer Give Form to the
Form
(Rev. November2017) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service I. Go to www.irs.gov /FormW9 for instructions and the latest information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name /disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to
0 following seven boxes. certain entities, not individuals; see
instructions on page 3):
❑ Individual /sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
m single- member LLC Exempt payee code (if any)
o c
u ❑ Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= Partnership) ►
2 Note: Check the appropriate box in the line above for the tax classification of the single- member owner. Do not check Exemption from FATCA reporting
id to LLC if the LLC is classified as a single- member LLC that is disregarded from the owner unless the owner of the LLC Is
code ( if any)
5 another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single- member LLC that
o- V is disregarded from the owner should check the appropriate box for the tax classification of its owner.
o ❑ Other (see instructions) ► (Applies to accounts maintained outside the U.S.)
d
5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional)
rli
6 City, state, and ZIP code
7 List account number(s) here (optional)
Part 1 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 instructions for Part I, later. For other — —
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later. or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and 1 Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
Part 11 Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments .
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign Signature of
Here U.S. person ■ Date ■
General Instructions • Form 1099 -DIV (dividends, including those from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise • Form 1099 -MISC (various types of income, prizes, awards, or gross
noted.
proceeds)
Future developments. For the latest information about developments • Form 1099 -B (stock or mutual fund sales and certain other
related to Form W -9 and its instructions, such as legislation enacted transactions by brokers)
after they were published, go to www.irs.gov /FormW9.
• Form 1099 -S (proceeds from real estate transactions)
Purpose of Form • Form 1099 -K (merchant card and third party network transactions)
An individual or entity (Form W -9 requester) who is required to file an • Form 1098 (home mortgage interest), 1098E (student loan interest),
information return with the IRS must obtain your correct taxpayer 1098 -T (tuition)
identification number (TIN) which may be your social security number • Form 1099 -C (canceled debt)
(SSN), individual taxpayer identification number (ITIN), adoption • Form 1099 -A (acquisition or abandonment of secured property)
taxpayer identification number (ATIN), or employer identification number Use Form W -9 only if you are a U.S. person (including a resident
(EIN), to report on an information return the amount paid to you, or other alien), to provide your correct TIN.
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following. If you do not return Form W -9 to the requester with a TIN, you might
• Form 1099 INT (interest earned or paid) be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W -9 (Rev. 11 -2017)
Form W -9 (Rev. 11 -2017) Page 2
By signing the filled -out form, you: Example. Article 20 of the U.S. -China income tax treaty allows an
1. Certify that the TIN you are giving is correct (or you are waiting for a exemption from tax for scholarship income received by a Chinese
number to be issued), student temporarily present in the United States. Under U.S. law, this
student will become a resident alien for tax purposes if his or her stay in
2. Certify that you are not subject to backup withholding, or the United States exceeds 5 calendar years. However, paragraph 2 of
3. Claim exemption from backup withholding if you are a U.S. exempt the first Protocol to the U.S. -China treaty (dated April 30, 1984) allows
the provisions of Article 20 to continue to apply even after the Chinese
payee. If applicable, you are also certifying that as a U.S. person, your student becomes a resident alien of the United States. A Chinese
allocable share of any partnership Income from a U.S. trade or business student who qualifies for this exception (under paragraph 2 of the first
is not subject to the withholding tax on foreign partners' share of protocol) and is relying on this exception to claim an exemption from tax
effectively connected income, and on his or her scholarship or fellowship income would attach to Form
4. Certify that FATCA code(s) entered on this form (if any) indicating W -9 a statement that includes the information described above to
support that exemption.
that you are exempt from the FATCA reporting, is correct. See What is
FATCA reporting, later, for further Information. If you are a nonresident alien or a foreign entity, give the requester the
appropriate completed Form W -8 or Form 8233.
