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Item C1 BOARD OF COUNTY COMMISSIONERS AGENDA ITEM SUMMARY Meeting Date: December 10, 2014 Division: Public Works/Engineering Bulk Item: Yes x No — Department: Facilities Maintenance Staff Contact Person/Phone#:Dent Pierce/292-4560 AGENDA ITEM WORDING: Approval of Agreement with Congressman Carlos Curbelo for office space, Room 1-213 at the Gato Building in Key West, FL ITEM BACKGROUND: Newly elected in 2014, Congressman Carlos Curbelo requested use of available County office space at the Gato Building. Congressman Carlos Curbelo's request for the use of office space, Room 1-213 is to commence January 03, 2015 and terminate January 02, 2017. PREVIOUS RELEVANT BOCC ACTION: None CONTRACT/AGREEMENT CHANGES: New Agreement STAFF RECOMMENDATIONS: Approval TOTAL COST: maintenance/utility costs INDIRECT COST: N/A BUDGETED: Yes X No DIFFERENTIAL OF LOCAL PREFERENCE: COST TO COUNTY: SaMe SOURCE OF FUNDS: REVENUE PRODUCING: Yes No X AMOUNT PER MONTH Year APPROVED BY: County Atty OMB/Pur fasing Risk Management DOCUMENTATION: Included X Not Required DISPOSITION: ....... AGENDA ITEM # PWI Revised 1/09 BOARD OF COUNTY COMMISSIONERS AGENDA ITEM SUMMARY Meeting Date: December 10, 2014 Division: Public Works/Engineering Bulk Item: Yes x No — Department: Facilities Maintenance Staff Contact Person/Phone#:Dent Pierce/292-4560 AGENDA ITEM WORDING: Approval of Agreement with Congressman Carlos Curbelo for office space, Room 1-213 at the Gato Building in Key West, FL ITEM BACKGROUND: Newly elected in 2014, Congressman Carlos Curbelo requested use of available County office space at the Gato Building. Congressman Carlos Curbelo's request for the use of office space, Room 1-213 is to commence January 03, 2015 and terminate January 02, 2017. PREVIOUS RELEVANT BOCC ACTION: None CONTRACT/AGREEMENT CHANGES: New Agreement STAFF RECOMMENDATIONS: Approval TOTAL COST: maintenance/utility costs INDIRECT COST: N/A BUDGETED: Yes X No DIFFERENTIAL OF LOCAL PREFERENCE: COST TO COUNTY:- same SOURCE OF FUNDS: REVENUE PRODUCING: Yes No X AMOUNT PER MONTH Year$ APPROVED BY: County Att IT OMB/Purchasing Risk Management DOCUMENTATION: Included X Not Required DISPOSITION: AGENDA ITEM # Rbevised 1/09 MONROE COUNTY BOARD OF COUNTY COMMISSIONERS CONTRACT SUMMARY Contract with: Congressman Contract# Carlos Curbelo Effective Date: J ...mm.. anuary 03,2015 Expiration Date: January 02,2017 Contract PurposelDescription: Agreement with Congressman Carlos Curbelo to lease 287 square feet of office space at the Gato BuiIdiinn ,Room 1 213 in Key West,FL Contract Manager: Alice Steryou 4549 Facilities Maint/Sto #4 (Name) (Ext.) (Department/Stop#) for BOCC meetin on 12/10/14 A end Deadline: 11/21/14 CONTRACT COSTS/REVENUE Total Dollar Value of Contract:$ -0- Current Year Portion:$ -0- Bud eted?Yes X No F1 Account Codes Grant: $ N/A ...m... .. ._._........._ u - - - - County Match: $ N/A ADDITIONAL COSTS Estimated Ongoing Costs: $ /yr For: Not included in dollar value alcove a ,raanrte uaitllm arutoal sslsrra ,alc,' µ CONTRACT REVIEW I Changes Date Out Date In Needed Division Director _ w Yes[]No / .......... . _. w g p � Risk Management .. "..._ Yes❑Niac „ O, " . Ntrc as ng � P Yes®No '( County Attorney Yes[]No0 � Comments: , LIMB Form " ed?r+27/ll!MCP#2 District Office Lease - Instructions NO LEASE OR ATTACHMENT CAN BE SIGNED BEFORE THEY HAVE BEEN APPROVED BY THE ADMINISTRATIVE COUNSEL. The term for a District Office Lease for the 114 1h Congress may not commence prior to January 3,2015. Members should endeavor to lease space through the last day of a congressional term rather than the last day of a calendar year. For the 114 1h Congress,leases should end on January 2, 2017,not December 31,2016. A. The preamble has three blank lines to be filled in: (1)Landlord's name-, (2)Landlord's address-, and(3) Member/Member-Elect's name. B. Section I has three blank lines to be filled in: (1) square