NCS000446_American Road COnservation Agreement_20201218

CONTRACT ROUTING CONTROL SHEET
Routing 01'dcr: (t) Department Director, (2) Purchasing and Contract Manager (3) Legal,
(4) Risk Manager, (5) Vendor for Signature (6) Finance Directnr, (7) Town Clerk, (8) Town Council/Town Manager
EVERY SECTION MUST BE COMPLETED
DEPARTMENT: PUBLIC WORKS 8 TRANSPORTATION �7�1 "
Department Contact Person for Contract: CHAD DLEMAsERS
Contractor/Vendor Name and address: Extension: 249.3412
AMERICAN ROAD CONSERVATION LLC, 314 NORTH ONION AVE CARY NC 27513
Contractor/Vendor Phonc: Contractor/Vendor Contact Person: RICARDO A. QUINONES [phone]
Purpose of Contract: STREET SWEEPING FOR THE TOWN OF APEX
Amount: s13s,ow,00 Budget Code: 10-500-44500
Type of Contract: 9f New ❑ Renew ❑ Amendment Exhibits/Attachments included: @ Yes ❑ N/A
Department Director's Signature: -1 _ _ .
Date: 4-14•20
All Contracts should be sent to the Purchasing and Contract Manager (Steve Maj�nar d). Steve Will determine
whether the Cotrtract will need to pro to 11te Le al De artntent or review or not.
LEGAL -
Reviewed by:
Comments: _Date: lz.a
❑Town Council approval required own Manager authorized to approve
ON/A — Purchasing and Contract Manager to forward
❑ Other Approvals required/permitted:
KISK MANAGER
Reviewed by and approved: _
.2-N/A — Purchasing and Contract Manage o forward
-2' Insurance specifications meet requirements.
❑ Insurance specifications have been revised.
,Date: Kil �b
❑ A pre -project safety review between the contractor and contracting department is required.
Return to Department Contact Person to have contract signed b3, Contractor prior to fot-trarding to Fitrrrnce Director Obtain a co , o%Certi rcate ofhrsrtrance that includes the propel- covers a and shows the Town as an additional insured FINANCE DIRECTOR
Zurttctent tunas are available in the proper category to pay for this expenditure.
This contract is conditioned upon appropriation by the Town Council of sufficient funds.
A budget amendment is necessary before this agreement is approved.
A budget amendment isfttached as required for approval of this agreement.
Finance Director:
I Date Received: I�1�2D� Signed by Conirac
+f Council Action qurred:— rward to Town Manager Agenda Date:
Approved by Council: ❑ YES ❑ NO
TOWN MANAGER'
This document h b
Town
3 YES ❑ NO--Rctum to Department
/ /2t)
as een review n J approval is recommended by the Town Manager: J9 YES ❑ NO
Date: OC
Atter approval and signatures, contract will be sent fi the Purchasing and Contracts Manager who will return it to Ehe Department Contact Person for Department to administer.
Scan signed contract to Department contracts folder (include Routing Sheet and copy of Certificate of Insurance)
W

STATE OF NORTH CAROLINA PURCHASE ORDER # 2021 — c2 03
COUNTY OF WADE STANDARD SERVICES CONTRACT
THIS AGREEMENT is entered into this A day of 91 2D2D by and between, American Road
Conservation , a North Carolina limited liability cornpan ith its principal business offices Iocated at 314
N. Dixon Ave Cary, NC 27513_(the "Contractor"), and the Town of Apex, a municipal corporation of the
State of North Carolina, (the "Town"). Town and Contractor may collectively be referred to as "Parties"
hereinafter.
WITNESSETH:
The Town and the Contractor, for the consideration stated herein, agree as follows:
I. SCOPE OF SERVICES.
The Contractor agrees to perform for the Town the following services:
1. Downtown Area as shown on Attachment A: ONCE EVERY TWO WEEKS.
Town Parking Lots as shown on Attachment B: ONCE EVERY MONTH.
3. Main Thoroughfares as shown on Attachment C: ONCE EVERY MONTH.
4. Town and NCDOT streets in Swift/Williams Creek watershed as identified on the attached map
(Attachment D): ONCE EVERY MONTH.
5. All other Town and NCDOT streets (Attachment E): ONCE EVERY 3 MONTHS.
6. Emergency Call Outs: As needed.
Winter Weather Clean -Up: As needed.
8. Special Events: As needed.
9. All costs associated with the proper disposal of sweepings shall be the responsibility of the
CONTRACTOR. No storage on Town property is available. All Federal, State and local requirements
regarding the proper disposal of street sweepings must be followed.
10. The CONTRACTOR shall provide monthly monitoring reports documenting the following:
Sweeping date, area swept (i.e. downtown area, Town parking lots, Town and NCDOT streets, Town and
NCDOT streets in the Swift/Williams Creek watershed, and main thoroughfares), tons collected, and
mixture ratio of sediment, yard waste, and trash. Monthly reports are to be submitted electronically by
the 15th of every month. Failure to consistently submit timely reports may result in termination of the
contract. The CONTRACTOR must be able to accurately account for the total street sweepings collected
from the Swift/Williams Creek watershed separately from all other portions of the Town. The extent of
the Swift/Williams Creek watershed is identified on the Town Street Sweeping reap (Attachment D).
11. The CONTRACTOR will notify the Town Environmental Programs Manager or designee in advance
of all work schedules.
I%twge 1 of 6 Revision dote 05/09/2019

