HomeMy WebLinkAboutPR 21329: ACCEPTING A GRANT FORM THE TEXAS COUNTS POOLED FUND, TEXAS CENSUS 2020 P. R. No. 21329
03/10/2020
RESOLUTION NO.
A RESOLUTION AFFIRMING THE CITY MANAGER' S ACTIONS IN
ACCEPTING A $25, 000 GRANT FROM 'THE TEXAS COUNTS POOLED
FUND" TO FUND ACTIVITIES OF TEXAS CENSUS 2020 EDUCATION AND
ENGAGEMENT ACTIVITIES
WHEREAS, the City Council of the City of Port Arthur fully
affirms the U. S. Constitutional mandate of a complete and accurate
count of the citizens of the United States in 2020; and,
WHEREAS, the City Council of the City of Port Arthur firmly
supports the participation of all its citizens in the 2020 Census;
and,
WHEREAS, in support of the foregoing the City Council
appointed a Complete Count Committee to actively engage the citizens
of Port Arthur regarding the 2020 Census; and,
WHEREAS, the Complete Count Committee (CCC) and the City of
Port Arthur submitted an application to the Texas Counts Pooled Fund
for funding to assist in community activities to support and
galvanize citizen participation in the 2020 Census; and,
WHEREAS, the City of Port Arthur has been notified that it is
a recipient of a grant in the amount of twenty-five thousand and
($25, 000.00) zero one-hundredths dollars; now, therefore,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PORT ARTHUR,
TEXAS:
Section 1: That the facts and opinions of the preamble are
true and correct.
P. R. No. 21329
03/10/2020 P.2
Section 2: That the City Council remains committed to the
goal of a complete count of all Port Arthur
citizens in the 2020 Census.
Section 3: That the City Council hereby affirms and approves
the City Manager' s actions in accepting the grant
from the "Texas Counts Pooled Fund" made part
hereof as Attachment "A" hereto.
Section 4 : That the City Council further directs and
authorizes expenditure of said grant funds in
compliance with the terms of said grant and the
allowed expenditure categories thereof as
presented by the Complete Count Committee
and approved by the City Manager.
Section 5: That the City Council directs that all required
grant reporting be accomplished by the City' s
administration.
Section 6: That a copy of the caption of the Resolution be
spread upon the Minutes of the City Council.
READ, ADOPTED, and APPROVED this day of A.D. ,
2020, at a Meeting of the City Council of the City
of Port Arthur, Texas, by the following vote:
AYES : Mayor Councilmembers
NOES:
P. R. No. 21329
03/10/2020 P.3
ATTEST:
Thurman B. Bartie
Mayor
Sherri Bellard
City Secretary
APPROVED AS TO FORM:
i Valeria Tizeno, Esq.
1/6t?t4-1 0')AiAg
e3
City Attorney
APPROVED FOR ADMINISTRATION:
Ronald Burton
City Manager
ATTACHMENT
3/11/2020 Mail-Albert Thigpen-Outlook
Congratulations from the Texas Counts Pooled Fund
Angela Broyles <abroyles@cftexas.org>
Tue 3/3/2020 1:37 PM
To: Albert Thigpen <thigpenat@lamarpa.edu>;shanell.perkins@portarthurtx.gov <shanell.perkins@portarthurtx.gov>
Cc: Amy Desler<adesler@cftexas.org>;Ann Beeson <beeson@cppp.org>;George Tang <gtang@cftexas.org>
li 4 attachments(520 KB)
City of Port Arthur TCPF Grant Agreement.pdf;ACH-Wire for Grant Form.pdf;W-9 December 2019.pdf;TCPF Financial Report.xlsx;
CAUTION: This email originated outside of LSCPA. Please verify the source of the email before you
click any links, open any attachments, or reply to the sender. Report suspicious emails to
abuse@lamarpa.edu.
Dear Dr.Thigpen,
On behalf of the Grants Committee of the Texas Counts Pooled Fund,we are pleased to approve a grant of up to
$25,000 to the City of Port Arthur. Subject to the terms and conditions of the grant agreement,granted funds are
designated to fund the activities of Texas Census 2020 education and engagement activities.
This grant agreement must be signed by the primary Executive Officer of the Recipient Organization or a designee who is
specifically empowered by the governing body to make legally binding agreements on its behalf. Inappropriately signed
agreements will substantially delay or preclude payment of the grant.Additionally,please fill out and sign attached W-9 for
your organization.
Please return to me(abroyles@cftexas.org),via scan,at your earliest convenience so that we may countersign and forward
the scheduled grant funds and your fully executed copy of the grant agreement as soon as all is in order. If you would like
to have your funds directly deposited to your bank account,please complete the attached Automatic Deposit Request form
and scan it back to me along with your signed grant agreement.
Please remember that all granted funds must be used appropriately under terms established in Sections 501(c)(3),or
170(b),as applicable,of the Internal Revenue Code.
Should you have any questions, please do not hesitate to contact me.And Congratulations!We appreciate your efforts
ensuring a complete count for Texas in 2020.
Sincerely,
Angela Broyles!Program and Grants Associate,Texas Counts Pooled Fund
Educate Texas I Communities Foundation of Texas
5500 Caruth Haven Lane I Dallas,Texas 75225
P: 214-346-5530 I C: 646-526-7442
www.Edtx.org
EDUCATE TEXAS
at COMMUNITIES FOUNDATION of TEXAS
https://outlook.office.com/mail/search/id/AAQkADEOODYzNDJmLTImNTQtNGVjMC1 iNTM1 LTIhMzE5YWFkZGRkMAAQAH Ifm0hfD03fv2000U Ut4ZM... 1/1
COMMUNITIES
FOUNDATION of TEXAS
Texas Counts Pooled Fund
Grant Agreement
This grant agreement("Agreement") is hereby made and entered into effective February 27,2020(the
"Effective Date")by and between City of Port Arthur("Recipient")and Communities Foundation of
Texas,a Texas nonprofit organization("CFT"}. This Agreement contains the terms and conditions of this
grant. This agreement is valid from the Effective Date until June 30,2020.