footage of the leased office(optional); (2)street address of the leased office; and(3)city,state and ZIP code of the leased office. C. Section 2 has boxes that can be checked on whether any lease amenities(such as parking, utilities,janitorial services,trash removal,etc.)are included in the lease. Note that this checklist is only for convenience and the listed amenities are not required. Some of the options have a blank line to be filled in to provide additional information about an amenity, D. Section 3 has two blank lines to be filled in: (1) date lease begins(must be on or after January 3, 2015); and(2)date lease ends(must be on or before January 2,2017), E. Section 4 has one blank line for the monthly rent amount(write"zero"if no rent is to be paid). F. Section 5 has one blank line—the number of days' notice required for either party to terminate the lease before the end of the term. A standard period is 30 days,but any figure is acceptable. If the lease may not be terminated early,enter"N/A"in this blank. G. Sections 1-9,other than filling in the blanks,may not be altered or deleted. H. Section 11 has space provided to list any additional lease provisions. I. Prior to either party signing a lease, the Member/Member-Elect must submit the proposed lease, accompanied by a copy of the District Office Lease Attachment for the 114"'Congress,to the Administrative Counsel for review and approval. If the proposed teens and conditions of the lease are determined to be in compliance with applicable law and House Rules and Regulations, the Administrative Counsel will notify the Member/Member-Elect that(s)he may proceed with the signing of the lease. Please submit the proposed lease and District Office Lease Attachment either by e-mail in PDF form(leases@)mail.house.gov) or fax (202-225-6999). J. The Member/Member-Elect is required to personally sign the documents. A signed and dated District Office Lease Attachment must accompany this lease. Once signed by both parties,the Lease and the District Office Lease Attachment must be submitted to the Administrative Counsel for final approval. They may be sent by email in PDF form or faxed to 202-225-6999,but the originals still inust be submitted by inter office mail(217 Ford House Office Building,Washington,D.C. 20515) after ernalling or faxing. K. If approved,Administrative Counsel will send the forms to Finance so that payment can begin. If there are errors on the form,the Member office will be contacted and required to correct them. V.S. Ifouse of 47mentatives Washington,D.C.20515 Dh&WMfth= (Page 1 of 3-1140'Congress) Pursuant to 2 U.S.C.A.§4313,and the Regulations of the Committee on House Administration(as modified firmn time to time by Committee Order)relating,to office space in home districts, 1100 Slomlon S(toof.Key West Flwlda 33040 (Landlord's name) (LarWWa sheet addmss,dty,stalle.ZP code) ("Lessor"),and'cwio4 carman FL 26 a Member/Member-Elect of the U.S.House of Representatives("Lessee"},agree as follows- I Location. Lessor shall lease to Lessee'297 square feet of office space located at The Gate 54idng.Rown 1-213.1100 Simonm:Str" (ofte 61reetaftem) in the city,state and ZIP code of Key west.ftrids U90 (office dty.state WW Zip) 2. Lease Amenities Note that this checklist is for convenience only and the listed amenities are not required. However,the interior wiring of a CAT Se or better and broadband inter net access to the building will likely,expedite the process for the office to be fully operational. The Lease includes(please check any and complete all that apply); f71Tejevhop_e Ecrvice Avaitablg. (interior wiring CAT Se or better) [IBro-adbud InIs=Awm to Djulding- (e.