12. The CONTRACTOR shall use street sweeping equipment equipped with a water spray system for
dust control.
13. The Town will provide water for sweeping services. Bulk water will be available at the Apex
Public Works and Utilities Department located at 105 Upchurch Street, Apex, NC during normal working
hours (7:30am to 4:30pm M-F),
14. The CONTRACTOR shall create and submit to the Town Environmental Programs Manager or
designee a sweeping route and schedule for approval. Once approved by the Town, the contractor will
not deviate from the schedule without prior approval. The Town, at its sole discretion may increase or
decrease sweeping frequency or alter the sweeping schedule as it deems necessary.
15. For safety purposes and to the maximum extent practicable, no street sweeping will be
performed in residential areas on the same day as garbage, recycling or yard waste collection.
16. The CONTRACTOR shall be responsible to repair any damage to streets, parking lots, curb and
gutter, sidewalks, mailboxes or utilities resulting from sweeping activities.
17. The CONTRACTOR shall be responsible for complying with all legal requirements to insure
employees maintain valid licenses and insurance requirements.
In the event of a conflict between the terms of the attached Scope of Services and this Agreement, this
Agreement shall control.
2. SPECHICATIONS.
Contractor shall provide services in accordance with all governing agency regulations and shall be held to
the same standard and shall exercise the same degree of care, skill and judgment in the performance of
services for Town as is ordinarily provided by a similar professional under the same or similar
circumstances at the time in North Carolina. Upon request by the Town, Contractor will provide plans
and specifications prior to engaging in any services under this Agreement. Contractor hereby
acknowledges that it is fully licensed to perform the work contemplated by this Agreement. In the event
of a conflict between any provided plans and specifications and this Agreement, this Agreement shall
control.
3. TIME Or COMMENCEMENT AND COWLETION.
Contractor shall commence the work required in this Agreement no later than 2 days after the date of
execution of this Agreement, and the Contractor shall complete entire work no later than 6/30/2021. If
Contractor has not satisfactorily commenced or completed the work within the times specified, the Town
may declare such delay a material breach of contract and may pursue all available legal and equitable
remedies. In the alternate, the Town in its sole discretion may for each calendar day past this contract time
receive $0 per day as liquidated damages. Any changes to the schedule(s) provided in the Agreement must
be agreed to in writing by the Town and the Contractor.
4. CONSIDERATION AND PAYMENT OF SERVICES.
In consideration of the above services, the Town will pay the Contractor the total sum of $ 135.000 to be
paid according to the following schedule: 30 days from receipt of invoice. Town has the right to require the
Page 2 of 6 Revlslon date 0510912019 '