Purpose: Recipient agrees that the funding received from the Texas Counts Pooled Fund at Communities
Foundation of Texas will be used solely to support educational and engagement activities for the 2020
Texas Census. The purpose of the fund is to support activities across the state that help ensure a complete
2020 Census count for the State of Texas. CFT prohibits the use of grant funds for non-charitable or for
political lobbying activities. The Recipient must receive approval from CFT if the use of the grant
will deviate from the approval application it provided.
Funds will be used,per grant proposal from the Recipient, for the activities outlined in Attachment A.
Charitable Use of Grant Funds: Grant funds may only be used for the Project Use of grant funds must be
appropriate under the terms and provisions of the Agreement and sections 501(cX3)and 170(b)of the Internal
Revenue Code of 1986,as amended.Any grant funds unexpended or uncommitted at the end of the Grant Term
must be promptly returned to CFT.Any change to a cost category of more than 10%must be approved in writing
by CFT in advance.Recipient may not use grant funds to reimburse any expenses incurred prior to the Effective
Date without written approval from CFT.
Equality:In the application of its resources to serve the public interest,CFT gives high priority to the realization
of equality of opportunity for all members of society.Accordingly,it is CFT's expectation that in carrying out this
grant Recipient will not discriminate based on race,color,religion,sex,sexual orientation,or national origin.
Record Maintenance and Inspection:CFI requires that Recipient maintain adequate records of the Project to
enable CFT to easily determine how the grant funds were expended. Recipient agrees to allow its personnel to
discuss the program and finances with CFT or its designee and to allow review of financial records connected with
the activities financed by the grant.
Indemnification: Recipient agrees to indemnify,defend and hold CFT harmless from and against any and all
liability, loss, and expense(including reasonable attorneys' fees and expenses)or claims for injury or damages
arising out of or resulting from,or that are alleged to arise out of or result from,the actions or omissions by Recipient
or of any of the officers,agents,employees,subgrantees,contractors or subcontractors with respect to the grant.
Recipient agrees that any activities by CFT in connection with the project, such as its review or proposal of
suggested modifications to the project,will not limit or constitute a waiver of CFT's rights under the paragraph.
Recipient's obligation to the indemnify CFT,including obligations resulting from the actions ofthe subgrantees or
subcontractors,will be limited to the extent permitted or precluded under applicable federal,state or local laws,
including federal or state tort claims acts,the federal anti-deficiency act,state governmental immunity acts,or state
constitutions. Nothing in the grant agreement will constitute an express or implied waiver of Recipient's
governmental and sovereign immunities. The obligation of the Recipient under this section will survive the
termination of this agreement.
Recognition:In all public announcements,credit and report of the grant will list the source of the grant as:Texas
Complete Count Fund at Communities Foundation of Texas
Assignment: This Agreement and any of the rights or obligations under this Agreement may not be assigned
without CFT's prior written consent.An assignment includes(a)any transfer of the Project(b)an assignment by
operation of law,including a merger or consolidation,or(c)the sale or transfer of all or substantially all of the
organization's assets.The terms and conditions of the Agreement will be binding upon the parties to it and upon
their successors or assigns,if any.
Applicable law: The terms and conditions of this Agreement will be governed by Texas law applicable to
agreements made and to be performed in Texas.
Schedule of Distributions: This is a one-time payment in the amount of$25,000. No further funds
will be received from CFT unless another application is submitted and approved.
Reporting: Recipient will provide CFT with a final report, the TCPF Financial Report (attached to
award letter),by June 30,2020,detailing the use of the funds and the activities conducted with the use
of the CFT grant, as described in Recipient's application. The report should include an accounting
of the use of granted funds, as well as a narrative description. Recipient does not need to provide
invoices, receipts or other documentation, but those items shall be maintained by Recipient for a
period of four(4)years.
AGREED as of the Effective Date:
Name,Recipient Date
Ceorge Tang, Managing Director, CFT Date
Sarah Cotton Nelson,Chief Philanthropy Officer,CFT Date
ATTACHMENT A
TEXAS COUNTS POOLED FUND GRANT APPLICATION
Organization Name:City of Port Arthur
Point of Contact:Dr. Albert T.Thigpen
Point of Contact Phone:409-728-0185
Point of Contact Email:thigpenat@lamarpa.edu
Authorized Organizational Representative:Ronald Burton
Authorized Organizational Representative Email: shanell.perkins@portarthurtx.gov
Are you a local Complete Count Committee or current member?:Yes
Region Served:East Texas
County Served:Jefferson
Cities Served(if applicable):Port Arthur
Will your work take place in specific counties not specified by a region?If so,please list::No
Please Describe: The city of Port Arthur is a highly diverse,multi-ethnic city, located in southeast
Texas.Port Arthur previously experienced damages from Hurricanes Rita, Ike,and Humberto,
respectively and most recently was severely impacted by Hurricane/Tropical Storm Harvey in 2017
and to a lesser extent by Tropical Storm Imelda in 2019. Further,Port Arthur is deemed to be at least
50%blighted with more than 30%living below the poverty level.Review of past census response
data as well as prior experience indicates that Port Arthur has several "hard to count" populations:
homeless,Hispanic,African-American, Vietnamese/Asian.Additionally,the census using an online
format will significantly increase the number of elderly/senior and computer/internet access
challenged individuals who will have difficulty in responding.These groups represent over 80%of
the city's population.The devastation to Port Arthur's population,community,and housing stock was
significant.This resulted in the displacing of numerous individuals and families.Many are
"homeless"though living with relatives/friends who will need to be identified and counted.The
crucialness of a complete count for Port Arthur cannot be overstated.Funding pivotal to
infrastructure repair,health,education,and housing are directly related to the city's census
population.The quality of life in Port Arthur is indeed in the balance.The combination of the impact
of the various storms,displacements,and hard to count populations presents a significant challenge
for the City and its Complete Count Committee to obtain an accurate count.The requested funding
will assist these entities in reaching the goals of a complete census count.
