Item C50
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: 09-19-01
Division:
County Administrator
Bulk Item: Yes X
No
Department: Airports
AGENDA ITEM WORDING:
Paradise.
Approval of Marathon Terminal Cleaning Contract with Birds of
ITEM BACKGROUND: Birds of Paradise was the lowest bidder in response to a RFB's published
in January 2001.
PREVIOUS REVELANT BOCC ACTION:
N/A
CONTRACT/AGREEMENT CHANGES:
airport was previously paying 500.00 per week.
A one year contract at 395.00 per week. The
ST AFF RECOMMENDATIONS:
Approval
TOTAL COST:
BUDGETED: Yes X No
COST TO COUNTY:
-1 '2.0,5'4D
AMOUNT PER YEAR $00.00
REVENUE PRODUCING: Yes x No
APPROVED BY: County Atty OMB/Purchasing _ Risk Management _
MARATHON AIRPORT MANAGER APPROVAL: ~.a
/ C ~~:Ok
DIVISION DIRECTOR APPROVAL: ~~~
James Roberts
County Administrator
DOCUMENTATION:
Included x
To Follow
Not Required_
AGENDA ITEM # J .(" S IJ
DISPOSITION:
Revised 2/27/01
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: Birds of Paradise Contract #
Effective Date: October 1,2001
Expiration Date: 9/02
Contract Purpose/Description:
One year contract for cleaning services at the Marathon Airport Terminal. $395.00 per
week
Contract Manager: Theresa Cook 6060 Airport/I 5
(Name) (Ext. ) (Department/Stop #)
for BOCC meeting on 9/19/01 Agenda Deadline: 9/5/01
CONTRACT COSTS
Total Dollar Value of Contract: $ 20,540.00
Budgeted? YesC8J No C8J Account Codes:
Grant: $
County Match: $ 0
Current Year Portion: $
~-~ol-~~()3LfO
ADDITIONAL COSTS
Estimated Ongoing Costs: $ _/yr For:
(Not included in dollar value above) (eg. maintenance, utilities, janitorial, salaries, etc.)
CONTRACT REVIEW
Division Director
Changes
Date In Needed . ~,Re\ieAver
'1-,..-.., YesDNo~~
--
Date Out
7-- t-, r
Risk Management c, \., \ i) \
.
\ .
MARATHON AIRPORT TERMINAL
CLEANING CONTRACT
THIS AGREEMENT, made and entered into this _ day of , 2001,
by and between MONROE COUNTY, FLORIDA, party of the first part (hereinafter
sometimes called the .Owner"), and Birds of Paradise's Cleaning Service, Inc., party of the
second part (hereinafter sometimes called the .Contractor").
WITNESSED: That the parties hereto, for the consideration hereinafter set forth,
mutually agree as follows:
SCOPE OF THE WORK
The Contractor shall provide janitorial services, required in the performance of same, and
perform all of the work described in the Specification entitled Janitorial Specification
for the Airport as Exhibit A attached hereto and incorporated as part of this contract
document.
THE CONTRACT SUM
The County shall pay to the Contractor for the faithful performance of said service on a
per week in arrears basis. The Contractor shall invoice the County weekly for janitorial
services performed under the Specifications contained herein. The Contract amount shall
be as calculated by the contractors proposal as follows: $395 per week.
CONTRACTOR'S ACCEPTANCE OF CONDITIONS
A. The Contractor hereby agrees that he has carefully examined the sites and has made
investigations to fully satisfy himself that such sites are correct and suitable ones for
this work and he assumes full responsibility therefore. The provisions of the Contract
shall control any inconsistent provisions contained in the specifications. All Specifications
have been read and carefully considered by the Contractor, who understands the same and
agrees to their sufficiency for the work to be done. Under no circumstances, conditions,
or situations shall this Contract be more strongly construed against the Owner than
against the Contractor and his Surety.