Contractor to produce for inspection all of Contractor's records and charges to verify the accuracy of all
invoices. Town shall pay Contractor's invoices at times set forth above unless a bona fide dispute exists
between Town and Contractor concerning the accuracy of said invoice or the services covered thereby.
5. INDEMNIFICATION.
To the extent permitted by law, the Contractor agrees to defend, pay on behalf of, indemnify, and hold -
harmless the Town of Apex, its elected and appointed officials, employees, agents, and volunteers against
any and all claims, demands, suits or losses, including all costs connected therewith, for any damages which
may be asserted, claimed or recovered against or from the Town of Apex, its elected or appointed officials,
employees, agents, and volunteers by reason of personal injury, including bodily injury or death and/or
property damage, including loss of use thereof resulting from the negligence of the Contractor.
6. APPLICABILITY OF LAWS AND REGULATIONS.
The Contractor shall adhere to all laws, ordinances, and regulations of the United States, the State of North
Carolina, the County of Wake, and the Town of Apex in the performance of the services outlined in this
Agreement and any attached specifications. This Agreement shall be governed by the laws of the State of
North Carolina.
7. E-VERIFY COMPLIANCE.
The Contractor shall comply with the requirements of Article 2 of Chapter 64 of the North Carolina General
Statutes (E-Verify). Contractor shall require all of the Contractor's subcontractors to comply with the
requirements of Article 2 of Chapter 64 of the North Carolina General Statutes (E-Verify).
S. ANTI -HUMAN TRAFFICICING.
The Contractor warrants and agrees that no labor supplied by the Contractor or the Contractor's
subcontractors in the performance of this Agreement shall be obtained by means of deception, coercion,
intimidation or force, or otherwise in violation of North Carolina law, specifically Article 10A, Subchapter
3 of Chapter 14 of the North Carolina General Statutes, Human Trafficking.
9. QUALITY AND WORKMANSHIP.
All work shall be performed to the satisfaction of the Town. The work shall not be considered complete nor
applicable payments rendered until the Town is satisfied with the services provided.
10. INSURANCE.
The Contractor shall maintain valid general liability insurance in the minimum amount of $1,000,000,
commercial automobile liability insurance in the minimum amount of $2,000,000, and provide certificates
of such insurance naming the Town of Apex as an additional insured by endorsement to the policies. If the
policy has a blanket additional insured provision, the contractor's insurance shall be primary and non-
contributory to other insurance. Additionally, the contractor shall maintain and show proof of workers'
compensation and employer's liability insurance in the minimum amount of $1,000,000. The Contractor
shall provide notice of cancellation, non -renewal or material change in coverage to the Town of Apex within
10 days of their receipt of notice from the insurance company. All required certificates of insurance,
endorsements, and blanket additional insured policy provisions are attached and considered part of this
document. Notwithstanding the foregoing, neither the requirement of Contractor to have sufficient
Page 3 of 6 Revision dote 0510912019

insurance nor the requirement that Town is named as an additional insured, shall constitute waiver of the
Town's governmental immunity in any respect, under North Carolina law.
11. PRE -PROJECT SAFETY REVIEW MEETING.
When specified by the Safety and Risk Manager, the Contractor shall attend a pre -project safety review
meeting with the contacting Department Head and Supervisors and Safety and Risk Manager prior to the
start of work.
12. DEFAULT.
In the event of substantial failure by Contractor to perform in accordance with the terms of this Agreement,
Town shall have the right to terminate Contractor upon seven (7) days written notice in which event
Contractor shall have neither the obligation nor the right to perform further services under this Agreement.
13. TERMINATION FOR CONVENIENCE.
Town shall have the right to terminate this Agreement for the Town's convenience upon thirty (30) days
written notice to Contractor. Contractor shall terminate performance of services on a schedule acceptable
to the Town. In the event of termination for convenience, the Town shall pay Contractor for all services
satisfactorily performed.
14. NOTICE.
Any formal notice, demand, or request required by or made in connection with this Agreement shall be
deemed properly made if delivered in writing or deposited in the United States mail, postage prepaid, to the
address specified below.
TO CONTRACTOR: TO TOWN: Town of Apex
American Road Conservation LLC. Attention: Steve Ma nard
314 N. Dixon Ave PO Box 250
Carv, NC 27513 Apex, NC 27502
office&croadservices.com Steve.Mavnard( [e-mail]
15. DELAY BEYOND THE CONTROL OF THE PARTIES.
Neither Contractor nor Town shall be in default of the provisions of this Agreement for delays in
performance due to forces beyond the control of the parties. "Forces beyond the control of the parties" shall
mean, but is not limited to, delay caused by fire, acts of God, flood, earthquakes, storms, Iightning,
epidemic, war, riot, and/or civil disobedience.
16. NONWAIVER FOR BREACH.
No breach or non-performance of any term of this Agreement shall be deemed to be waived by either party
unless said breach or non-performance is waived in writing and signed by the parties. No waiver of any
breach or non-performance under this Agreement shall be deemed to constitute a waiver of any subsequent
breach or non-performance and for any such breach or non-performance each party shall be relegated to
such remedies -as provided by law.
17. CONSTRUCTION.
Page 4 of 6 Revision date 05/og/1o19