Total Population Impacted by Proposal:60000
Hard-To-Count Populations Targeted by Proposal:
Young children under the age of 5:True
Low-income individuals and families: True
People experiencing homelessness:True
Foreign-born individuals(including undocumented immigrants and refugees):True
Senior citizens: True
People with mental or physical disabilities:True
Highly mobile people such as transient workers or people who do not live in traditional housing: True
Lesbian,gay,bisexual,transgender and queer(LGBTQ)persons:False
People of Color.False
Amount Requested:63000
Strategic Area of Focus:
Educational community events(forums,town hall discussions,rallies,etc.):True
Phone banks to educate and encourage participation in the census:False
Educational door-to-door canvassing:True
Help stations,mobile units,kiosks and Internet access points for people to fill out the census:True
Educational material(yard signs,mailers,emails):True
Media(TV&Radio):True
Digital marketing(including text services):True
Engaging&supporting community,civic,and faith-based organizations to encourage participation in
the Census: True
Other, please describe:False
Other:
Please Describe:Coordinated efforts with Jefferson County Complete Count Committee.Coordinated
efforts with Texas Hispanic Complete Count Committee.Coordinated efforts with National Pan-
Hellenic Census Complete Count Initiatives.
PROJECT TIMELINE,TEXAS COUNTS POOLED FUND
game of Appecad
(Grant..Omani..*Ion) City of Port Arthur EMAIL tldIDeartfl.mema..CO
Mom.of Ninon'.palls.
loped Dr.Albert T.Thi9pEr PHONE 409-728-0t85
IGrant T.ml Start Date: _,'1.vxl:
Gant Term find Dare
1
TASKS/ACTIVITIES flat a description of actA87es ID bo completed cluing Iris period) ACTIVITY START DALE ACTIVITY END DAT!
":�.` `:: .Mo/f]cY/Yea Mc/i7nVrta1
;ons bad CCC.A.wr vpMt.m and pad moons/to menet,cam.octm.".Meet rilb e,Wi,a CCCa n me eacn ma pm rowan/co e:lul: 11111201,
12113/AIY
...In.70201001,..411/f.a.. 12/11/201! 12/1470I9
Wroopt#dclyluvt.1n ay Cen..theme.Pod Adfw2023.AIIMOne ClvIOn.Carit tum1wa OW am.Ced lf.out AayW.102. 12/147019 8/3112119
MCMer adlb.pof.M1nead2/lh,d/o.ol.potlan Aida re Iatnofiiepise od1 OA 31.7W0 12/142019 '/31/X127
7 2/I 112014t 2 Corso,Rd/FMS 013/1/2320 '/21/00
311ie13Adret a.Cama Rd.Eva.t 211/2020 7/29/2]71
Patton Npwlbn 1 GvML tidy Fetes 3/1/2020 331/2070
/1040.3/Ww'No Orme mu 1/1/7020 113112720
..ensu V...r.03.Ilid.EMV.nlov.2/doeleho:'.011T000L teMO. 211/2020 3/15/2130
Molter Como*.Cart Committee Meeting 12/14/2219 '/!1/2323
MonI/to CMc.Soc11 Cornmaretv.Ii'lltaad Orpa:ri!cca Conan AcnAin :7/14'219 --..../51/X123
oodinO of Cees[bowl.yap etf.00.1.n /2/142310 '131/270
Hoole Ste forowrcedon 04 Cemw Dv.0./.Ware!and COrnaaa meets oed.pud 1/1/2070 '131/220
M.4aplomot'gnllado.Iv.NO;sower[mono&on/octal mea. ,2/142019 '`11/7010
S.PIN 3/p/coordndYq/palYyaiq/Oaaaneedigcomlwnly,IDlliowa,CMc,panlwipnk,Nc.Cm.*vvalltb/adn/Ytlml/..da 121142019 731.1016
vole:00611m0 lulo.q vita.Seoyr•o canlfve olds nddado0ti4Y,1!.01104'0431/2022 for conpetedocvnedd.on ondnm..lurn Wp.at on Candor"Co,.
COMMUNITIES
FOUNDATION of TEXAS
Domestic ACH/Wire for Grant
Recipient/Beneficiary information:
Recipient/Beneficiary Name:
Address:
City,State&Zip Code:
Contact Name:
Contact Email Address:
Bank Information for ACH or Fed Wire
Recipient/Beneficiary Bank Name:
Bank Address:
Bank City,State&Zip Code:
ACH Routing Number:
ACH Routing Number:
Account Number:
Bank Account Type: Checking 0 Savings 0
Federal Wire Routing Number:
Fed Wire Routing Number:
Account Number:
For the Benefit of:
Authorization:
I am authorizing Communities Foundation of Texas,Inc.to process payment for this grant request to the above-
mentioned account.
Signature Title
E-mail Address Date
Domestic ACH/Wire for Grant Form-(May 2019)
Form W'9 Request for Taxpayer Give Form to the
(Rev.October 2018) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service ►Go to www.irs.gov/FormW9 for instructions and the latest information.
1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank.