B. Any ambiguity or uncertainty in the Specifications shall be interpreted and construed
by the Owner, and his decision shall be final and binding upon all parties.
C. The passing, approval, and/or acceptance of any part of the work or material by the
Owner shall not operate as a waiver by the Owner of strict compliance with the terms of
this Contract, and Specifications covering said work. Failure on the part of the
Contractor, immediately after Notice to correct workmanship shall entitle the Owner, if
it sees fit, to correct the same and recover the reasonable cost of such replacement
and/or repair from the Contractor, who shall in any event be jointly and severally liable to
the Owner for all damage, loss, and expense caused to the Owner by reason of the
Contractor's breach of this Contract and/or his failure to comply strictly and in all things
with this Contract and with the Specifications.
TERM OF CONTRACT/RENEWAL
A. This contract shall be for a period
, 2001 and terminating on
of one (1) year, commencing on
, 2002.
B. The Owner shall have the option to renew this agreement after the first year, and each
succeeding year, for two additional one year periods. The contract amount agreed to
herein may be adjusted annually in accordance with the percentage change in the Consumer
Price Index (CPI) for Wage Earners and Clerical Workers in the Miami, Florida area index,
and shall be based upon the annual average CPI computation from January 1 through
December 31 of the previous year. Increases in the contract amount during each option
year period shall be extended in the succeeding years.
HOLD HARMLESS
The CONTRACTOR shall defend, indemnify and hold harmless the County as outlines on
the attached for identified as Exhibit B
INDEPENDENT CONTRACTOR
At all times and for all purposes under this agreement the Contractor is an independent
contractor and not an employee of the Board of County Commissioners for Monroe County.
No statement contained in this agreement shall be construed so as to find the contractor
or any of his/her employees, contractors, servants, or agents to be employees of the
Board of County Commissioners for Monroe County.
ASSURANCE AGAINST DISCRIMINATION
The Contractor shall not discriminate against any person on the basis of race, creed, color,
national origin, sex, age, or any other characteristic or aspect which is not job related, in
its recruiting, hiring, promoting, terminating, or any other area affecting employment
under this agreement or with the provision of services or goods under this agreement.
ASSIGNMENT
The Contractor shall not assign this agreement, except in writing and with the prior
written approval of the Board of County Commissioners for Monroe County and Contractor,
which approval shall be subject to such conditions and provisions as the Board and
Contractor may deem necessary. This agreement shall be incorporated by reference into
any assignment and any assignee shall comply with all of the provisions of this agreement.
Unless expressly provided for therein, such approval shall in no manner or event be
deemed to impose any obligation upon the Board in addition to the total agreed-upon price
of the services/goods of the contractor.
COMPUANCE WITH THE LAW
In providing all services/goods pursuant to this agreement, the contractor shall abide by
all statutes, ordinances, rules and regulations pertaining to, or regulating the provisions of,
such services, including those now in effect and hereinafter adopted. Any violation of said
statutes ordinances, rules and regulation shall constitute a material breach of this
agreement and shall entitle the Board to terminate this contract immediately upon
delivery of written notice of termination to the contractor. The Contractor shall possess
proper licenses to perform work in accordance with these specifications throughout the
term of this contract.
INSURANCE
Prior to execution of this agreement, the Contractor shall furnish the Owner Certificates
of Insurance indicating the minimum coverage limitations as indicated by an .X" on the
attached form, Exhibit C, each attached hereto and incorporated as Exhibit C as part of
this contract document, and all other requirements found to be in the best interest of
^"onroe County as may be imposed by the Monroe County Risk Management Department.
FUNDING AV AILABIUTY
In the event that funds from Airports Contractual Services are partially reduced or
cannot be obtained or CQMot be continued at level sufficient to allow for the purchase of
the services/goods specified herein, this agreement may then be terminated immediately
at the option of the Board by written notice of termination delivered in person or by mail
to the contractor. The Board shall not be obligated to pay for any services provided by
the contractor after the contractor has received written notice of termination.
