HomeMy WebLinkAbout20053604.tiff RESOLUTION
RE: APPROVE DESIGNATION OF ADDITIONAL BANK AS A DEPOSITORY FOR WELD
COUNTY FUNDS - COLORADO EAST BANK AND TRUST OF LASALLE
WHEREAS,the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS,Section 30-10-708(1), C.R.S., as amended, states as follows:
"In all counties of this state,the county treasurer shall deposit all the
funds and moneys of whatever kind that come into his possession by
virtue of his office, in his name as such treasurer, in one or more
state banks,national banks having their principal offices in this state,
or, in compliance with the provisions of article 47 of title 11, C.R.S.,
savings and loan associations having their principal offices in this
state which have theretofore been approved and designated by
written resolution duly adopted by a majority vote of the board of
county commissioners, which shall be entered into its minutes...",
and
WHEREAS, Section 11-4(1)of the Home Rule Charter for Weld County, Colorado, states
as follows: "The County Treasurer shall,with prudence,deposit available funds in accordance with
the statutes of the State of Colorado giving preference to Weld County financial institutions," and
WHEREAS, the Board of County Commissioners, on January 5, 2005, by
Resolution #2005-0039, designated a list of banks, and savings and loan associations as
depositories for the funds of Weld County, and
WHEREAS,the Weld County Treasurer has recommended the addition of Colorado East
Bank and Trust of LaSalle to said list, and has presented a Government/Municipal/Public Funds
Banking Resolution,a copy of which is attached hereto, and incorporated herein by reference, and
NOW,THEREFORE,BE IT RESOLVED by the Board of County Commissioners of Weld
County,Colorado,that Colorado East Bank and Trust of LaSalle be, and hereby is, designated as
an additional depository for the funds of Weld County.
BE IT FURTHER RESOLVED that the Chair be, and hereby is, authorized to sign the
attached form.
2005-3604
TR0023
CC .fire /IC/ 17, 04 0/-D6, Of
RE: ADDITION OF DEPOSITORY FOR FUNDS
PAGE 2
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 12th day of December, A.D., 2005.
=O ARD OF COUNTY COMMISSIONERS
E Ica�� LD COUNTY, COLORADO
0` I`
pn4
ATTEST: ILI/ / � I ;r . 1♦1 '/
r„ = lf.m H. Berke, Chairman
Weld County Clerk to the Bo.�.�Ounill����
BY: Yln 1 I ati PG, r.•��r
Duty CI to the Boatl
� D id E. Long
/
pR0WD AS TO FORM:
Robert D. Masden
j County Attorney
Glenn Vaad
Date of signature: I Z LC-;
2005-3604
TR0023
GOVERNMENT / MUNICIPAL / PUBLIC FUNDS BANKING RESOLUTION
(for Deposit Accounts)
Depositor: Weld County Treasurer Financial Colorado East Bank &Trust
1400 N 17th Ave Institution: LaSalle
Greeley, CO 80631-0000 207 First Avenue
LaSalle, CO 80645
Account No: 0870289023
I, the undersigned Official of the Government, Municipal or Public Entity ("Entity") named above, HEREBY CERTIFY that the Entity is organized,
exists and is duly authorized to transact business under the laws of the state or jurisdiction where it is located.
ACCOUNT HOLDER. Weld County Treasurer is the complete and correct name of the Account Holder,
I FURTHER CERTIFY that at a meeting of the governing body of the Entity, duly and regularly called and held on
, the following resolutions were adopted:
RESOLVED, that the Financial Institution named above at any one or more of its offices or branches, be and it hereby is designated as a
depository for the funds of this Entity, which may be withdrawn on checks, drafts, advices of debit, notes or other orders for the payment of
monies bearing the following appropriate number of signatures: Any one (1) of the following named officers or employees of this Entity
("Agents"), who actual sign tures are shown below:
x /2 ',.l.a�
Donald Mueller Designated Agent of Weld County
Treasurer /y.
X �/ /
Sue Young, Designated ent of Weld County
Treasurer
and that the Financial Institution shall be and is authorized to honor and pay the same whether or not they are payable to bearer or to the
individual order of any Agent or Agents signing the same.