2 Business name/disregarded entity name,if different from above
3 Check appropriate box for federal tax classification of the person whose name Is entered on line 1.Check only one of the 4 Exemptions(codes apply only to
is following seven boxes. certain entities,not individuals;see
a
❑ C instructions on page 3):
p ❑ IndividuaVsole proprietor or Corporation ❑S Corporation ❑ Partnership ❑Trust/estate
oa single member LLC Exempt payee code(if any)
❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)►
o 2 Note:Check the appropriate box In the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting
LLC If the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that Is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that code(if any)
d u Is disregarded from the owner should check the appropriate box for the tax classification of its owner.
(see instructions)►
❑ Other (Applies to accounts maintained outside the U.S.)
5 Address(number,street,and apt.or suite no.)See instructions. Requester's name and address(optional)
A
6 City,state,and ZIP code
7 List account number(s)here(optional)
Part I Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid J Social security number
backup withholding.For individuals,this is generally your social security number(SSN).However,for a
resident alien,sole proprietor,or disregarded entity,see the instructions for Part I,later.For other _ -
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN,later.
or
Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and I Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
Part II Certification
Under penalties of perjury,I certify that:
1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2.I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3.I am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,
acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments
other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions for Part II,later.
Sign Signature of
Here I U.S.person► betel.
General Instructions •Form 1099-DIV(dividends,including those from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise •Form 1099-MISC(various types of income,prizes,awards,or gross
noted. proceeds)
Future developments.For the latest information about developments •Form 1099-B(stock or mutual fund sales and certain other
related to Form W-9 and its instructions,such as legislation enacted transactions by brokers)
after they were published,go to www.irs.gov/FormW9.
•Form 10995
(proceeds from real estate transactions)
Purpose of Form •Form 1099-K(merchant card and third party network transactions)
An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(student loan interest),
information return with the IRS must obtain your correct taxpayer 1098-T(tuition)
identification number(TIN)which may be your social security number •Form 1099-C(canceled debt)
(SSN),individual taxpayer identification number(ITIN),adoption
taxpayer identification number(ATIN),or employer identification number •Form 1099-A(acquisition or abandonment of secured property)
(EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S.person(including a resident
amount reportable on an information return.Examples of information alien),to provide your correct TIN.
returns Include,but are not limited to,the following. If you do not return Form W-9 to the requester with a 77N,you might
•Form 1099-INT(interest earned or paid) be subject to backup withholding.See What is backup withholding,
later.
Cat.No.10231X Form W-9(Rev.10-2018)
Form W-9(Rev.10-2018) Page 2
By signing the filled-out form,you: Example.Article 20 of the U.S.-China income tax treaty allows an
1.Certify that the TIN you are giving is correct(or you are waiting for a exemption from tax for scholarship income received by a Chinese
number to be issued), student temporarily present in the United States.Under U.S.law,this
student will become a resident alien for tax purposes if his or her stay in
2.Certify that you are not subject to backup withholding,or the United States exceeds 5 calendar years.However,paragraph 2 of
3.Claim exemption from backup withholding if you are a U.S.exempt the first Protocol to the U.S.-China treaty(dated April 30,1984)allows
payee.If applicable,you are also certifying that as a U.S.person,your the provisions of Article 20 to continue to apply even after the Chinese
allocable share of any partnership income from a U.S.trade or business student becomes a resident alien of the United States.A Chinese
is not subject to the withholding tax on foreign partners'share of student who qualifies for this exception(under paragraph 2 of the first
effectively connected income,and protocol)and is relying on this exception to claim an exemption from tax
4.Certify that FATCA code(s)entered on this form(if any)indicating on his or her scholarship or fellowship income would attach to Form
that you are exempt from the FATCA reporting,is correct.See What is W-9 a statement that includes the information described above to
FATCA reporting, later,for further information. support that exemption.
Note:If you are a U.S.person and a requester gives you a form other If you are a nonresident alien or a foreign entity,give the requester the
than Form W-9 to request your TIN,you must use the requester's format appropriate completed Form W-8 or Form 8233.
it is substantially similar to this Form W-9.
Backup Withholding
Definition of a U.S.person.For federal tax purposes,you are
considered a U.S.person if you are: What is backup withholding?Persons making certain payments to you
•An who is a U.S.citizen or U.S.resident alien; must under certain conditions withhold and pay to the IRS 24%of such
•Aindividualcorporation,company, payments.This is called"backup withholding." Payments that may be
partnership, rp or association created or subject to backup withholding include interest,tax-exempt interest,
organized in the United States or under the laws of the United States; dividends,broker and barter exchange transactions,rents,royalties,
•An estate(other than a foreign estate);or nonemployee pay,payments made in settlement of payment card and
•A domestic trust(as defined in Regulations section 301.7701 7). third party network transactions,and certain payments from fishing boat
operators.Real estate transactions are not subject to backup
Special rules for partnerships.Partnerships that conduct a trade or withholding.
business in the United States are generally required to pay a withholding You will not be subject to backup withholding on payments you
tax under section 1446 on any foreign partners'share of effectively receive if you give the requester your correct TIN,make the proper
connected taxable income from such business.Further,in certain cases certifications,and report all your taxable interest and dividends on your
where a Form W-9 has not been received,the rules under section 1446 tax return.
require a partnership to presume that a partner is a foreign person,and
pay the section 1446 withholding tax.Therefore,if you are a U.S.person Payments you receive will be subject to backup withholding if:
that is a partner in a partnership conducting a trade or business in the 1.You do not furnish your TIN to the requester,
United States,provide Form W-9 to the partnership to establish your 2.You do not certify
U.S.status and avoid section 1446 withholding on your share of your TIN when required(see the instructions for
partnership income. Part II for details),
In the cases below,the following person must give Form W-9 to the 3.The IRS tells the requester that you furnished an incorrect TIN,
partnership for purposes of establishing its U.S.status and avoiding 4.The IRS tells you that you are subject to backup withholding
withholding on its allocable share of net income from the partnership because you did not report all your interest and dividends on your tax
conducting a trade or business in the United States. return(for reportable Interest and dividends only),or
•In the case of a disregarded entity with a U.S.owner,the U.S.owner 5.You do not certify to the requester that you are not subject to
of the disregarded entity and not the entity; backup withholding under 4 above(for reportable interest and dividend
•In the case of a grantor trust with a U.S.grantor or other U.S.owner, accounts opened after 1983 only).
generally,the U.S.grantor or other U.S.owner of the grantor trust and Certain payees and payments are exempt from backup withholding.
not the trust;and See Exempt payee code, later,and the separate Instructions for the
•In the case of a U.S.trust(other than a grantor trust),the U.S.trust Requester of Form W-9 for more information.