&,COMCAST,COX or like provider) Ekarking,M_no.of assigned parking spaces 21—no,of unassigned parking spaces []General off-street parking on an as available basis aJAilities. Includes: WaLer&Electric EVartikqdal Smigg, Frequency- Qg!il_y__ � Rcmoval. Frequency:12WIy_,_ ElCaug Clmin . Frequency- UEindow'W 13Window TreatM"n rITcagnt Al!pmfi2ns Inclydgd In Rental Rate. 1Aft Hogg Building Access. MGS Emil Includes: maser.QIajM_ 17table TV Accessble. If checked,Included in Rental RatcEl YesMo OBwilding Man [30nsite 010n Call Contact Name:Ki i Gggi ez Phone:Number:305-797-1492 Email Ad&=:.g.Qn7jigz-kihi@mon=counly_-A 3. Term Lessee shall have and hold the leased premises,for the period beginning JanuM 2 , 20_Lc,L and ending JgMUMU 2 7 20 16 . The term of this District Office Lease("Lease') may not exceed two(2)years arm:may not extend beyond January 2,2017,which is the end of the constitutional term of the Congress to which the Member is elected. 4. RenL The monthly rent shall be so-Do ,and is payable in arrears on or before the last day of each calendar month. Rent payable under this Lease shall be prorated on a daily basis for any fraction of a month of occupancy. V.S. ifouse of Representatives Washington,D.C. 20515 District Office Lease (Page 2 of 3—114b Congress) 5. Early Termination. This Lease may be terminated by either party giving 60 days' prior written notice to the other party. The commencement date of such termination notice shall be the date such notice is delivered or,if mailed,the date such notice is postmarked. 6. Payments. During the term of this Lease,rent payments under Section 4 of this Lease shall be remitted to the Lessor by the Chief Administrative Officer of the U.S.House of Representatives (the"CAO") on behalf of the Lessee. 7. District Office Lease Attachment for 114`h Congress. The District Office Lease Attachment attached hereto is incorporated herein by reference,and this Lease shall have no force or effect unless and until accompanied by an executed District Office Lease Attachment for the 1101 Congress. 8. Counterparts. This Lease may be executed in any number of counterparts and by facsimile copy,each of which shall be deemed to be an original but all of which together shall be deemed to be one and the same instrument. 9. Section Headings. The section headings of this Lease are for convenience of reference only and shall not be deemed to limit or affect any of the provisions hereof. 10. Modifications. Any amendments,additions or modifications to this Lease inconsistent with Sections 1 through 9 above shall have no force or effect to the extent of such inconsistency. 11. Other. Additionally,the Lessor and the Lessee agree to the following: [Signature page follows.] V.S. Yfouse of Representatives Washington,D.C. 20515 918ViCt Offt L8888 (Page 3 of 3-1141'Congress) IN WITNESS WHEREOF, the parties have duly executed this District Office Lease as of the later date written below by the Lessor or the Lessee. Print Name of LessorlLandlordlCompany Print Name of Lessee By: _— _ _ ...__......... w .................. Lessor Signature Lessee Signature Name: Title: .............. wwwwww.... Date Date This District Office Lease must be accompanied with an executed District Office Lease Attachment. District Office Lease Attachment- Instructions The District Office Lease Attachment is a 4-page document that must accompany every Lease or District Office Lease Amendment that is submitted for a Member/Member-Elect's District Office. NO LEASE,AMENDMENT OR ATTACHMENT CAN BE SIGNED BEFORE THEY HAVE BEEN APPROVED BY THE ADMINISTRATIVE COUNSEL. The term of a District Office Lease or Amendment for the 114'h Congress may not commence prior to January 3,2015. Members should endeavor to lease space through the last day of a congressional term rather than the last day of a calendar year. For the 114" Congress,leases should end on January 2,2017,not December 31,2016. Four things are required: 1. the signature of the Landlord and date; 2. the signature of the Member/Member-Elect of Congress and date; 3. contact information for the person in the Member/Member-Elect's office whom we should call if there are any problems or questions(scheduler,etc,);and 4. the