PROFESSIONAL RESPONSIBIUTY
The Contractor warrants that it is authorized by law to engage in the performance of the
activities encompassed by the project herein described, subject to the terms and
conditions set forth. The provider shall at all times exercise independent, professional
judgment and shall assume professional responsibility for the services to be provided.
Continued funding by the Board is contingent upon retention of appropriate local, state,
and/or federal certification and/or licenser of contractor.
NOTICE REQUIREMENT
Any notice required or permitted under this agreement shall be in writing and hand
delivered or mailed, postage prepaid, to the other party by certified mail, returned
receipt requested, to the following:
FOR COUNTY
Marathon Airport
9400 Overseas Highway
Marathon, FL 33050
FOR CONTRACTOR
Birds of Paradise
P.O. Box 501856
Marathon, FL 33050
CANCELLATION
A. The County may cancel this contract for cause with seven (7) days notice to the
contractor. Cause shall constitute a breach of the obligations of the Contractor to
perform the services enumerated as the Contractor's obligations under this contract.
B. Either of the parties hereto may cancel this agreement without cause by giving the
other party sixty (60) days written notice of its intention to do so.
IN WITNESS WHEREOF the parties hereto have executed this Agreement on the day
and date first above written.
(SEAL)
ATTEST: DANNY L. KOLHAGE, CLERK
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By
By
Deputy Clerk
Mayor/Chairman
BIRDS OF PARADISE
CLEANING SERVICE
By
Title
Witnesses
jdairportMAPclean
JANITOR SERVICES SPECIFICATIONS
With reference to the Florida Keys Marathon Airport terminal, 9400 Overseas Highway,
Marathon Florida 33050, provide janitorial services for the entire terminal building inside
and under the canopies outside, as follows.
DAIL Y INSIDE
Clean I st floor bathrooms twice a day before 10:00 a.m" and after 2:00 p.m.
Empty and clean as necessary, all trash cans (1st floor and manager's office).
Sweep the entire I st floor.
Clean 2nd floor bathrooms once a day before opening hours.
Mop floors as needed for spot clean-up.
Wipe off and clean lounge furniture as needed.
Wipe walls as needed.
DAILY OUTSIDE
Empty and clean all trash cans.
Empty ash stands.
Pick-up litter as necessary on walkway in front of Airport.
Sweep and clean up walkways and curbs as needed (front).
Wipe off benches, mailboxes, etc., as needed
WEEKLY INSIDE
Mop entire I st floor.
Wipe off and polish wood benches as needed.
Wipe off and polish wood handrails.
Wipe off and polish stainless steel items.
Vacuum all chair cushions and lounge seats as needed,
Dust and clean A TM, Advertising brochure racks,
Pay telephones, Mounted fish, Display cases, etc,
Vacuum stairs, 2nd floor hallway, and manager's office suite,
Clean, dust, and sweep out elevator.
Dust and clean all window sills 1 st and 2nd floors.
Dust and clean furniture in manager's office suite.
Vacuum all chair cushions in manager's office suite.
WEEKLY OUTSIDE
Sweep and clean 2nd floor outside back deck.
Sweep and clean behind airline office and bag claim belt.
Wash 1 st floor glass at front two entry doors daily, both departure gates and all
windows with accordion storm shutters.
MONTHLY
Wash all 2nd floor glass windows and doors inside and out.
Wash inside of all glass windows with Bahama storm shutters.
Dust and clean baseboards in manager's office suite,
OTHER
Maintain inventories of cleaning supplies. Coordinate ordering with
manager's office.
Windows outside every 6 months.
Shampoo 2nd floor carpets and stairway as needed.
Dust and clean overhead soffits as needed.
Water indoor plants and oversee their care.
SPECIAL EVENTS
Police and cleanup as needed during and after Airport Terminal special events.