(other than a grantor trust)and not the beneficiaries of the trust. Also see Special ivies for partnerships,earlier.
Foreign person.If you are a foreign person or the U.S.branch of a What is FATCA Reporting?
foreign bank that has elected to be treated as a U.S.person,do not use
Form W-9.Instead,use the appropriate Form W-8 or Form 8233(see The Foreign Account Tax Compliance Act(FATCA)requires a
Pub.515,Withholding of Tax on Nonresident Aliens and Foreign participating foreign financial institution to report all United States
Entities). account holders that are specified United States persons.Certain
Nonresident alien who becomes a resident alien.Generally,only a payees are exempt from FATCA reporting.See Exemption from FATCA
nonresident alien individual may use the terms of a tax treaty to reduce reporting code,later,and the Instructions for the Requester of Form
or eliminate U.S.tax on certain types of income.However,most tax W-9 for more information.
treaties contain a provision known as a"saving clause."Exceptions Updating Your Information
specified in the saving clause may permit an exemption from tax to
continue for certain types of income even after the payee has otherwise You must provide updated information to any person to whom you
become a U.S.resident alien for tax purposes. claimed to be an exempt payee if you are no longer an exempt payee
If you are a U.S.resident alien who is relying on an exception and anticipate receiving reportable payments in the future from this
contained in the saving clause of a tax treaty to claim an exemption person.For example,you may need to provide updated information if
from U.S.tax on certain types of income,you must attach a statement you are a C corporation that elects to be an S corporation,or if you no
to Form W-9 that specifies the following five items. longer are tax exempt.In addition,you must furnish a new Form W-9 if
1.The treaty country.Generally,this must be the same treaty under the name or TIN changes for the account;for example,if the grantor of a
which you claimed exemption from tax as a nonresident alien. grantor trust dies.
2.The treaty article addressing the income. Penalties
3.The article number(or location)in the tax treaty that contains the
saving clause and its exceptions. Failure to furnish TIN.If you fail to furnish your correct TIN to a
4.The type and amount of income that qualifies for the exemption requester,you are subject to a penalty of$50 for each such failure
from tax. unless your failure is due to reasonable cause and not to willful neglect.
5.Sufficient facts to justify the exemption from tax under the terms of CMI penalty for false information with respect to withholding.If you
the treaty article. make a false statement with no reasonable basis that results in no
backup withholding,you are subject to a$500 penalty.
Form W-9(Rev.10-2018) Page 3
Criminal penalty for falsifying information.Willfully falsifying IF the entity/person on line 1 is THEN check the box for...
certifications or affirmations may subject you to criminal penalties a(n)...
including fines and/or imprisonment.
Misuse of TINs.If the requester discloses or uses TINs in violation of • Corporation Corporation
federal law,the requester may be subject to civil and criminal penalties. • Individual IndividuaVsole proprietor or single-
• Sole proprietorship,or member LLC
Specific Instructions • Single-member limited liability
company(LLC)owned by an
Line 1 individual and disregarded for U.S.
You must enter one of the following on this line;do not leave this line federal tax purposes.
blank.The name should match the name on your tax return.
• LLC treated as a partnership for Limited liability
If this Form W-9 is for a joint account(other than an account company and enter
I U.S.federal tax purposes, the appropriate tax classification.
maintained by a foreign financial institution(FFI)),list first,and then • LLC that has filed Form 8832 or (P=Partnership;C=C corporation;
circle,the name of the person or entity whose number you entered in 2553 to be taxed as a corporation, or S=S corporation)
Part I of Form W-9.If you are providing Form W-9 to an FFI to document or
a joint account,each holder of the account that is a U.S.person must • LLC that is disre arded as an
provide a Form W-9. 9
entity separate from its owner but
a. Individual.Generally,enter the name shown on your tax return.If the owner is another LLC that Is
you have changed your last name without informing the Social Security not disregarded for U.S.federal tax
Administration(SSA)of the name change,enter your first name,the last purpo
name as shown on your social security card,and your new last name.
Note:!TIN applicant Enter your individual name as it was entered on • Partnership Partnership
your Form W-7 application,line la.This should also be the same as the • Trust/estate Trust/estate
name you entered on the Form 1040/1040A/1040EZ you filed with your Line 4, Exemptions
ptions
b. Sole proprietor or single-member LLC.Enter your individual If you are exempt from backup withholding and/or FATCA reporting,
name as shown on your 1040/1040N1040EZ on line 1.You may enter enter in the appropriate space on line 4 any code(s)that may apply to
your business,trade,or"doing business as"(DBA)name on line 2. you.
c. Partnership,LLC that is not a single-member LLC,C Exempt payee code.
corporation,or S corporation.Enter the entity's name as shown on the • Generally,individuals(including sole proprietors)are not exempt from
entity's tax retum on line 1 and any business,trade,or DBA name on backup withholding.
line 2. • Except as provided below,corporations are exempt from backup
d. Other entities.Enter your name as shown on required U.S.federal withholding for certain payments,including interest and dividends.