Note: If you are a U.S. person and a requester gives you a form other
than Form W -9 to request your TIN, you must use the requester's form if Backup Withholding
it is substantially similar to this Form W -9. What is backup withholding? Persons making certain payments to you
Definition of a U.S. person. For federal tax purposes, you are must under certain conditions withhold and pay to the IRS 28% of such
considered a U.S. person if you are: payments. This is called "backup withholding." Payments that may be
• An individual who is a U.S. citizen or U.S. resident alien; subject to backup withholding include interest, tax- exempt interest,
• A partnership, corporation, company, or association created or dividends, broker and barter exchange transactions, rents, royalties,
organized in the United States or company, the laws of the United or nonemployee pay, payments made in settlement of payment card and
third party network transactions, and certain payments from fishing boat
• An estate (other than a foreign estate); or operators. Real estate transactions are not subject to backup
• A domestic trust (as defined in Regulations section 301.7701 -7). withholding.
Special rules for partnerships. Partnerships that conduct a trade or You will not be subject to backup withholding on payments you
business in the United States are generally required to pay a withholding receive if you give the requester your correct TIN, make the proper
tax under section 1446 on any foreign partners' share of effectively certifications, and report all your taxable interest and dividends on your
connected taxable income from such business. Further, in certain cases tax return.
where a Form W -9 has not been received, the rules under section 1446 Payments you receive will be subject to backup withholding if:
require a partnership to presume that a partner is a foreign person, and 1. You do not fumish your TIN to the requester,
pay the section 1446 withholding tax. Therefore, if you are a U.S. person
that is a partner in a partnership conducting a trade or business in the 2. You do not certify your TIN when required (see the instructions for
United States, provide Form W -9 to the partnership to establish your Part II for details),
U.S. status and avoid section 1446 withholding on your share of 3. The IRS tells the requester that you furnished an incorrect TIN,
partnership income. 4. The IRS tells you that you are subject to backup withholding
In the cases below, the following person must give Form W -9 to the because you did not report all your interest and dividends on your tax
partnership for purposes of establishing its U.S. status and avoiding return (for reportable interest and dividends only), or _
withholding on its allocable share of net income from the partnership 5. You do not certify to the requester that you are not subject to
conducting a trade or business in the United States. backup withholding under 4 above (for reportable interest and dividend
• In the case of a disregarded entity with a U.S. owner, the U.S. owner accounts opened after 1983 only).
of the disregarded entity and not the entity; Certain payees and payments are exempt from backup withholding.
• In the case of a grantor trust with a U.S. grantor or other U.S. owner, See Exempt payee code, later, and the separate Instructions for the
generally, the U.S. grantor or other U.S. owner of the grantor trust and Requester of Form W -9 for more information.
not the trust; and Also see Special rules for partnerships, earlier.
• In the case of a U.S. trust (other than a grantor trust), the U.S. trust
(other than a grantor trust) and not the beneficiaries of the trust. What is FATCA Reporting?
Foreign person. If you are a foreign person or the U.S. branch of a The Foreign Account Tax Compliance Act (FATCA) requires a
foreign bank that has elected to be treated as a U.S. person, do not use participating foreign financial institution to report all United States
Form W -9. Instead, use the appropriate Form W -8 or Form 8233 (see account holders that are specified United States persons. Certain
Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign payees are exempt from FATCA reporting. See Exemption from FATCA
Entities). reporting code, later, and the Instructions for the Requester of Form
Nonresident alien who becomes a resident alien. Generally, only a W -9 for more information.
nonresident alien individual may use the terms of a tax treaty to reduce
or eliminate U.S. tax on certain types of income. However, most tax Updating Your Information
treaties contain a provision known as a "saving clause." Exceptions You must provide updated information to any person to whom you
specified in the saving clause may permit an exemption from tax to claimed to be an exempt payee if you are no longer an exempt payee
continue for certain types of income even after the payee has otherwise and anticipate receiving reportable payments in the future from this
become a U.S. resident alien for tax purposes. person. For example, you may need to provide updated information if
If you are a U.S. resident alien who is relying on an exception you are a C corporation that elects to be an S corporation, or if you no
contained in the saving clause of a tax treaty to claim an exemption longer are tax exempt. In addition, you must furnish a new Form W -9 if
from U.S. tax on certain types of income, you must attach a statement the name or TIN changes for the account; for example, if the grantor of'a
to Form W -9 that specifies the following five items. grantor trust dies.