Apr-19-02 09:22A Risk Management
305 295 4364
P.Ol
~EA..~R OF UABJLlTV AND MEDfC'..AL CLAIMS
FOR INDIVrntJ . WHO VOl.UN'I'EER OR PARTICIPANT)N A.CTIVITIES ON
M NROE COUNTY OWNIWJC()NTROLLED LAND
~
In considtmltion Of~. participation in ltn activity on land oWl1cd or cnntrol1ed by The
Munroe County Bo' of County Cnmmissil')ners, T agree thai r am engaging in said
acth.ity at my own ri It I further stipulate that 1 hereby waive. releWfC. indemniJy and
hold Juumless, Mo. County Dace from any and all claims fOr bodily injury,
(including death), PCJ1ONl.'. injury, and prop"rly damage. (including proporty owned by
Monroe Cuunty). an~ any olher Josses. dnrnuges. and expenses, (including attomey's
fees). which arise 0* o1~ in cnnncction with, or by reason of the use of Cuunty
owncdlconlruJJed proPerty.
Locatiun nf Activity Florida Keys Marathon Airport
Name of Activity:
Clp-~n;na of Airoort
Date of Activity:, On r.ni ng
Name of Participant:
Date:
DRUG-FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that:
Af(lJs OJ} ?/iI?4S /SC (\ IU1JV/oA'j
(Name of Business)
1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that
will be taken against employees for violations of such prohibition.
2. Inform employees about the dangers of drug abuse in the workplace, the business's policy of
maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance
programs, and the penalties that may be imposed upon employees for drug abuse violations.
3. Give each employee engaged in providing the commodities or contractual services that are under bid a
c9PY of the statement specified in subsection (1).
4. In the statement specified in subsection (1), notify the employees that, as a condition of working on
the commodities or contractual services that are under bid, the employee will abide by the terms of the
statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any
violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any
state, for a violation occurring in the workplace no later than five (5) days after such conviction.
5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or
rehabilitation program if such is available in the employee's community, or any employee who is so
convicted.
6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of this
section.
As the person authorized to sign the statement, I certify that this firm complies fully with the above
requirements.
OJ, ~l 01
Date
NON-COLLUSION AFFIDAVIT
I, G-A ll- W\ '/ R 1 C. fL:: ]-( DLLe y
cm~~-w
of the city
of
according to law on my oath, and under
penalty of perjury, depose and say that;
1) I arr08. ?ll:l^/tJ t.2'f e.Js ..,.4ff."",J&.: d(~J tho blddor making tho
Proposal for the project des Ibed as follows:
fYJ j1 iZ ~/j, /) AJ fl if flip) (1/ r /J {j ,. "'j :;:; e I' III (: P 5,
2) The prices in this bid have been arrived at independently without collusion,
consultation, communication or agreement for the purpose of restricting competition, as
to any matter relating to such prices with any other bidder or with any competitor;
3) Unless otherwise required by law, the prices which have been quoted in this bid
l:Iave not been knowingly disclosed by the bidder and will not knowingly be disclosed by
the bidder prior to bid opening, directly or Indirectly, to any other bidder or to any
competitor; and
4) No attempt has been made or will be made by the bidder to induce any other
person, partnership or corporation to submit, or not to submit, a bid for the purpose of
restricting competition;
5) The statements contained in this affidavit are true and correct, and made with
full knowledge that Monroe County relies upon the truth of the statements contained In
this affidavit In awarding contracts for said project.
tzz ~ -I
STATE OF .?121 A J/
COUNTY9#'~~
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
c;.AIL.. A. VV\ 'IR l ~ I-I~~,~ft~rst being sworn by me, (name of
Individual signing) affixed his/her signature in the space provided above on this
~~ day of ~~. .~/ .