tax documents on line 1.This name should match the name shown on the • Corporations are not exempt from backup withholding for payments
charter or other legal document creating the entity.You may enter any made in settlement of payment card or third party network transactions.
business,trade,or DBA name on line 2.
e. Disregarded entity.For U.S.federal tax purposes, • Corporations are not exempt from backup withholding with respect to
9 an entity that is attorneys'fees or gross proceeds paid to attorneys,and corporations
disregarded as an entity separate from its owner is treated as a that provide medical or health care services are not exemptwith respect
"disregarded entity."
eg fty." See Regulations section 301.7701-2(cx2)(ii).Enter to payments reportable on Form 1099-MISC.
the owner's name on line 1.The name of the entity entered on line 1
should never be a disregarded entity.The name on line 1 should be the The following codes identify payees that are exempt from backup
name shown on the income tax return on which the income should be withholding.Enter the appropriate code in the space in line 4.
reported.For example,if a foreign LLC that is treated as a disregarded 1—An organization exempt from tax under section 501(a),any IRA,or
entity for U.S.federal tax purposes has a single owner that is a U.S. a custodial account under section 403(b)(7)if the account satisfies the
person,the U.S.owner's name is required to be provided on line 1.If requirements of section 401(f)(2)
the direct owner of the entity is also a disregarded entity,enter the first 2—The United States or any of its agencies or instrumentalities
owner that Is not disregarded for federal tax purposes.Enter the
disregarded entity's name on line 2,"Business name/disregarded entity 3—A state,the District of Columbia,a U.S.commonwealth or
name."If the owner of the disregarded entity is a foreign person,the possession,or any of their political subdivisions or instrumentalities
owner must complete an appropriate Form W-8 instead of a Form W-9. 4—A foreign government or any of its political subdivisions,agencies,
This is the case even if the foreign person has a U.S.TIN. or instrumentalities
Line 2 5—A corporation
If you have a business name,trade name,DBA name,or disregarded 6—A dealer In securities or commodities required to register in the
entity name,you may enter it on line 2. United States,the District of Columbia,or a U.S.commonwealth or
Line 3 possession
7—A futures commission merchant registered with the Commodity
Check the appropriate box on line 3 for the U.S.federal tax Futures Trading Commission
classification of the person whose name is entered on.line 1.Check only 8—A real estate investment trust
one box on line 3.
9—An entity registered at all times during the tax year under the
Investment Company Act of 1940
10—A common trust fund operated by a bank under section 584(a)
11—A financial institution
12—A middleman known in the investment community as a nominee or
custodian
13—A trust exempt from tax under section 664 or described in section
4947
Form W-9(Rev.10-2018) Page 4
The following chart shows types of payments that may be exempt M—A tax exempt trust under a section 403(b)plan or section 457(g)
from backup withholding.The chart applies to the exempt payees listed plan
above,1 through 13. Note:You may wish to consult with the financial institution requesting
IF the payment is for... THEN the payment is exempt this form to determine whether the FATCA code and/or exempt payee
for... code should be completed.
Interest and dividend payments All exempt payees except Line 5
for 7 Enter our address(number,street,and
Yapartment or suite number).
Broker transactions Exempt payees 1 through 4 and 6 This is where the requester of this Form W-9 will mail your information
through 11 and all C corporations. returns.If this address differs from the one the requester already has on
S corporations must not enter an file,write NEW at the top.If a new address is provided,there is still a
exempt payee code because they chance the old address will be used until the payor changes your
are exempt only for sales of address in their records.
noncovered securities acquired Line 6
prior to 2012.
Barter exchange transactions and Exempt payees 1 through 4 Enter your city,state,and ZIP code.
patronage dividends Part I. Taxpayer Identification Number (TIN)
Payments over$600 required to be Generally.exempt payees Enter your TIN in the appropriate box.If you are a resident alien and
reported and direct sales over 1 through 5' you do not have and are not eligible to get an SSN,your TIN is your IRS
$5,000 individual taxpayer identification number(ITIN).Enter it in the social
security number box.If you do not have an ITIN,see How to get a TIN
Payments made in settlement of Exempt payees 1 through 4 below.
payment card or third party network
transactions If you are a sole proprietor and you have an EIN,you may enter either
your SSN or EIN.
1 See Form 1099-MISC, Miscellaneous Income,and its instructions. If you are a single-member LLC that is disregarded as an entity
2 separate from its owner,enter the owner's SSN(or EIN,if the owner has
However,the following payments made to a corporation and one).Do not enter the disregarded entity's EIN.If the LLC is classified as
reportable on Form 1099-MISC are not exempt from backup a corporation or partnership,enter the entity's EIN.
withholding:medical and health care payments,attorneys'fees,gross
proceeds paid to an attorney reportable under section 6045(0,and Note:See What Name and Number To Give the Requester,later,for
payments for services paid by a federal executive agency. further clarification of name and TIN combinations.
Exemption from FATCA reporting code.The following codes identify How to get a TIN.If you do not have a TIN,apply for one immediately.
payees that are exempt from reporting under FATCA.These codes To apply for an SSN,get Form SS-5,Application for a Social Security
apply to persons submitting this form for accounts maintained outside Card,from your local SSA office or get this form online at
of the United States by certain foreign financial institutions.Therefore,ifwww.SSA.gov.You may also get this form by calling 1-800-772-1213.
you are only submitting this form for an account you hold in the United Use Form W-7,Application for IRS Individual Taxpayer Identification
Number,to apply for an ITIN,or Form SS-4,Application for Employer
States,you may leave this field blank.Consult with the person
requesting this form if you are uncertain if the financial institution is Identification Number,to apply for an EIN.You can apply for an EIN
subject to these requirements.A requester may indicate that a code is online by accessing the IRS website at www.irs.gov/Businesses and
not required by providing you with a Form W-9 with"Not Applicable"(or clicking on Employer Identification Number(EIN)under Starting a
any similar indication)written or printed on the line for a FATCA Business.Go to www.irs.gov/Forms to view,download,or print Form
exemption code. W-7 and/or Form SS-4. Or,you can go to www.irs.gov/OrderForms to
A—An organization exempt from tax under section 501(a)or any place an order and have Form W-7 and/or SS-4 mailed to you within 10
individual retirement plan as defined in section 7701(a)(37) business days.