FURTHER RESOLVED, that the Financial Institution is hereby directed to accept and pay without further inquiry any item drawn against any of
the Entity's accounts with the Financial Institution bearing the signature or signatures of Agents, as authorized above or otherwise, even though
drawn or endorsed to the order of any Agent signing or tendered by such Agent for cashing or in payment of the individual obligation of such
Agent or for deposit to the Agent's personal account, and the Financial Institution shall not be required or be under any obligation to inquire as
to the circumstances of the issue or use of any item signed in accordance with the resolutions contained herein, or the application or disposition
of such item or the proceeds of the item.
FURTHER RESOLVED, that any one of such Agents is authorized to endorse all checks, drafts, notes and other items payable to or owned by
this Entity for deposit with the Financial Institution, or for collection or discount by the Financial Institution; and to accept drafts and other items
payable at the Financial Institution,
FURTHER RESOLVED, that the above named agents are authorized and empowered to execute such other agreements, including, but not limited
to, special depository agreements and arrangements regarding the manner, conditions, or purposes for which funds, checks, or items of the
Entity may be deposited, collected, or withdrawn and to perform such other acts as they deem reasonably necessary to carry out the provisions
of these resolutions. The other agreements and other acts may not be contrary to the provisions contained in this Resolution,
FURTHER RESOLVED, that the authority hereby conferred upon the above named Agents shall be and remain in full force and effect until written
notice of any amendment or revocation thereof shall have been delivered to and received by the Financial Institution at each location where an
account is maintained. Financial Institution shall be indemnified and held harmless from any loss suffered or any liability incurred by it in
continuing to act in accordance with this resolution. Any such notice shall not affect any items in process at the time notice is given.
I FURTHER CERTIFY that the persons named above occupy the positions set forth opposite their respective names and signatures; that the
foregoing Resolutions now stand of record on the books of the Entity; that they are in full force and effect and have not been modified in any
manner whatsoever.IN TESTIMONY WHEREOF, I have hereunto set my hand on 4)e C C'v"Vl be ir 12- , 2005 and attest that the signatures set
opposite the names listed above are their genuine signatures.
CERTIFIED TO AND ATTESTED BY:
,•_`
a\
.a, 'OfOciel William H. Jerke, Chair
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11 t ti — ` fittest:
?fir CO-" ial
Na l ti° �� By G O /442/12/2005
tnn
-soar Dep y Cl to the Bo rd
'NOTE: In case the Official is❑esignated by the foregoing resolutions as one of the signing agents,this certificate shot I also be signed by a second Official of the Entity.
DEPOSIT VRo,vs 2.113 00.002 my,Harland Pow ma snW,nn..Inn.cant 20CA Mi Pohl.Romped. co. -P.\LLSEepeo¢nfR\V,a PR,5407
2005-3604
Colorado East Bank & Trust 0870289023
Account Holder Name(s):Weld County Treasurer
Reporting SSN/TIN
84-60008134.
Mailing Address: 1400 N 17th Ave,Greeley,CO 80631-0000
Telephone Number: (9701353.3845 Work#: (970)353-3545
Number of Signatures Required: 1 CIF Number: 846000813
Sig tures of Auth,JQrized Individuals. This Agrreeeement is subject to all terms below.
meld Mueller,Agent bf Weld County Treasurer Sue Young,Agent of Weld y Treasurer
(Signatures and printed names of each account signer)
The Authorized Individuallsl signing above agree(s), that the Account Holder's Accountlsl will be governed by the
terms set forth in the Deposit Account Agreement and Disclosure,the Time Certificate of Deposit or Confirmation of
Time Deposit Agreement (if applicablel, the Rate and Fee Schedule, the Funds Availability Policy Disclosure, the
Substitute Check Policy Disclosure,the Electronic Funds Transfer Agreement and Disclosure,Of requested below),as
amended by the Financial Institution from time to time, and such other authorization documents provided to the
Financial Institution from time to time. The Authorized Individual(s)also acknowledge that they have received at least
one copy of these deposit account documents. The Authorized Individuallsl understandls)accounts opened after 2:00
PM are dated effective the next business day. The Authorized Individuallsl represent(s)that they hold the positionlsl
indicated above and they are authorized to enter into this Agreement on behalf of the Account Holder.