1. The treaty country. Generally, this must be the same treaty under
which you claimed exemption from tax as a nonresident alien. Penalties
2. The treaty article addressing the income. Failure to furnish TIN. If you fail to furnish your correct TIN to a
3. The article number (or location) in the tax treaty that contains the requester, you are subject to a penalty of $50 for each such failure
saving clause and its exceptions. unless your failure is due to reasonable cause and not to willful neglect.
4. The type and amount of income that qualifies for the exemption Civil penalty for false information with respect to withholding. If you
from tax. make a false statement with no reasonable basis that results in no
5. Sufficient facts to justify the exemption from tax under the terms of backup withholding, you are subject to a $500 penalty.
the treaty article.
Form W -9 (Rev. 11 -2017) Page 3
Criminal penalty for falsifying information. Willfully falsifying IF the entity /person on line 1 is THEN check the box for ... •
certifications or affirmations may subject you to criminal penalties a(n) .. .
including fines and /or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of • Corporation Corporation
federal law, the requester may be subject to civil and criminal penalties. • Individual Individual /sole proprietor or single-
• Sole proprietorship, or member LLC
Specific Instructions • Single - member limited liability
company (LLC) owned by an
Line 1 individual and disregarded for U.S.
You must enter one of the following on this line; do not leave this line federal tax purposes.
blank. The name should match the name on your tax return. • LLC treated as a partnership for Limited liability company and enter
If this Form W -9 is for a joint account (other than an account U.S. federal tax purposes, the appropriate tax classification.
maintained by a foreign financial institution (FFI)), list first, and then • LLC that has filed Form 8832 or (P= Partnership; C= C corporation;
circle, the name of the person or entity whose number you entered in 2553 to be taxed as a corporation, or S= S corporation)
Part I of Form W -9. If you are providing Form W -9 to an FFI to document or
a joint account, each holder of the account that is a U.S. person must • LLC that is disregarded as an
provide a Form W -9. entity separate from its owner but
a. Individual. Generally, enter the name shown on your tax return. If the owner is another LLC that is
you have changed your last name without informing the Social Security not disregarded for U.S. federal tax
Administration (SSA) of the name change, enter your first name, the last purposes.
name as shown on your social security card, and your new last name.
Note: ITIN applicant: Enter your individual name as it was entered on 'Partnership Partnership
your Form W -7 application, line 1 a. This should also be the same as the • Trust/estate Trust/estate
name you entered on the Form 1040/1040A/1040EZ you filed with your
application. Line 4, Exemptions
b. Sole proprietor or single member LLC. Enter your individual If you are exempt from backup withholding and /or FATCA reporting,
name as shown on your 1040/1040A/1040EZ on line 1. You may enter enter in the appropriate space on line 4 any code(s) that may apply to
your business, trade, or "doing business as" (DBA) name on line 2. you.
Exempt payee code.
c. Partnership, LLC that is not a single LLC, C • Generally, individuals (including sole proprietors) are not exempt from
corporation, or S corporation. Enter the entity's name as shown on the backup withholding.
entity's tax return on line 1 and any business, trade, or DBA name on
line 2. • Except as provided below, corporations are exempt from backup
d. Other entities. Enter your name as shown on required U.S. federal withholding for certain payments, including interest and dividends.
tax documents on line 1. This name should match the name shown on the • Corporations are not exempt from backup withholding for payments
charter or other legal document creating the entity. You may enter any made in settlement of payment card or third party network transactions.
business, trade, or DBA name on line 2. • Corporations are not exempt from backup withholding with respect to
e. Disregarded entity. For U.S. federal tax purposes, an entity that is attorneys' fees or gross proceeds paid to attorneys, and corporations
disregarded as an entity separate from its owner is treated as a that provide medical or health care services are not exempt with respect
"disregarded entity." See Regulations section 301.7701- 2(c)(2)(iii). Enter to payments reportable on Form 1099 -MISC.