If you are asked to complete Form W-9 but do not have a TIN,apply
B—The United States or any of its agencies or instrumentalities for a TIN and write"Applied For"in the space for the TIN,sign and date
C—A state,the District of Columbia,a U.S.commonwealth or the form.and give it to the requester.For interest and dividend
possession,or any of their political subdivisions or instrumentalities payments,and certain payments made with respect to readily tradable
instruments,generally you will have 60 days to get a TIN and give it to
D—A corporation the stock of which is regularly traded on one or
more established securities markets,as described in Regulations the requester before you are subject to backup withholding on
section 1.1472-1(c)(1)() payments.The 60-day rule does not apply to other types of payments.
You will be subject to backup withholding on all such payments until
E—A corporation that is a member of the same expanded affiliated you provide your TIN to the requester.
group as a corporation described in Regulations section 1.1472-1(c)(1)(i)
Note:Entering"Applied For"means that you have already applied for a
F—A dealer in securities,commodities,or derivative financial TIN or that you intend to apply for one soon.
instruments(including notional principal contracts,futures,forwards,
and options)that is registered as such under the laws of the United Caution:A disregarded U.S.entity that has a foreign owner must use
States or any state the appropriate Form W-8.
G—A real estate investment trust Part II. Certification
H—A regulated investment company as defined in section 851 or an To establish to the withholding agent that you are a U.S.person,or
entity registered at all times during the tax year under the Investment resident alien,sign Form W-9.You may be requested to sign by the
Company Act of 1940 withholding agent even if item 1,4,or 5 below indicates otherwise.
I—A common trust fund as defined in section 584(a) For a joint account,only the person whose TIN is shown in Part I
J—A bank as defined in section 581 should sign(when required).In the case of a disregarded entity,the
K—A broker person identified on line 1 must sign.Exempt payees,see Exempt payee
L—A trust exempt from tax under section 664 or described in section code, earlier.
4947(a)(1) Signature requirements.Complete the certification as indicated in
items 1 through 5 below.
Form W-9(Rev.10-2018) Page 5
1.Interest,dividend,and barter exchange accounts opened For this type of account Give name and EIN of:
before 1984 and broker accounts considered active during 1983.
14.Account with the Department of The public entity
You must give your correct TIN,but you do not have to sign the
certification. Agriculture in the name of a public
entity(such as a state or local
2.Interest,dividend,broker,and barter exchange accounts government,school district,or
opened after 1983 and broker accounts considered inactive during prison)that receives agricultural
1983.You must sign the certification or backup withholding will apply.If program payments
you are subject to backup withholding and you are merely providing
your correct TIN to the requester,you must cross out item 2 in the 15.Grantor trust filing under the Form The trust
certification before signing the form. 1041 Filing Method or the Optional
3.Real estate transactions.You must sign the certification.You may Form 1099 Filing Method 2(see
cross out item 2 of the certification. Regulations section 1.671-4(b)(2)(i)(B))
4.Other payments.You must give your correct TIN,but you do not List first and circle the name of the person whose number you furnish.
have to sign the certification unless you have been notified that you If only one person on a joint account has an SSN,that person's number
have previously given an incorrect TIN."Other payments"include must be furnished.
payments made in the course of the requester's trade or business for 2 Circle the minor's name and furnish the minor's SSN.
rents,royalties,goods(other than bills for merchandise),medical and
health care services(including payments to corporations),payments to 3 You must show your individual name and you may also enter your
a nonemployee for services,payments made in settlement of payment business or DBA name on the"Business name/disregarded entity"
card and third party network transactions,payments to certain fishing name line.You may use either your SSN or EIN(if you have one),but the
boat crew members and fishermen,and gross proceeds paid to IRS encourages you to use your SSN.
attorneys(including payments to corporations). 4 List first and circle the name of the trust,estate,or pension trust.(Do
5.Mortgage interest paid by you,acquisition or abandonment of not furnish the TIN of the personal representative or trustee unless the
secured property,cancellation of debt,qualified tuition program legal entity itself is not designated in the account title.)Also see Special
payments(under section 529),ABLE accounts(under section 529A), rules for partnerships,earlier.
IRA,Coverdell ESA,Archer MSA or HSA contributions or *Note:The grantor also must provide a Form W-9 to trustee of trust.
distributions,and pension distributions.You must give your correct
Note:If no name is circled when more than one name is listed,the
TIN.but you do not have to sign the certification. number will be considered to be that of the first name listed.
What Name and Number To Give the Requester Secure Your Tax Records From Identity Theft
For this type of account: Give name and SSN of: Identity theft occurs when someone uses your personal information
1.Individual The indivicual such as your name,SSN,or other identifying information,without your
2.Two or more individuals(joint The actual owner of the account or,if permission,to commit fraud or other crimes.An identity thief may use
account)other than an account combined funds,the first individual on your SSN to get a job or may file a tax return using your SSN to receive
maintained by an FFI the account' a refund.
3.Two or more U.S.persons Each holder of the account To reduce your risk:
(joint account maintained by an FFI) •Protect your SSN,
4.Custodial account of a minor I The minor2 •Ensure your employer is protecting your SSN,and
(Uniform Gift to Minors Act) •Be careful when choosing a tax preparer.