Account Purpose: Non Consumer EFT Services: No
OWNERSHIP TYPE Government/Municipal/Public Funds
ACCOUNT TYPE 12 Month CD Public Funds
ACCOUNT NUMBER 0870289023 I OPENED BY 821
Date Opened Date Revised Opening Deposit ATM Verified By Account Formerly With
Card
11-30-05 $1,041,481.21 N ChexSystems
Date Closed Closing Balance Closed By Reason For Closing Statement Service Chg
Disposition Disposition
Mail
eepoAT PRO.v..a.ez.W.wz cun..a,,.,d FFn@N a*Hun,.,me.IMe.1tC ul nyhu F.r'M. Co -Ve.'it n re.m,oz
Colorado East Bank &Trust 0870289023
Account Holder Name(s):Weld County Treasurer
Reporting SSN/TIN:
84-6000813:'.
Mailing Address: 1400 N 17th Ave,Greeley,CO 80631-0000
Telephone Number (9701353-38451. Work #: (970)353-3845"'..
Number of Signatures Required: 1 CIF Number: 846000813
�nL Signatures of Authorized Individuals
a
Do Mueller,Agent of Wel nt reasurer Sue Vaurg, nt of INe1F6eUM1tµ'{reasurer
)
The following information may be used to further identify individualls) for telephone
instructions, large transactions, or if a signature varies. MMN=Mother's Maiden Name
Name: Donald Mueller SSN: 505-50-2638
Street: 1400 N 17th Ave, Greeley, CO 80631-0000
Mailing:
Phone: (H): (970) 353-3845 (W): (970) 353-3845
Job: Weld County Treasurer
DOB:
ID: Drivers License 92-093-5973 MMN:
Name: Sue Young SSN: 521-74-5014
Street: 4623 1st St Dr, Greeley, CO 80634
Mailing:
Phone: (HI: (W): (970) 353-3845
Job:
DOB:
ID: Drivers License 92-258-5331 MMN:
/ Form VV-9 Request for Taxpayer Give form to the
(Rev. January 2005) requester. Do not
Identification Number and Certification send to the IRS.
Department of the Treasury
Internal Revenue Service
Name las shown on your income tax return)
Print Weld County Treasurer
or Business name,if different from above
type
Weld County Treasurer
See El Exemptfrom backup
specific Check appropriate box: ❑Individual/Sole proprietor 0 Corporation 0 Partnership ® Other Government Entity withholding
Instructions Address)number,street,and apt.or suite no.) Requester's name and address)optional)
on Colorado East Bank&Trust
page 1400 N 17th Ave LaSalle
2.
City,stale,and ZIP code 207 First Avenue
LaSalle, CO 80645
Greeley, CO 80631-0000
List account number(s)here(optional)
0870289023
.........................
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given Social security number
on Line 1 to avoid backup withholding. For individuals,this is your social security
number ISSN). However, for a resident alien, sole proprietor, or disregarded entity, see
the Part I instructions on page 3. For other entities, it is your employer identification or
number (EIN). If you do not have a number, see How to Get a TIN on page 3.
Employer identification number
Note: If the account is in more than one name, see the chart on page 4 for guidelines 84-6000813
on whose number to enter.
Part ff 'P. 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. person (including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to
backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2
does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an
individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the
Certification, but you must pr , ide your corre TIN. (See the instructions on page 4.)
Sign Signature of y1
Here U.S.person► Z9- Vine. Date Ilk f / leis
d,
Purpose of For / • Any estate (other than a foreign estate) or trust. See
A person who is requi d to file an inform tion retur with the Regulations sections 301.7701-6(a) and 7(a) for additional
IRS, must obtain your correct taxpayer ide>'cation n mber information.
(TIN) to report, for example, income paid to you,That estate Foreign person. If you are a foreign person, do not use Form
transactions, mortgage interest you paid, acquisition or W-9. Instead, use the appropriate Form W-8 (see Publication
abandonment of secured property, cancellation of debt, or 515, Withholding of Tax on Nonresident Aliens and Foreign
contributions you made to an IRA. Entities).
U.S. person. Use Form W-9 only if you are a U.S. person Nonresident alien who becomes a resident alien.