the owner's name on line 1. The name of the entity entered on line 1 The following codes identify payees that are exempt from backup
should never be a disregarded entity. The name on line 1 should be the withholding. Enter the appropriate code in the space in line 4.
name shown on the income tax return on which the income should be 1 —An organization exempt from tax under section 501(a), any IRA, or
reported. For example, if a foreign LLC that is treated as a disregarded a custodial account under section 403(b)(7) if the account satisfies the
entity for U.S. federal tax purposes has a single owner that is a U.S. requirements of section 401(f)(2)
person, the U.S. owner's name is required to be provided on line 1. If
the direct owner of the entity is also a disregarded entity, enter the first 2 —The United States or any of its agencies or instrumentalities
owner that Is not disregarded for federal tax purposes. Enter the 3 —A state, the District of Columbia, a U.S. commonwealth or
disregarded entity's name on line 2, "Business name /disregarded entity possession, or any of their political subdivisions or instrumentalities
name." If the owner of the disregarded entity is a foreign person, the 4 —A foreign government or any of its political subdivisions, agencies,
owner must complete an appropriate Form W -8 instead of a Form W -9. or instrumentalities
This is the case even if the foreign person has a U.S. TIN.
5 —A corporation
Line 2 6 —A dealer in securities or commodities required to register in the
If you have a business name, trade name, DBA name, or disregarded United States, the District of Columbia, or a U.S. commonwealth or
entity name, you may enter it on line 2. possession
Line 3 7 —A futures commission merchant registered with the Commodity
Futures Trading Commission
Check the appropriate box on line 3 for the U.S. federal tax 8 —A real estate investment trust
classification of the person whose name Is entered on line 1. Check only 9 —An entity registered at all times during the tax year under the
one box on line 3. Investment Company Act of 1940
10 —A common trust fund operated by a bank under section 584(a)
11 —A financial institution
12 —A middleman known in the investment community as a nominee or
custodian
13 —A trust exempt from tax under section 664 or described in section
4947
Form W -9 (Rev. 11 -2017) Page 4
The following chart shows types of payments that may be exempt M —A tax exempt trust under a section 403(b) plan or section 457(g)
from backup withholding. The chart applies to the exempt payees listed plan
above, 1 through 13. Note: You may wish to consult with the financial institution requesting
IF the payment is for ... THEN the payment is exempt this form to determine whether the FATCA code and /or exempt payee
for ... code should be completed.
Interest and dividend payments All exempt payees except Line 5
for 7 Enter your address (number, street, and apartment or suite number).
Broker transactions Exempt payees 1 through 4 and 6 This is where the requester of this Form W -9 will mail your information
through 11 and all C corporations. returns. If this address differs from the one the requester already has on
S corporations must not enter an file, write NEW at the top. If a new address is provided, there is still a
exempt payee code because they chance the old address will be used until the payor changes your
are exempt only for sales of address in their records.
noncovered securities acquired
prior to 2012. Line 6
Barter exchange transactions and Exempt payees 1 through 4 Enter your city, state, and ZIP code.
patronage dividends Part I. Taxpayer Identification Number (TIN)
Payments over $600 required to be Generally, exempt payees Enter your TIN in the appropriate box. If you are a resident alien and
reported and direct sales over 1 through 5 you do not have and are not eligible to get an SSN, your TIN is your IRS
$5,000 individual taxpayer identification number (ITIN). Enter it in the social
Payments made in settlement of Exempt payees 1 through 4 security number box. If you do not have an ITIN, see How to get a TIN
below.
payment card or third party network
transactions If you are a sole proprietor and you have an EIN, you may enter either
your SSN or EIN.
1 See Form 1099 -MISC, Miscellaneous Income, and its instructions. If you are a single- member LLC that is disregarded as an entity
2 separate from its owner, enter the owner's SSN (or EIN, if the owner has
However, the following Payments made to a corporation and
reportable on Form 1099 -MISC are not exempt from backup one). Do not enter the disregarded entity's EIN. If the LLC is classified as
withholding: medical and health care payments, attorneys' fees, gross a corporation or partnership, enter the entity's EIN.
proceeds paid to an attorney reportable under section 6045(f), and Note: See What Name and Number To Give the Requester, later, for
payments for services paid by a federal executive agency. further clarification of name and TIN combinations.