Should any portion of this Agreement require judicial interpretation, it is agreed that the Court or Tribunal
construing the same shall not apply a presumption that the terms hereof shall be more strictly construed
against any one party by reason of the rule of construction that a document is to be more strictly construed
against the party who prepared the documents.
18. NO REPRESENTATIONS.
The parties hereby warrant that no representations about the nature or extent of any claims, demands,
damages, or rights that they have, or may have, against one another have been made to them, or to anyone
acting on their behalf, to induce them to execute this Agreement, and they rely on no such representations;
that they have fully read and understood this Agreement before signing their names; and that they act
voluntarily and with full advice of counsel.
19. SEVERABILITY.
In the event for any reason that any provision or portion of this Agreement shall be found to be void or
invalid, then such provision or portion shall be deemed to be severable from the remaining provisions or
portions of this Agreement, and it shall not affect the validity of the remaining portions, which portions
shall be given full effect as if the void or invalid provision or portion had not been included herein.
20. COUNTERPARTS.
This Agreement may be executed in two or more counterparts, each of which shall be deemed an original,
and all of which together shall constitute one instrument.
21. MODIFICATION.
This Agreement contains the full understanding of the parties. Any modifications or addendums to this
Agreement must be in writing and executed with the same formality as this Agreement.
22. BINDING EFFECT.
The terms of this Agreement shall be binding upon the parties' heirs, successors, and assigns.
23. ASSIGNMENT.
Contractor shall not assign, sublet, or transfer any rights under or interest in (including, but without
limitation, monies that may become due or monies that are due) this Agreement without the written consent
of the Town. Nothing contained in this paragraph shall prevent Contractor from employing such
independent consultants, associates, and sub -contractors as it may deem appropriate to assist Contractor in
the performance of services rendered.
24. INDEPENDENT CONTRACTOR.
Contractor is an independent contractor and shall undertake performance of the services pursuant to the
terms of this Agreement as an independent contractor. Contractor shall be wholly responsible for the
methods, means and techniques of performance.
25. NON -APPROPRIATION.
Page 5 of 6
Revision date 0510912019

Notwithstanding any other provisions of this Agreement, the parties agree that payments due hereunder
from the Town are from appropriations and monies from the Town Council and any other governmental
entities. In the event sufficient appropriations or monies are not made available to the Town to pay the terms
of this Agreement for any fiscal year, this Agreement shall terminate immediately without fiuther obligation
of the Town.
26. IRAN DIVESTMENT ACT CERTIFICATION.
N.C.G.S. 147-86.60 prohibits the State of North Carolina, a North Carolina local government, or any other
political subdivision of the State of North Carolina from contracting with any entity that is listed on the
Final Divestment List created by the North Carolina State Treasurer pursuant to N.C.G.S. 147-86.58.
N.C.G.S. 147-86.59 further requires that contractors with the State, a North Carolina local govemient, or
any other political subdivision of the State of North Carolina must not utilize any subcontractor found on
the State Treasurer's Final Divestment List. As of the date of execution of this Agreement the Contractor
hereby certifies that the Contractor is not listed on the Final Divestment List created by the North Carolina
State Treasurer and that the Contractor will not utilize any subcontractors found on the Final Divestment
List.
27. ELECTRONIC SIGNATURE.
Pursuant to Article 40 of Chapter 66 of the North Carolina General Statutes (the Uniform Electronic
Transactions Act) this Agreement and all documents related hereto containing an electronic or digitized
signature are legally binding in the same manner as are bard copy documents executed by hand signature.
The Parties hereby consent to use electronic or digitized signatures in accordance with the Town's
Electronic Signature Policy and intend to be bound by the Agreement and any related documents. If
electronic signatures are used the Agreement shall be delivered in an electronic record capable of retention
by the recipient at the time of receipt.
In mess f f, the c tracting parties, by their authorized agents, affix their signatures and seals this
day of 2020.
Contractor
Name:
Name of Contractor (type or) --
By:
_. tzg=���
(Signature ww
Title: K a
Attest:
(Secretary, if a corporation)
Aoge 6 of 6
Town of Ape
Town Manager
A st: WA4�
Town Clerk
This instrument has beenpreaudited in the manner required
by the Local Government Budget and Fiscal Control Act.