(including a resident alien), to provide your correct TIN to the Generally, only a nonresident alien individual may use the
person requesting it (the requester) and, when applicable, to: terms of a tax treaty to reduce or eliminate U.S.tax on certain
types of income. However, most tax treaties contain a
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued), provision known as a "saving clause." Exceptions specified in
the saving clause may permit an exemption from tax to
2. Certify that you are not subject to backup withholding, or continue for certain types of income even after the recipient
3. Claim exemption from backup withholding if you are a has otherwise become a U.S. resident alien for tax purposes.
U.S. exempt payee. If you are a U.S. resident alien who is relying on an
exception contained in the saving clause of a tax treaty to
Note: If a requester gives you a form other than Form W-9
claim an exemption from U.S. tax on certain types of income,
to request your TIN, you must use the requester's form if it is
substantially similar to this Form W-9. you must attach a statement to Form W-9 that specifies the
following five items:
For federal tax purposes you are considered a person if you 1. The treaty country. Generally, this must be the same
are: treaty under which you claimed exemption from tax as a
• An individual who is a citizen or resident of the United nonresident alien.
States, 2. The treaty article addressing the income.
• A partnership, corporation, company, or association created 3. The article number (or location) in the tax treaty that
or organized in the United States or under the laws of the contains the saving clause and its exceptions.
United States, or
SFA Form W-9 )Rev.1-20051
Form W-9 (Rev. 1-2005) Page 2
4. The type and amount of income that qualifies for the Misuse of TINs. If the requester discloses or uses TINs in
exemption from tax. violation of federal law, the requester may be subject to civil
5. Sufficient facts to justify the exemption from tax under and criminal penalties.
the terms of the treaty article.
Example.Article 20 of the U.S.-China income tax treaty allows Specific Instructions
an exemption from tax for scholarship income received by a
Chinese student temporarily present in the United States. Name
Under U.S. law, this student will become a resident alien for If you are an individual, you must generally enter the name
tax purposes if his or her stay in the United States exceeds 5 shown on your social security card. However, if you have
calendar years. However, paragraph 2 of the first Protocol to changed your last name, for instance, due to marriage without
the U.S.-China treaty (dated April 30, 1984) allows the informing the Social Security Administration of the name
provisions of Article 20 to continue to apply even after the change, enter your first name, the last name shown on your
Chinese student becomes a resident alien of the United States. social security card, and your new last name.
A Chinese student who qualifies for this exception (under
paragraph 2 of the first protocol) and is relying on this If the account is in joint names, list first, and then circle, the
exception to claim an exemption from tax on his or her name of the person or entity whose number you entered in
scholarship or fellowship income would attach to Form W-9 a Part I of the form.
statement that includes the information described above to Sole proprietor. Enter your individual name as shown on your
support that exemption. social security card on the "Name" line. You may enter your
If you are a nonresident alien or a foreign entity not subject to business,trade, or "doing business as (DBAI" name on the
backup withholding give the requester the appropriate "Business name" line.
completed Form W-6. Limited liability company (LLCI. If you are a single-member
What is backup withholding? Persons making certain LLC (including a foreign LLC with a domestic owner) that is
payments to you must under certain conditions withhold and disregarded as an entity separate from its owner under
pay to the IRS 28% of such payments (after December 31, Treasury regulations section 301.7701-3, enter the owner's
2002). This is called "backup withholding." Payments that name on the "Name" line. Enter the LLC's name on the
may be subject to backup withholding include interest, "Business name" line. Check the appropriate box for your
dividends, broker and barter exchange transactions, rents, filing status (sole proprietor, corporation, etc.(, then check the
royalties, nonemployee pay, and certain payments from fishing box for "Other" and enter "LLC" in the space provided.
boat operators. Real estate transactions are not subject to Other entities. Enter your business name as shown on
backup withholding. required Federal tax documents on the "Name" line. This
You will not be subject to backup withholding on payments name should match the name shown on the charter or other
you receive if you give the requester your correct TIN, make legal document creating the entity. You may enter any
the proper certifications, and report all your taxable interest business,trade, or DBA name on the "Business name" line.
and dividends on your tax return. Note:You are requested to check the appropriate box for your
Payments you receive will be subject to backup withholding if: status (individual/sole proprietor, corporation, etc.).
1. You do not furnish your TIN to the requester, or
2. You do not certify your TIN when required (see the Part Exempt From Backup Withholding
II instructions on page 4 for details), or If you are exempt, enter your name as described above and
3. The IRS tells the requester that you furnished an check the appropriate box for your status, then check the
incorrect TIN, or "Exempt from backup withholding" box in the line following
4. The IRS tells you that you are subject to backup the business name, sign and date the form.
withholding because you did not report all your interest and Generally, individuals (including sole proprietors) are not
dividends on your tax return (for reportable interest and exempt from backup withholding. Corporations are exempt
dividends only), or from backup withholding for certain payments, such as
5. You do not certify to the requester that you are not interest and dividends.
subject to backup withholding under 4 above (for reportable Note: If you are exempt from backup withholding, you should
interest and dividend accounts opened after 1983 only). still complete this form to avoid possible erroneous backup
withholding.