signature from the Office of the Administrative Counsel. A few things to keep in mind: A. The Member/Member-Elect is required to personally sign the documents, B. The Attachment SHALL NOT have any provisions deleted or changed. �C. Even if rent is zero,an Attachment is still required. D. Prior to either party signing a Lease or Amendment,the Member/Member-Elect must submit the proposed Lease or Amendment, accompanied by a copy of the Attachment,to the Administrative Counsel for review and approval. If the Administrative Counsel determines that the proposed terms and conditions of the Lease or Amendment are in compliance with applicable law and House Rules and Regulations,the Administrative Counsel will notify the Member/Member-Elect that(s)be may proceed with the execution of the Lease or Amendment. Please submit the proposed Lease or Amendment and Attachment either by e-mail in PDF forin (leases @/mail.house.gov) or by fax(202-225-6999), E. Once signed by both parties,the Lease or Amendment and the Attachment must be submitted to the Administrative Counsel for final approval. The Attachment should be submitted at the same time the Lease or Amendment is sent to the Administrative Counsel. They may be sent by email in PDF form or taxed to(202-225-6999),but the originals still must be submitted by interoffice mail (217 Ford House Office Building,Washington, D.C.20515)after emailing or faxing. F. Without a properly signed and submitted Attachment,the Lease or Amendment cannot be approved and payments will not be made. The parties agree that any charges for default,early termination or cancellation of the Lease or Amendment which result from actions taken by or on behalf of the Lessee shall be the sole responsibility of the Lessee,and are not reimbursable from the Member's Representational Allowance. G. Lessor shall provide a copy of any assignment estoppel certificate'notice of a bankruptcy or foreclosure,or notice of a sale or transfer of the leased Dremises to the Administrative Counsel by e-mail in PDF form(leases(kmail.house.gov). V.S. Mouse of Representatives Washington,D.C. 20515 District Office Lease Attachment (Page 1 of 4—114 1h Congress) 1. Incorporated District Office Lease Attachment. Lessor(Landlord)and Lessee (Member/Member-Elect of the U.S. House of Representatives)agree that this District Office Lease Attachment("Attaclu-nent")is incorporated into and made part of the Lease("Lease")and, if applicable,District Office Lease Amendment("Amendment")to which it is attached. 2. Performance. Lessor expressly acknowledges that neither the U.S.House of Representatives (the"House")nor its Officers are liable for the performance of the Lease. Lessor further expressly acknowledges that payments made by the Chief Administrative Officer of the House (the"CAO")to Lessor to satisfy Lessee's rent obligations under the Lease—which payments are made solely on behalf of Lessee in support of his/her official and representational duties as a Member of the House—shall create no legal obligation or liability on the part of the CAO or the House whatsoever. Lessee shall be solely responsible for the performance of the Lease and Lessor expressly agrees to look solely to Lessee for such performance. 3. Modifications. Any amendment to the Lease must be in writing and signed by the Lessor and Lessee. Lessor and Lessee also understand and acknowledge that the Administrative Counsel for the CAO ("Administrative Counsel")must review and give approval of any amendment to the Lease prior to its execution. 4. Compliance with House Rules and Regulations. Lessor and Lessee understand and acknowledge that the Lease shall not be valid,and the CAO will not authorize the disbursement of funds to the Lessor,until the Administrative Counsel has reviewed the Lease to determine that it complies with the Rules of the House and the Regulations of the Committee on House Administration, and approved the Lease by signing on page 4 of this Attachment. 