Attachment A
Downtown Area Map
Date; 2/5/2013
Street
Road Mile
Distance (Feet)
Street
To
From
Salem Street
0.66
3494
Salem Street
Hunter Street
E. Williams Street
Templeton Street
0.07
359
Templeton Street
Saunders Street
N. Salem Street
Seaboard Street
0.14
752
Seaboard Street
N. Salem Street
Chatham Street
Commerce Street
0.08
415
Commerce Street
Chatham Street
Saunders Street
Saunders Street
0.16
85Z
852
Saunders Street
Apex Police Dept
N. Salem Street
CentersStret
0.16
149
Chatham Street
0.07
344
Center Street
CSX Railroad
N. Salem Street
Total:
L20
6355
Chatham Street
Commerce Street
Seaboard Street

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Attachment C
Legend
State'
Town
Apex Corporate Limits
I1 Date:21812013
h
APE%
k
q
Main Thoroughfare Map
Street
ApeaPeakway
E williams5treet
w vnuumt5treet
OldRalailh Road
Laura Duncan Road
Hunter Street
centerstreet
TenTanRoad
Olive Chapel Road
N. Salem 5treel
S, Salem Street
W. Chatham5treet
E. Chatham Street
Apex Barbecue Road
tlelly Road
ttolland Road
Beaver Creek Commons Drive
Zeno Road
Jenks ROW
Oldlenks Road
Davis Drive
Green level Church Road
Salem Church Road
Sunset lake Road
take Pine Drive
"Olt Road
Evans Road
Wplano Avenue
tlumle 011ve Road
Perry Road
Tin{en Road
5ctleltl In tgad5
investment Boulevard
Lull n Ibar13
Apex Peakway
TOtah
State Ta W
TCII'3i31
Road Mlle
dstante (Peat)
3.40
179"
3.49
IM13
14W
2.91
GU7
L61
236
mat
Los
556?
L
am
7175
36
L3
195
MW
52
13307
107
%W
0.6
3423
37M
0.61
254
133BB
L92
10115
0.76
g033
aim
L55
0.70
3670
0.94
4964
L670.23
t3793
1219
5235
0.
(199
6006
L14
2446
0.46
3473
0.66
5813
I.w
5778
Los
a55
2902
0.41
2177
6109
L16
M77
4091
L62
aw
0.61
3247
7B95
L
L34
am
49A7
25909G
3L49
We
203239
55>!SB
d-0,
'fit :IGII

Town & NCDOT Streets
Swift/Williams Creek Watershed
Attachment D Apex, NC

u
SRO
Town & NCDNOT Streets
Attachment E
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z
n-LO
LO
U
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Z' 0��
5~
RD
APEX
4
O
VP
s
All Streets
Town -Maintained Streets
Apex Corporate Limits
Rp
Town of Apex Planning Department
February 2013

CERTIFICATE OF LI,
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONL
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITL
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the
If SUBROGATION IS WAIVED, subject to the terns and conditions of t
this certificate does not confer rights to the certificate holder In lieu of s
IODUCER 919-467-6339
I Moore $ Associates, Inc.
3-B Kllmayne Drive
Road Conservation LLC
AMIF-RI-2
kBILITY INSURANCE DATEIMMmDrrm) W..
04/15/2020
Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
TE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
pollcy(tes) must have ADDITIONAL INSURED provisions or be endorsed.
1e policy, certain Policies may require an endorsement. A statement on
ich endorsements .
co cr Paul R Henkens
PHONE [phone] FAx
uc Na Ex, : Arc Na :919.467-6434
AI p en ens a moors nsurance.com
INSURERS AFFOROINe COVERAGE NA[C #
INSURERA:The Cincinnati Companies
INSURER B r Progressive Insurance Co.
INSURERC,iSurity/Carolina Mutual
14090
INSURER D :
INSURERE:
INSURER F
THIS IS T6 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE :NSURED 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 AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
0
TYPE OF INSURANCE M uv
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE Q OCCUR X
'L AGGREGATE LIMIT APPLIES PER:
POLICY ❑: P �
LOC
OTHER
]MOBILE LIABILITY
ANYAUTO
AU�T@O�S
ONLY
X
AUVNOppSyyUyyL'EggB❑p
AUTOS ONLY
X
AUTOS ONLY
UMBRELLA LIAR I X I OCCUR
EXCESS LIAR IIiI1 CLAIMS
a
ANYPPERO�PRIEToRmAARTMERE ECUTIVE YIN �IN1A
endatory In NHj
If yes, describe under
638-8
0112512020 1 0112512021
01 /291202010112912021
011251202010112512021
02/2112021
DESCRIPTION OF OPERATIONS f LOCATIONS IVEHICLES (ACORD 101, Addhlonal Remarks schedule, maybe attached If more space Is required)
town of Apex Is Included as an additional insured with respects to General
_lability when required by written contract.
LIMrs
1
l0
TOWNO-2
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Apex THE EXPIRATION
DATE THE POLICY THEREOF,
PROVISIONS.
E WILL BE DELIVERED IN
P. O, Box 250
Apex, NC 27502
AUTHORIZED REPRESENTATIVE
Paul R Henkens
ACORD 25 (2016103) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD