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate Exempt payees. Backup following withholding is not required on any
to
Instructions for the Requester of Form W-9. payments made to the payees:
1. An organization exempt from tax under section 501(a),
any IRA, or a custodial account under section 403(b)(7) if the
Penalties account satisfies the requirements of section 401(0(2),
Failure to furnish TIN. If you fail to furnish your correct TIN to 2. The United States or any of its agencies or
a requester, you are subject to a penalty of $50 for each such instrumentalities,
failure unless your failure is due to reasonable cause and not 3. A state, the District of Columbia, a possession of the
to willful neglect. United States, or any of their political subdivisions or
Civil penalty for false information with respect to withholding. instrumentalities,
If you make a false statement with no reasonable basis that 4. A foreign government or any of its political subdivisions,
results in no backup withholding, you are subject to a $500 agencies, or instrumentalities, or
penalty. 9
Criminal penalty for falsifying information. Willfully falsifying 5. An international organization or any of its agencies or
instrumentalities.
certifications or affirmations may subject you to criminal
penalties including fines and/or imprisonment. Other payees that may be exempt from backup withholding
include:
6. A corporation,
Form W-9 °Rev. 1-2005) Page 3
7. A foreign central bank of issue, Part I. Taxpayer Identification
8. A dealer in securities or commodities required to register Number (TIN)
in the United States,the District of Columbia, or a possession Enter of the United States, your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an SSN,
9. A futures commission merchant registered with the your TIN is your IRS individual taxpayer identification number
Commodity Futures Trading Commission, IITIN). Enter it in the social security number box. If you do
10. A real estate investment trust, not have an ITIN, see How to get a TIN below.
11. An entity registered at all times during the tax year If you are a sole proprietor and you have an EIN, you may
under the Investment Company Act of 1940, enter either your SSN or EIN. However,the IRS prefers that
you use your SSN.
12. A common trust fund operated by a bank under section
584(a), If you are a single-owner LLC that is disregarded as an entity
separate from its owner (see Limited liability company ILLC)on
13. A financial institution, page 2), enter your SSN (or EIN, if you have one). If the LLC
14. A middleman known in the investment community as a is a corporation, partnership, etc., enter the entity's EIN.
nominee or custodian, or Note: See the chart on page 4 for further clarification of name
15. A trust exempt from tax under section 664 or described and TIN combinations.
in section 4947. How to get a TIN. If you do not have a TIN, apply for one
The chart below shows types of payments that may be immediately. To apply for an SSN, get Form SS-5, Application
exempt from backup withholding. The chart applies to the for a Social Security Card, from your local Social Security
exempt recipients listed above, 1 through 15. Administration office or get this form on-line at
www.socialsecurity,gov/online/ss-5.pdf. You may also get this
form by calling 1-800-772-1213. Use Form W-7, Application
IF the payment is for . . . THEN the payment Is exempt for IRS Individual Taxpayer Identification Number,to apply for
for . . . an ITIN, or Form SS-4, Application for Employer Identification
Number,to apply for an EIN. You can apply for an EIN online
Interest and dividend payments All exempt recipients except by accessing the IRS website at www.irs.gov/businesses/and
for 9 clicking on Employer ID Numbers under Related Topics. You
can get Forms W-7 and SS-4 from the IRS by visiting
www.irs.gov or by calling 1-800-TAX-FORM
Broker transactions Exempt recipients 1 through (1-800-829-3676).
13. Also, a person registered
under the Investment If you are asked to complete Form W-9 but do not have a
Advisers Act of 1940 who TIN, write "Applied For" in the space for the TIN, sign and
regularly acts as a broker date the form, and give it to the requester. For interest and
dividend payments, and certain payments made with respect
to readily tradable instruments, generally you will have 60
Barter exchange transactions Exempt recipients 1 through 5 days to get a TIN and give it to the requester before you are
and patronage dividends subject to backup withholding on payments. The 60-day rule
does not apply to other types of payments. You will be
Payments over S600 required Generally, exempt recipients subject to backup withholding on all such payments until you
to be reported and direct 1 through 72 provide your TIN to the requester.
sales over $5,000' Note: Writing "Applied For" means that you have already
applied for a TIN or that you intend to apply for one soon.