5. Payments. The Lease is a fixed term lease with monthly installments for which payment is due in arrears on or before the end of each calendar month. In the event of a payment dispute,Lessor agrees to contact the Office of Finance of the House at 202-225-7474 to attempt to resolve the dispute before contacting Lessee. 6. Void Provisions. Any provision in the Lease purporting to require the payment of a security deposit shall have no force or effect. Furthermore,any provision in the Lease purporting to vary the dollar amount of the rent specified in the Lease by any cost of living clause,operating expense clause,pro rata expense clause, escalation clause,or any other adjustment or measure during the term of the Lease shall have no force or effect. 7. Certain Charges. The parties agree that any charge for default,early termination or cancellation of the Lease which results from actions taken by or on behalf of the Lessee shall be the sole responsibility of the Lessee, and shall not be paid by the CAO on behalf of the Lessee. 8. Death,Resignation or Removal. In the event Lessee dies,resigns or is removed from office during the term of the Lease,the Clerk of the House may,at his or her sole option,either: (a) terminate the Lease by giving thirty(30)days'prior written notice to Lessor; or(b)assume the obligation of the Lease and continue to occupy the premises for a period not to exceed sixty(60) days following the certification of the election of the Lessee's successor. In the event the Clerk elects to terminate the Lease,the commencement date of such thirty(30) day termination notice shall be the date such notice is delivered to the Lessor or, if mailed,the date on which such notice is postmarked. V.S. Yfouse of(epresentatives Washington, D.C. 20515 District Office Lease Attachment (Page 2 of 4—114"'Congress) 9. Term. The term of the Lease may not exceed the constitutional term of the Congress to which the Lessee has been elected. The Lease may be signed by the Member-Elect before taking office. Should the Member-Elect not take office to serve as a Member of the 114"'Congress,the Lease will be considered null and void. 10. Early Termination. If either Lessor or Lessee terminates the Lease under the terms of the Lease, the tenninating party agrees to promptly file a copy of any termination notice with the Office of Finance,U.S.House of Representatives,B-245 Longworth House Office Building,Washington, D.C.20515,and with the Administrative Counsel by e-mail at leases@mail.house.gov. 11. Assignments. Lessor shall not have the right to assign(by operation of law or otherwise)any of its rights,interests and obligations under the Lease,in whole or in part,without providing thirty (30)days prior written notice to Lessee,and any such purported assignment without such notice shall be void. Lessor shall promptly file a copy of any such assignment notice with the Administrative Counsel by e-mail at leascs(ir,mail.house.gov. 12. Sale or Transfer of Leased Premises. Lessor shall provide thirty(30) days prior written notice to Lessee in the event(a)of any sale to a third party of any part of the leased premises,or(b) Lessor transfers or otherwise disposes of any of the leased premises, and provide documentation evidencing such sale or transfer in such notice. Lessor shall promptly file a copy of any such sale or transfer notice with the Administrative Counsel by e-mail at leases@mail.house.gov. 13. Bankruptcy and Foreclosure. In the event(a)Lessor is placed in bankruptcy proceedings (whether voluntarily or involuntarily),(b)the leased premises is foreclosed upon,or(c)of any similar occurrence, Lessor agrees to promptly notify Lessee in writing. Lessor shall promptly file a copy of any such notice with the Office of Finance,U.S. House of Representatives,B-245 Longworth House Office Building,Washington,D.C. 20515,and with the Administrative Counsel by e-mail at leases @ mail.house.gov. 14. Estoppel Certificates. Lessee agrees to sign an estoppel certificate relating to the leased premises(usually used in instances when the Lessor is selling or refinancing the building)upon the request of the Lessor. Such an estoppel certificate shall require the review of the Administrative Counsel,prior to Lessee signing the estoppel certificate. Lessor shall promptly provide a copy of any such estoppel certificate to the Administrative Counsel by e-mail at leases(a)mail.house.gov. 15. Maintenance of Common Areas. Lessor agrees to maintain in good order,at its sole expense, all public and common areas of the building including,but not limited to,all sidewalks,parking areas,lobbies,elevators,escalators,entryways,exits,alleys and other like areas. 16. Maintenance of Structural Components. Lessor also agrees to maintain in good order,repair or replace as needed,at its sole expense, all structural and other components of the premises including,but not limited to,roofs,ceilings,walls (interior and exterior),floors,windows,doors, foundations,fixtures,and all mechanical,plumbing,electrical and air conditioning/heating systems or equipment (including window air conditioning units provided by the Lessor) serving the premises. V.S. Oouse of 9?fpresentatives Washington,D.C. 20515 District Office Lease Attachment (Page 3 of 4-114 1h Congress) 17. Lessor Liability for Failure to Maintain. Lessor shall be liable for any damage,either to persons or property,sustained by Lessee or any of his or her employees or guests,caused by Lessor's failure to fulfill its obligations under Sections 15 and 16. 18. Initial Alterations. Lessor shall make any initial alterations to the leased premises, as requested by Lessee and subject to Lessor's consent,which shall not be unreasonably withheld. The cost of such initial alterations shall be included in the annual rental rate. 19. Federal Tort Claims Act. Lessor agrees that the Federal Tort Claims Act,28 U.S.C. §§ 267 1- 80,satisfies any and all obligations on the part of the Lessee to purchase private liability insurance. Lessee shall not be required to provide any certificates of insurance to Lessor. 20. Limitation of Liability. Lessor agrees that neither Lessee nor the House nor any of the House's officers or employees will indemnify or hold harmless Lessor against any liability of Lessor to any third party that may arise during or as a result of the Lease or Lessee's tenancy. 21. Compliance with Laws. Lessor shall be solely responsible for complying with all applicable permitting and zoning ordinances or requirements, and with all local and state building codes, safety codes and handicap accessibility codes (including the Americans with Disabilities Act), both in the common areas of the building and the leased space of the Lessee. 22. Electronic Funds Transfer. Lessor agrees to accept monthly rent payments by Electronic Funds Transfer and agrees to provide the Office of Finance,U.S. House of Representatives,with all banking information necessary to facilitate such payments. 23. Refunds. Lessor shall promptly refund to the CAO,without formal demand, any payment made to the Lessor by the CAO for any period for which rent is not owed because the Lease has ended or been ten-ninated. 24. Conflict. Should any provision of this Attachment be inconsistent with any provision of the attached Lease or attached Amendment,the provisions of this Attachment shall control, and those inconsistent provisions of the Lease or the Amendment shall have no force and effect to the extent of such inconsistency. 25. Construction. Unless the clear meaning requires otherwise,words of feminine,masculine or neuter gender include all other genders and,wherever appropriate,words in the singular include the plural and vice versa. 26. Fair Market Value. The Lease or Amendment is entered into at fair market value as the result of a bona fide, arms-length,marketplace transaction. 