5.a.The usual revocable savings trust The grantor-trustee' If your tax records are affected by identity theft and you receive a
(grantor is also trustee) notice from the IRS,respond right away to the name and phone number
b.So-called trust account that is not The actual owner printed on the IRS notice or letter.
a legal or valid trust under state law
If your tax records are not currently affected by identity theft but you
6.Sole proprietorship or disregarded The owner3 think you are at risk due to a lost or stolen purse or wallet,questionable
entity owned by an individual credit card activity or credit report,contact the IRS Identity Theft Hotline
7.Grantor trust filing under Optional The grantor' at 1-800-908-4490 or submit Form 14039.
Form 1099 Filing Method 1(see For more information,see Pub.5027,Identity Theft Information for
Regulations section 1.671-4(b)(2)(i) Taxpayers.
(A)) Victims of identity theft who are experiencing economic harm or a
For this type of account: Give name and EIN of systemic problem,or are seeking help in resolving tax problems that
8.Disregarded entity not owned by an The owner have not been resolved through normal channels,may be eligible for
individual Taxpayer Advocate Service(TAS)assistance.You can reach TAS by
9.A valid trust,estate,or pension trust Legal entity.' calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD
1-800-829-4059.
to.Corporation or LLC electing The corporation Protect yourself from suspicious emails or phishing schemes.
corporate status on Form 8832 or Phishing is the creation and use of email and websites designed to
Form 2553 mimic legitimate business emails and websites.The most common act
11.Association,club,religious, The organization is sending an email to a user falsely claiming to be an established
charitable,educational,or other tax- legitimate enterprise in an attempt to scam the user into surrendering
exempt organization private information that will be used for identity theft.
12.Partnership or multi-member LLC The partnership
13.A broker or registered nominee The broker or nominee
Form W-9(Rev.10-2018) Page 6
The IRS does not initiate contacts with taxpayers via emails.Also,the Privacy Act Notice
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers,passwords,or similar secret access Section 6109 of the Internal Revenue Code requires you to provide your
information for their credit card,bank,or other financial accounts. correct TIN to persons(including federal agencies)who are required to
If you receive an unsolicited email claiming to be from the IRS, file information retums with the IRS to report interest,dividends,or
forward this message to phishing@irs.gov.You may also report misuse certain other income paid t t you;f property;o interest the youcpaid;theo
of the IRS name,logo,or other IRS property to the Treasury Inspector debt;acquisition or trr abandonment made secured tan IRA,Arch cancellation of
General for Tax Administration(TIGTA)at 1-800-366-4484.You can ofcectb g ions you us to n information on theMSform HSA.The
forward suspicious emails to the Federal Trade Commission at person collecting tiur this form uses the ingthothe to file
spam®uce.gov or report them at www.ftc.gov/complaint.You can information returns with the IRS,reporting the above information.
contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT(877-438-4338). Routine uses of this information include giving it to the Department of
JusticIf you have been the victim of identity theft,see www.IdentityTheft.gov Columbia,fara civilU.Sand criminal litigationeland to cities,states,the District of
and Pub.5027. and U.S.commonwealths and possessions for use in
administering their laws.The information also may be disclosed to other
Visit www.irs.gov/IdentityTheft to learn more about identity theft and countries under a treaty,to federal and state agencies to enforce civil
how to reduce your risk. and criminal laws,or to federal law enforcement and intelligence
agencies to combat terrorism.You must provide your TIN whether or
not you are required to file a tax return.Under section 3406,payers
must generally withhold a percentage of taxable interest,dividend,and
certain other payments to a payee who does not give a TIN to the payer.
Certain penalties may also apply for providing false or fraudulent
information.
Z Q
O D 0 o pn Zn -c7 Co CD DDz- 3 Q oZ * On N
V . CDN N m
c > < 3' o N rp
-4- O V I N .'+0 rr (Q -. Q
'i O 0 Z 13.
'
-, I cD -< C 3 2•
a 2 N ____
-7 _
D 1 a 0
en m
73
rD
F--
D
m z
n.
E -n+ m M
N
O Nn =
n z
O a m "i
N ` Q O T
en
X a - Z
a
Q Q
-' 3 (1) n
c -o
Vgo D0. <
j 5 cap73
rD
m
a
FOE-, 0
E = pa
if
71
°. m -I
n rn
o• D
N O m O
, mn m Z
x ..-.I
i (D O N
U' 'G
N
CD 0
- N c
Z 3 v
x c -n
Q C
m -
z
v
tel
a 3
I) '-.,-q
2
- -a
3o
Q c
n o
if O
o Q = 1
I
O 'O0 0000 00 — D 3
m CD
o 3
70 a
-< =i
n W
O
V
rn
p 0 m Qq < nm Ti
o=' m n(D 3—c3 Q-
rnN QQ (5 ( Q o D n y 7 p: n 21 Q Q Q
5).
C g), 3 N 3 0 Q ` n
O a Q Q C 3 O O 0
0 D q a r -3:
O O (D 3 �
0 �5 3: 7 a 3 -<
n - Q D CIT( O C C 1
p
(Q Q flu Q(Q O 3 0 O
03 (0 N N ,cn rn
Q CX co O6 o Q Q n
7 -� 3 'r < (D N
n• (D 3 0 • (-) p
C
Q n' a (0 o 3
o P. a' N
5. Q cD 3O
D 3 (D Q 0
a Q _� 0
n ° — n Q o
(D - n 'O = {
CD Q Q 0
cin ,,, p" (� lD
Q
D
C
Na 5. O c
O (D :^ c
0
jQ
rt
CD
02 XI
a3
ca Q
5
o a
Q c
i
t
1