NOT~
My commission expires:
8-(:<. (p IO(
.....'./...... 0 Y YOUNG
f:fA!ri'~~~ MY COMMIsSION' CC 674684
~'. :Ji EXPIRES: August 26. 2001
"l.7l'.RF ...'{..... Bonded Thru NolllY PuIlllc Underwritlll
tn'
OMS - MCP FORM #1
ACORD.MO CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDIYY)
10/13/2000
PRODUCER (305)743-0494 (305)743-0582 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Keys Insurance Agency of Monroe County, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 500280 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Marathon, FL 33050-0280 INSURERS AFFORDING COVERAGE
INSURED Ga 11 Holley INSURER A: L10yds of London
PO Box 501856 INSURER B:
Marathon, FL 33050 INSURER c:
INSURER 0:
I INSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AF.FORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
~ TYPE OF INSURANCE POUCY NUMBER DATE '/MM/DDIYYI DATE IMM/DDIVYl LIMITS
~NERAL LIABILITY UNDER 089004 10/13/2000 10/13/2001 EACH OCCURRENCE $ 100,000
X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) $ 50,000
1 CLAIMS MADE m OCCUR MED EXP (Anyone person) $ 5,000
A PERSONAL & ADV INJURY $ 100,000
GENERAL AGGREGATE $ 200,000
GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS. COMP/OP AGG $ 100,000
h .nPRO. "n
POLICY JECT LOC
~TOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
-
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
-
- HIRED AUTOS BODILY INJURY
$
NON-OWNED AUTOS (Per accident)
-
PROPERTY DAMAGE $
_.._~._m~_..___T' (PerACC"jdenl)
~GE LIABILITY AUTO ONLY. EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
:=JESS LIABILITY EACH OCCURRENCE $
OCCUR 0 CLAIMS MADE AGGREGATE $
$
:=J DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I TORY LIMITS! IU~~-
EMPLOYERS' LIABILITY $
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE. POLICY LIMIT $
OTHER
~ESCRIPTION OF OPERATlONSlLOCATIONSNEHICLESlEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
dditiona1 Insured: Monroe County Board of County Commissioners
CERTIFICATE HOLDER . I I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Monroe County -1!L DA" """"'~ ~"'- ..."''''... '"".
Board of County Commissioners BUT FAILURE TO MAIL UCH NOT HALL IMPOSE NO OBLIGATION OR LIABILITY
PO Box 1680 OF ANY KIND UPON THI CO . ITS AGENTS OR REPRESENTATIVES.
Key West, FL 33040 AUTHORaEDREPRESENT~~~
...
ACORD 25-8 (7/97)
@ACORDCORPORATION 1988
COVERAGES
.......a'a. . . - ..__
-- -- - --- - - - - -- - - .-.. "-':1:11-..."".-
19M &ladD4
MONROE COUNI'Y,ILORIDA
Request For W*.,.
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1D.llr:lllce Requlrelllepts
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... or modItt.d aa duljlbllDWiDa conQDd. /
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Scope of WOIk:
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IIaoa (or Waiver:
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1_7/ / 1 --1J ~ %': ~:v e- cjY'l}n~~:J
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Not AppIVYed:
Dace:
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: Appl'OVM:
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MeetiD. Due: ,
Aclnainisnlian (QStnlC:ltan :
"'109.2 ;
Not Approved:
10'
W,.9
Request for Taxpayer
Identification Number and Certification
. . \. .'--,,~...
Give fann to the
requester. Do NOT
send to the IRS.
e:.
Partnership 0 Other. ................................
Requester's name and address (optionaQ
Identification Number
Enter your TIN In the approprlate box. For
indMduals, this Is your socIaJ security number
(SSN). For sole proprietors, see the instructions
on page 2. For other entitles, it Is your employer
identification number (8N). If you do not have a
number, see How To Get a nN below.
Note: " the account Is In more than one name,
see the chart on page 2 for guidelines on whose
number to enter.