'The Lessor and Lessee certify that the parties are not relatives nor have had,or continue to have,a professional or legal relationship (except as a landlord and tenant). 27. District Certification. The Lessee certifies that the office space that is the subject of the Lease is located within the district the Lessee was elected to represent unless otherwise authorized by Regulations of the Committee on House Administration. V.S. Mouse of Representatives Washington, D.C.20515 District 0111ce Lease Attacliment (Page 4 of 4—114 1h Congress) 28. Counterparts. This Attachment may be executed in any number of counterparts and by facsimile copy,each of which shall be deemed to be an original but all of which together shall be deemed to be one and the same instrument. 29. Section Readings. The section headings of this Attachment are for convenience of reference only and shall not be deemed to limit or affect any of the provisions hereof. IN WITNESS WHEREOF,the parties have duly executed this District Office Lease Attachment as of the later date written below by the Lessor or the Lessee. Print Name ofLessorILandlord Print Name of Lessee By: ...................... ............. Lessor Signature Lessee Signature Name: Title: Date Date IFrom the Member's Office,who is the point of contact for questions? Name m.mmPhone E-mail niail.t This District Office Lease Attachment and the attached Lease or Amendment have been reviewed and are approved,pursuant to Regulations of the Committee on House Administration. Signed ........ Date 20 . (Administrative Counsel) T" F1�1V�.Y J, Date— Send completed forms to:Administrative Counsel,2l7 flood House Office Building, Washington,,D.C.20515. Cbpw5 inqy also befareel to 202-225-6999. U.S. House of Representatives Substitute W-9 and ACH Vendor/Miscellaneous Payment Enrollment Form Internal Revenue Code 6109,31 U.S.C.3322,31 CFR.210 and the,1996 Debt Collection Improvement Act require all entities that do business with the United States Government to provide a Tax Identification Number(TfN)and Electronic Funds Transfer(EFT)information for payment. PL 93-579 profects your privacy and mandates that the information never be published or used for any other purpose than to pay you. Please eamplete till seetions below,sign and return vier the entail or fax number listed. RETURN FORM TO: VendorEFT(citmail.houseaov FAX NUMBER: (202)225-6914 SECTIONI UNITED STATES HOUSE OF REPRESENTATIVES INFORMATION ADDRESS . .................. ............ ACCOUNTING,, , 31,10-0-N E-LIL FEDERAL 9UILDIINO,WASHINGTOIN DC 20515 AGENCY IDENJIFIER 53-6002523 AGENCY LOCATION CODE 4832 TELEPHONE NUMBER (202)226.2277 SECTION II PAYEE/COMPANY INFORMATION NAME(AS SHOWN ON YOUR INCOME TAX RETURN) CHECK APPROPRIATE BOX FOR FEDERAL TAX CLASSIFICATION{required) 0 Individuall Sole []C corporation rjS Corporation[]Partnership []TrustJEstate Proprietor BUSINESS THAN ABOVE Limited Liability Company Enter lax classification E-Xem,p t (C=,C corporation,S=S corporation,P=Partnership) --- ------------- Payee El E OF I TAX I I I I BE NTIFICATION-kUMBEIR ENT ER-T-AX I'D EN-TIRI G A-710-N N-L)M B E R OTHER (Otheir enlities,Enter youeay iness name below as shown on requiSOCIAL SECURITY N s"Nme" e.Thidtchrneoeroth legal EIN documentcag thee ,You enter any business,trade,or IDEA name on'the"Business name/disregard�ed entiy name .) ADDRIEMICIMSTATEIZIP PURCHASE ORDER ADDRESSICITYISTATEIZIP CONTACT PERSON NAME EMAIL EMAIL --- ----------- 4' &kb�iNbMBER FAX NUMBER TELEPHON-E-NUMBER IN LIM,B,E R-- REMIT TO ADDRESS SECTIONIII FINANCIAL INSTITUTION INFORMATION BANK NAME(Branch City,Stale) A&COORDINATOR NAME TELEPHONE N6-M'6LR 11-N1INE-DIGIT ROUTING TRANSIT INLIMikk ................. ....................... DEPOSITOR A6C66NffAE.................... . .....-—---------------- ......... .......................... ------ ..................... DEPOSITOR ACCOUNT NUMBER LOCKBOX NUMBER TYPE 1 0 1 F-ACCOUNT..,,,,,,, CCO I U I IN I T 11.................. 