' See Form 1099-MISC, Miscellaneous Income, and its Caution: A disregarded domestic entity that has a foreign
instructions. owner must use the ap
propriate Form W-8.
'However, the following payments made to a corporation
(including gross proceeds paid to an attorney under section
6045(f), even if the attorney is a corporation) and reportable
on Form 1099-MISC are not exempt from backup
withholding: medical and health care payments, attorneys'
fees; and payments for services paid by a Federal executive
agency.
Form W-9 (Rev. 1-20051 Page 4
Part II. Certification What Name and Number To Give the
To establish to the withholding agent that you are a U.S. Re uester
person, or resident alien, sign Form W-9. You may be For this type of account: Give name and SSN or:a
requested to sign by the withholding agent even if items 1, 4, _ _
and 5 below indicate otherwise. 1. Individual The individual
For a joint account, only the person whose TIN is shown in 2. Two or more individuals joint The actual owner of the account or,if
Part I should sign (when required). Exempt recipients, see account) combined funds,the first individual
Exempt From Backup Withholding on page 2. on the account
Signature requirements. Complete the certification as 3. Custodian account of a minor tine minor
indicated in 1 through 5 below. )uniform Gift to Minors Act)
1. Interest,dividend, and barter exchange accounts opened
before 1984 and broker accounts considered active during 4. a. The usual revocable savings The grantor-trustee
1983. You must give your correct TIN, but you do not have to trust(grantor is also trustee)
sign the certification. b. So-called trust account that is The actual owner'
2. Interest, dividend, broker, and barter exchange accounts not a legal or valid trust under
opened after 1983 and broker accounts considered inactive state law
during 1983. You must sign the certification or backup 5. Sole proprietorship or single-owner The owner'
withholding will apply. If you are subject to backup LLC
withholding and you are merely providing your correct TIN to
the requester, you must cross out item 2 in the certification For this type of account: Give name and UN of:
before signing the form.
6. Sole proprietorship or single-owner The owner a
3. Real estate transactions. You must sign the certification. LLC
You may cross out item 2 of the certification.
7' A valid trust,estate,or pension Legal entity
4. Other payments. You must give your correct TIN, but trust
you do not have to sign the certification unless you have been
notified that you have previously given an incorrect TIN. e. Corporate or LLC electing corporate The corporation
"Other payments" include payments made in the course of the status on Form 8832
requester's trade or business for rents, royalties, goods (other 9. Association,club,religious, The organization
than bills for merchandise), medical and health care services charitable,educational,or other
(including payments to corporations), payments to a tax-exempt organization
nonemployee for services, payments to certain fishing boat
crew members and fishermen, and gross proceeds paid to 10.Partnership or multi-member LLC The partnership
attorneys (including payments to corporations). 11.A broker or registered nominee The broker or nominee
5. Mortgage interest paid by you, acquisition or 12.Account with the Department of The public entity
abandonment of secured property, cancellation of debt, Agriculture in the name of a public
qualified tuition program payments(under section 529), IRA, entity(such as a state or local
Coverdell ESA, Archer MSA or HSA contributions or government,school district,or
distributions,and pension distributions. You must give your prison)that receives agricultural
correct TIN, but you do not have to sign the certification. program payments
List first and circle the name of the person whose number you furnish. If only
one person on a joint account has an SSN,that person's number must be
furnished.
2 Circle the minor's name and furnish the minor's SSN.
a You must show your individual name and you may also enter your business or
"DBA"name on the second name line. You may use either your SSN or EIN(if
you have one). If you are a sole proprietor,IRS encourages you to use your
SSN.
List first and circle the name of the legal trust,estate,or pension trust. (Do not
furnish the TIN of the personal representative or trustee unless the legal entity
itself is not designated in the account title.)
Note: If no name is circled when more than one name is
listed,the number will be considered to be that of the first
name listed.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with
the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment
of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for
identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department
of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their tax laws. We may also
disclose this information to other countries under a tax treaty, or to federal and state agencies to enforce federal nontax 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. Payers must generally withhold 28% of taxable
interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
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