Exemption from FATCA reporting code. The following codes identify How to get a TIN. If you do not have a TIN, apply for one immediately.
payees that are exempt from reporting under FATCA. These codes To apply for an SSN, get Form SS -5, Application for a Social Security
apply to persons submitting this form for accounts maintained outside Card, from your local SSA office or get this form online at
of the United States by certain foreign financial institutions. Therefore, if www.SSA.gov. You may also get this form by calling 1- 800 - 772 -1213. .
you are only submitting this form for an account you hold in the United Use Form W -7, Application for IRS Individual Taxpayer Identification
States, you may leave this field blank. Consult with the person Number, to apply for an ITIN, or Form SS -4, Application for Employer
requesting this form if you are uncertain if the financial institution is Identification Number, to apply for an EIN. You can apply for an EIN
subject to these requirements. A requester may indicate that a code is online by accessing the IRS website at www.irs.gov /Businesses and
not required by providing you with a Form W -9 with "Not Applicable" (or clicking on Employer Identification Number (EIN) under Starting a
any similar indication) written or printed on the line for a FATCA Business. Go to www.irs.gov /Forms to view, download, or print Form
exemption code. W -7 and /or Form SS -4. Or, you can go to www.irs.gov /OrderForms to
A —An organization exempt from tax under section 501 (a) or any place an order and have Form W -7 and /or SS -4 mailed to you within 10
individual retirement plan as defined in section 7701(a)(37) business days.
B —The United States or any of its agencies or instrumentalities If you are asked to complete Form W -9 but do not have a TIN, apply
for a TIN and write "Applied For" in the space for the TIN, sign and date
C —A state, the District of Columbia, a U.S. commonwealth or the form, and give it to the requester. For interest and dividend
possession, or any of their political subdivisions or instrumentalities payments, and certain payments made with respect to readily tradable
D —A corporation the stock of which is regularly traded on one or instruments, generally you will have 60 days to get a TIN and give it to
more established securities markets, as described in Regulations the requester before you are subject to backup withholding on
section 1.1472- 1(c)(1)(i) payments. The 60 -day rule does not apply to other types of payments.
E —A corporation that is a member of the same expanded affiliated You will be subject to backup withholding on all such payments until
group as a corporation described in Regulations section 1.1472- 1(c)(1)(i) you provide your TIN to the requester.
F —A dealer in securities, commodities, or derivative financial Note: Entering "Applied For" means that you have already applied for a
instruments (including notional principal contracts, futures, forwards, TIN or that you intend to apply for one soon.
and options) that is registered as such under the laws of the United Caution: A disregarded U.S. entity that has a foreign owner must use
States or any state the appropriate Form W -8.
G —A real estate investment trust Part II. Certification
H —A regulated investment company as defined in section 851 or an To establish to the withholding agent that you are a U.S. person, or
entity registered at all times during the tax year under the Investment resident alien, sign Form W -9. You may be requested to sign by the
Company Act of 1940 withholding agent even if item 1, 4, or 5 below indicates otherwise.
I —A common trust fund as defined in section 584(a) For a joint account, only the person whose TIN is shown in Part I
J —A bank as defined in section 581 should sign (when required). In the case of a disregarded entity, the
K —A broker person identified on line 1 must sign. Exempt payees, see Exempt payee
L —A trust exempt from tax under section 664 or described in section code, earlier.
4947(a)(1) Signature requirements. Complete the certification as indicated in
items 1 through 5 below.