CertIfIcation
Under penalties of perjury, I certify that:
1. The number shown on this form Is my correct taxpayer ldentlftcatlon number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (8) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue ServIce 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.
CertItIcatIon IriatructIons.-You must cross out Item 2 above If you have been notified by the IRS that you are currenUy subject to backup
withholding because of unden"portlllg Interest or dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage
Interest pald, the acquisition or abandoI.rnent of secured property, cancellation of debt, contributions to an IndMdual retirement arrangement
(IRA), and generally payments other tIwIlnterest and dividends, you are not requlr8d to sign the CertIfIcatlon, but you must provide your correct
TIN. (Also see Pert 10 InatrucIIons on page 2.~
::.: I SIgn8bn ~~----~ 9 . \ . D8Ie ~ b;; /~ I
-- """""""'.. ~ ;"'L __ _ -. ccndIIIans. ThIs is 1_ and ~~........_
Revenue Code. called -backup withhoIdIng.- Payments after 1983 only), or
Purpoee of Form.-A person who is that cau!d ~ subject to backup 5. You do not certify your TIN. See the
required to file an information return wiIh wilhholding Include interest. dividends, Part III Instructions for exceptions.
the IRS must get yaw correct TIN to report broker and barter exchange transactions, Certaln ~ and payments ant
income paid to you. 1'181 estate rents, royalties. noI'18I11pIoyee pay, and -,-
transactions, mortgage interest you paid certaln payments from fishing boat exempt from backup withholding and
the acquisition or abandonment of ~ operators. Real estate trm1sactIons ant not Information reporting. See the Part II
property, cancellation of debt, or subject to backup withhoIdlng. instructions and the separate ln8IructIons
contributions you made to an IRA. Use If you give the nIqUeSter your correct for the Requester of Fonn W-e.
Fonn W-9 to give your COIT8Ct TIN to the TIN, make the proper certifications, and How To Get a nN.-If you do not have a
requester (the person requesting yaw TIN) report all your taxable interest and TIN, apply for one Immediately. To apply,
and, When applicable, (1) to certify the TIN dividends on your tax 1'8lUm, your get Fonn S8-8, Application far a Social
you ant gMng Is COIT8Ct (or you 818 waiting payments will not be subject to backup Security Number Card (for inc:tMduals),
for a number to be Issued), (2) to certify withholding. Payments you receive will be from your local office of the Social Security
you ant not subject to backup withholding, subject to backup withholding If: Administration, or Fonn S8-4, AppflcatIon
or (3) to clalrn exemption from backup far Employer Identification Nwnber' (for
withholding if you ant an exempt payee. 1. You do not furnish your TIN to the businesses and all oth.. entities), from
GMng your correct TIN and making the requester. or your local IRS office.
appropriate certifications will prevent 2. The IRS tel~ the requester that you If you do not have a TIN, write -Applied
certain payments from being subject to furnished an Incbmlct TIN, or For" In the space for the TIN In Part I, sign
backup wilhholdlng. 3. 1he IRS tells you that you ant subject and date the form, and give It to the
Note: " a requester gives you a form other to backup withholding because you did not requester. Generally, you will then have 60
than a W-9 to request your TIN, you tmJSt report all your Interest and dMdends on days to get a TIN and give it to the
use the requester's form if It Is substantIaJ/y your tax return (for reportable interest and requester. If the requester does not l'8C8Ive
similar to this Form W-9. dividends onJy), or your TIN within 60 days, backup
What Is Backup Wllhholdlng1-Persons 4. You do not certify to the requester withholding, if applicable, will begin and
making certain payments to you must that you ant not subject to backup continue until you furnish your TIN.
withhold and pay to the IRS 31 % of such withholding under 3 above (for reportable
list account number(s) here (optional)
OR
For Payees Exempt From Backup
Withholding (See Part II
instructions on page 2)
t:rr:c:rrr:W
~
Cat. No. 10231X
Fonn W-9 (Rev. 3-94)