6HIECKiNIG L-OCKBOX SEVIIONIV SOCIO-ECONOMIC INFORMATION Type of Business []Large Business-No Socio-Economic Designations Elminority[]SMBUSOess []Sm-Dlsardv1MrPorjfy []Sm-DisadvOnly []SmMinOnly qEm-erg-jn-q-S-mafiBus)ness I IN I om I en-Ow I n e I d I Bu I s 1 1 1 n I ass Sm-Disadvantarged Business Pro g 8(a)Firm IHUBZon.Program f Eflqdbire Other Preference Programs []Buy Indian []Directed toJWOC),Non-Profit[]NoPrefere-,colNotLfst,,d [Ismalt Business Set-Aside []Very Small Business --1-1-1-I'll,1-1 1 1------------- ---111-1111 ❑--- --------------------------------------- .......... .... .... ..................-- -❑------ ------------------------------- Veteran Owned Status No,-Vet Owned SnnBus[20ther Val Owned S.Bus []Ser-v-Disabled Val Other Bus[]Serv-Disabled Vat Owned SB®Vet-Owned Other Bus ----------- ----------------------- ...................................... ............ -—---------------------— ----- Size of Business (A)50 orloss [](B)51-100 [:],(C)101-250 [](D)251-500 E](E)501 1500 F)751-1,0,00 �(G)Over 1,000[3(U)lmifl[on or less (N)1,1-2 m0drr [JfP)„,1.3,6 mifflon—OP)3,1.5 nai ion, [3(s)5,1-10 Minion 0 -Q10,147million 0 I;)Ovet 17 million SECTION V CERTIFICATION OF DATA BY PAYEE/COMPANY NAME '�TITLEIPCSITION S I G IN AT UR E DATE TELIEPHIONE NUMBER USHR 2013 V I Instructions for Completing U'S' House mf Representatives SmbsttwtmW-9 and ACH Vendor/Miscellaneous Payment Enrollment Form Section I -Agency Information —Includes the name and address, agency identifier, agency location code and telephone number for the House ofRepresentatives. Section N ' Payee/Company Information—Print or type the name ofthe payee/company and address that will receive payment, social security or taxpayer ID number, contact person name,telephone number and email of the payee/company. Print or type the purchase order and remit to addresses if different from the payeelcompany address. Check the appropriate boxes for federal tax classification. Section III - Financial Institution Information —Printortypathenemeandeddreeoofthepeyee/uompony's financial institution who will receive the ACH payment,ACH coordinator name and telephone number, nine-digit routing transit number, depositor(payee/company)account title and account number. Check the appropriate box for type ofaccount. Payee/Company may include o voided check with this form. ACH'4000mnt Information Located ona Check orDeposit Ticket FINANCIAL INSTITUTION NAME name of the financial institution 10 which the payments are tnbedirected ROUTING TRANSIT NUMBER(RTN) financial institution's 9 digit routing transit number; found nn the bottom o/a check ordeposit ticket o/from your Financial Institution ACCOUNT TITLE employee's or vendor's name om the account ACCOUNT NUMBER account number a1 the financial!institution f. RnudngTransit Number(RTN) ----'---------------------- —ninedigits|ooatadbomeon RSON 101 two symbols. This number ��H�a identifies the hmnlk holding your account and check processing center. 2. Ancnuntnumber—thiaisynur complete account number. Your account number can bo upto17 digits. Please include � Seuff 9=Pu,vww leading zeros. n me 3. AOH Routing Transit Number— Automated Clearing House routing number, use this 123456 r890m~ CIO& number for your Routing � Transit Number( if you � 2 lo, 1 bank with SunTrust Bank. 4. Chaoknumber—Thin 2 3 4 information is notneceaaory- � dn not provide Section IV-Socio-Economic Information —Check the boxes for each category, if applicable:type of business, small disadvantaged business program, HUBZone program, emerging small business,women-owned business, other preference programs,Veteran owned status and size of business. Detailed information related to Small � Business programs can bo found at . � Section V-Certification of Data By Payee/Company—Print or type the name, title/position and phone number of � the Authorized official. The Authorized official must signand date the form.