Form W -9 (Rev. 11 -2017) Page 5
1. Interest, dividend, and barter exchange accounts opened For this type of account: Give name and EIN of:
before 1984 and broker accounts considered active during 1983. 14. Account with the Department of The public entity
You must give your correct TIN, but you do not have to sign the Agriculture in the name of a public
certification.
entity (such as a state or local
2. Interest, dividend, broker, and barter exchange accounts government, school district, or
opened after 1983 and broker accounts considered inactive during prison) that receives agricultural
1983. You must sign the certification or backup withholding will apply. If program payments
you are subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2 in the 15. Grantor trust filing under the Form The trust
certification before signing the form. 1041 Filing Method or the Optional
3. Real estate transactions. You must sign the certification. You may Form 1099 Filing Method 2 (see
cross out item 2 of the certification. Regulations section 1.671 4(b)(2)(i)(B))
4. Other payments. You must give your correct TIN, but you do not 1 List first and circle the name of the person whose number you furnish.
have to sign the certification unless you have been notified that you If only one person on a joint account has an SSN, that person's number
have previously given an incorrect TIN. "Other payments" include must be furnished.
payments made in the course of the requester's trade or business for 2 Circle the minor's name and fumish the minor's SSN.
rents, royalties, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to 3 You must show your individual name and you may also enter your
a nonemployee for services, payments made in settlement of payment business or DBA name on the "Business name /disregarded entity"
card and third party network transactions, payments to certain fishing name line. You may use either your SSN or EIN (if you have one), but the
boat crew members and fishermen, and gross proceeds paid to IRS encourages you to use your SSN.
attorneys (including payments to corporations). 4 List first and circle the name of the trust, estate, or pension trust. (Do
5. Mortgage interest paid by you, acquisition or abandonment of not furnish the TIN of the personal representative or trustee unless the
secured property, cancellation of debt, qualified tuition program legal entity itself is not designated in the account title.) Also see Special
payments (under section 529), ABLE accounts (under section 529A), rules for partnerships, earlier.
IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct *Note: The grantor also must provide a Form W -9 to trustee of trust.
TIN, but you do not have to sign the certification. Note: If no name is circled when more than one name is listed, the
What Name and Number To Give the Requester number will be considered to be that of the first name listed.
For this type of account: Give name and SSN of: Secure Your Tax Records From Identity Theft
1. Individual The individual Identity theft occurs when someone uses your personal information
2. Two or more individuals (joint The actual owner of the account or, if such as your name, SSN, or other identifying information, without your
account) other than an account combined funds, the first individual on permission, to commit fraud or other crimes. An identity thief may use
maintained by an FFI the account' your SSN to get a job or may file a tax return using your SSN to receive
a refund.
3. Two or more U.S. persons Each holder of the account To reduce your risk:
(joint account maintained by an FFI)
• Protect your SSN,
4. Custodial account of a minor The minor • Ensure your employer is protecting your SSN, and
(Uniform Gift to Minors Act)
5. a. The usual revocable savings trust The grantor - trustee • Be careful when choosing a tax preparer.
(grantor is also trustee) If your tax records are affected by identity theft and you receive a
b. So called trust account that is not The actual owner' notice from the IRS, respond right away to the name and phone number
a legal or valid trust under state law printed on the IRS notice or letter.
6. Sole proprietorship or disregarded The owner3 If your tax records are not currently affected by identity theft but you
entity owned by an individual think you are at risk due to a lost or stolen purse or wallet, questionable
credit card activity or credit report, contact the IRS Identity Theft Hotline
7. Grantor trust filing under Optional The grantor' at 1 - 800 - 908 - 4490 or submit Form 14039.
Form 1099 Filing Method 1 (see
Regulations section 1.671 4(b)(2)(i) For more information, see Pub. 5027, Identity Theft Information for
(A)) Taxpayers.
For this type of account: Give name and EIN of: Victims of identity theft who are experiencing economic harm or a
8. Disregarded entity not owned by an The owner systemic problem, or are seeking help in resolving tax problems that
individual have not been resolved through normal channels, may be eligible for
Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
9. A valid trust, estate, or pension trust Legal entity calling the TAS toll -free case intake line at 1 -877- 777 -4778 or TTY/TDD
10. Corporation or LLC electing The corporation 1
corporate status on Form 8832 or Protect yourself from suspicious emails or phishing schemes.
Form 2553 Phishing is the creation and use of email and websites designed to
mimic legitimate business emails and websites. The most common act
11. Association, club, religious, The organization is sending an email to a user falsely claiming to be an established
charitable, educational, or other tax legitimate enterprise in an attempt to scam the user into surrendering
exempt organization private information that will be used for identity theft.