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Numbdr TQ j3Nb the Bequoster far.gti)d4ribs, on .dose numbertp enter. .r'r isl
Uridee penaltles of perjWtY, I 1 000y that;
1...Tha tiurttber.s]ioiNn Qnthis form is my core eci taxpayer Identiiicotititt number (d' I aryl t�faiting foi''d number to be issued ed h e)i and
e f to bdgkVip-vAjM'dldIng b'eoause: (a) I arrt $Xempt from backup W.6hof d,nd ' of (bj.! have. not beep p- y;he lrtitgmal.Revent}e
2. am not slit!( G"
erv7ae �(ipS)y tfiati -' n subject lb. backup v¢Ifttiihblding as a result pt a failure-tq report al:�lnterest or dldldands,.n'r (o) iha IEas has ndlifiiett me that ( tm
aolangnr suts)rictt6 b9d!60W1hhdl¢irfg; ap¢
3.1 afni a U:S. ritken of offidr U.S. person (Obillnod below); And
d, the FATCA code(s) entered on this form Pf any) Indicating that I am exemptfrom FA�GP, reporting is t:orrect
Cerflticatjoti lnslruct(otie, You dust cross. but item 2 shave if you have been nbf ){fell by the 19S thatyod,afe burrently subject td backup vrlihholding because
you have failt�,fo rapar( all intereal and divldende on your tax reium. Far ref elf ate transactions, {tern 2 !lass not apply. For mortgage interest Feld,
aCqulitlorC orabandanmedt of secured properly, cancellation of debt, eontnts . Ions toast Iridttindtia( ret(rrseiiant arrangement {INA), and generally, payments
othier than (merest and d[vldend5, you are not required to sign the certiticatian, tiutyriu must provide your oanecl life. See the inslructirtns tar Par! N, facer.
tignolure elf
115. parson i
'Oeneral instructions
Section referehces aPe ttl the'Interrial Reverlop Coda unless otherwise
ngipd.
Outure develdpirlents, Forth©.Istest iriformatlon about developments
related io Farris tN-9 and Its Instrudildns, sbch'sb IAglslatlort onaoted
After they viere published, go to tti►A+ctr,fis,i1i2V1F6rMW9.
porpos�.of Form
An indigii .del or Entity firm W-9 requester) who Is.ret uliW (o f ltc an
informatlort.return w)tbi file IRS must obtt.ln your correct taupe*
ldenti11oallob.nuri bee VIN) y4hjt h' may be your soc,al senility number
($Bra, ihdividua(ta3i(iayi3r WAtlflcation number (11 TIN), adoptipn
tapayerideitflrcatloti numbed {AT1N}, or employer Identification number
repot! o ft 6ififodn'itidri return the amount paid to you, or other
amount re
�ortabit3 on an Fri(oeingtlon reium. Examples of Information
On
Include; but are not I•ifnI ed to, the fol+ow'ng.
Form iOss-WT (ntdrett earrttid or paid)
i Form 1099-DiV (g)videpds, including chose from stooks or mttttial
fuhds)
Forfri 1099-.MISC (various type$.of jncnrrte, prizes, awards, ar grass
"praaegP
• Form! 1099-13•(stdck orrhutual fund sates and certalri other
traiisRdllofis by bbetiRars)
Form itJ99-$ {proc0edsfrom real estate transac0ofis
• Farrft 1099-K (rmorchrt Gard 'arid third patty nefw0rk tran4eatfons)
•'Form 1096 (homatnnrfgage intefest),10913-!=(student loan Irileresi),
1495-`r (tullion)
• Form 1090-0canceled debt)
• i±orm 160-A (acopisilion ati abandOhmeilt of sutured prgperty)
M4 Farm W-9 only if you are,.$ U.S, person jinotuding a resident
tillen), to provide your correct TIN.
Ifyou do not return Form W 9 to iha requester %+ Ijh n TIP, ynq Mj71)f
bgsubfect to bdcWp.withholding. See What is backup withhafding,
later.
' i.At, No_iU231X FarmW�9 (gev.11l-2bt&}