12. Partnership or multi- member LLC The partnership
13. A broker or registered nominee The broker or nominee
Form W -9 (Rev. 11 -2017) Page 6
The IRS does not initiate contacts with taxpayers via emails. Also, the Privacy Act Notice
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers, passwords, or similar secret access Section 6109 of the Internal Revenue Code requires you to provide your
information for their credit card, bank, or other financial accounts. correct TIN to persons (including federal agencies) who are required to
If you receive an unsolicited email claiming to be from the IRS, file information returns with the IRS to report interest, dividends, or
forward this message to phishing@irs.gov. You may also report misuse certain other income paid to you; mortgage interest you paid; the
of the IRS name, logo, or other IRS property to the Treasury Inspector acquisition or abandonment of secured property; the cancellation of
General for Tax Administration (TIGTA) at 1- 800 - 366 -4484. You can debt; or contributions you made to an IRA, Archer MSA, or HSA. The
forward suspicious emails to the Federal Trade Commission at person collecting this form uses the information on the form to file
spam@uce.gov or report them at www.ftc.gov /complaint. You can information returns with the IRS, reporting the above information.
contact the FTC at www.ftc.gov /idtheft or 877 - IDTHEFT (877- 438 - 4338). Routine uses of this information include giving it to the Department of
If you have been the victim of identity theft, see www.IdenfityTheft.gov Justice for civil and criminal litigation and to cities, states, the District of
and Pub. 5027. Columbia, and U.S. commonwealths and possessions for use in
administering their laws. The information also may be disclosed to other
Visit www.irs.gov /IdentityTheft to learn more about identity theft and countries under a treaty, to federal and state agencies to enforce civil
how to reduce your risk. and criminal laws, or to federal law enforcement and intelligence
agencies to combat terrorism. You must provide your TIN whether or
not you are required to file a tax return. Under section 3406, payers
must generally withhold a percentage of taxable interest, dividend, and
certain other payments to a payee who does not give a TIN to the payer.
Certain penalties may also apply for providing false or fraudulent
information.
STATE OF FLORIDA TRAVELER AGENCY
VOUCHER FOR REIMBURSEMENT HEADQUARTERS
OF TRAVEL EXPENSES X OFFICER/EMPLOYEE _ NON EMPLOYEE /IND. CONTRACTOR RESIDENCE (CITY)
Hour of Meals for Per Diem Map Vicinity Other Other
Travel Performed From Point of Purpose or Reason Class C
Date Origin To Destination (Name of Conference) Departure Class A & or Actual Meals Mileage Mileage Expenses Expenses
And Return B Travel Lodging Claimed Claimed Amount Type
Statement of Benefits to the State: (Conference or Convention) Column Column Column MILES Column SUMMARY
Total Total Total @ 0.530 Total TOTAL
Revolving Fund: Check No. Advance: Warrant No.:
Check Date Warrant Date LESS ADVANCE RECEIVED
Agency Voucher No. Statewide Doc. No. LESS CLASS C MEALS (Officers /Employees Only)
Agency Voucher No. NET AMOUNT DUE
I hereby certify or affirm that the above expenses were actually incurred by me as necessary travel expenses in the Pursuant to Section 112061 (3)(a), Florida Statutes, I hereby
performance of my official duties, attendance at a conference or convention was directly related to official duties of the certify or affirm that to the best of my knowledge the above
agency; any meals or lodging included in a conference or convention, registration fee have been deducted from this travel was on official business of the State of Florida and was
travel claim and that this travel claim is true and correct in every material matter and same conforms in every respect performed for the payee(s) stated above.
with the requirement of Section 11261 Florida Statutes.
TRAVELER'S SIGNATURE: SUPERVISOR'S SIGNATURE:
DALE
PREPARED TITLE: SUPERVISOR'S TITLE: DATE:
Z: \SABRAMS \VAB 2018\2018 Org Mtg \Special Magistrates \Travel Voucher to fill in CLERK Travel Form