HomeMy WebLinkAboutContract 57919 CSC No. 57919
PUBLIC UTILITIES VENDOR AGREEMENT
COMPREHENSIVE ENERGY ASSISTANCE PROGRAM
The purpose of the Comprehensive Energy Assistance Program ("CEAP") funded from the Low-Income
Home Energy Assistance Program ("LIHEAP") grant is to maintain an energy supply to heat and cool the
residences of eligible low-income clients.
The Energy Services provider ("Vendor"), agrees to honor the purpose of the CEAP grant and to accept
pledges of payment from CEAP agencies only for certified customers to whom Vendor continues to
provide energy services. The Energy Assistance Provider ("Agency"), agrees to make payments only for
eligible low-income clients.
This vendor agreement is by and between:
City of Fort Worth
and
Energy Assistance Provider(Agency) ,6RMKC.F_T
Ns — ACACIA Energy sm,.A &f Gcr /C,�w� �,2, z ri4L
(Vendor)
Vendor and Agency agree to assist customers in the following counties: Tarrant County
This agreement shall be effective from the 1st day of July 2022 —and will expire on the
31st _day of December 2023.. Either party may terminate this agreement by written notice.
Such written notice of termination shall not affect any obligation by either party incurred prior to the
receipt of such notice.Notice shall be sent via certified mail with return receipt requested.
ACACIA Energy
(Vendor Name)
PoB �3ysa3 ,�iol�s, rX �3�3 -ysa
(Vendor Mailing Address)
City of Fort Worth; Neighborhood Services Department
(Agency Name)
200 Texas Street Fort Worth,TX 76102
(Agency Mailing Address)
1 RevisE OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
The Agency named above represents and warrants to Vendor that it is a subrecipient of the Texas
Department of Housing and Community Affairs ("TDHCA") and as such is authorized and has received
funding from the TDHCA to provide bill payment assistance service for eligible low-income households.
The Vendor named above represents and warrants that it will apply any payments received from Agency
to the account of the customer that the Agency has determined to be eligible under the CEAP guidelines
and such is a "Certified Customer".
Vendor will,with reference to a Certified Customer:
• Extend the CEAP applicant's energy service for up to five business days while the Agency
determines whether the CEAP applicant is eligible pursuant to the CEAPguidelines.
• Upon accepting pledge from Agency for Certified Customer, continue or restore energy service
to Certified Customer with no increases in charges,service charges or other charges affecting the
total cost of the bill, except as allowed by the stated tariff cost registered with the Public Utility
Commission "PUC" and/or Texas Railroad Commission.
• In the event the full past due balance is not paid by the Agency,the Certified Customer must pay
the remaining balance on or before the disconnect date stated in the customer's Disconnect
Notice required by PUC regulations in order to avoid disconnection or be eligible for
reconnection. Nothing in this agreement requires the Vendor to reconnect the customer upon
receipt of a pledge that does not cover the full past due balance or if the customer has already
been disconnected by the time the pledge is received by the Vendor.
• Invoice the Certified Customer in accordance with Vendor's normal billing practices.
• Upon verbal or written request from Agency, provide at no cost to the Agency the Certified
Customer's billing and usage history for previous twelve months, or available history plus
monthly estimates if less than twelve months of billing history and usage is available. Vendor will
transmit such billing history via electronic mail or facsimile as soon as possible, but no later than
forty-eight hours following the request.
• Work with Agency and Certified Customer to explore the feasibility of offering flexible payment
arrangements that may include, without limitation, waiving security deposits, reconnect fees,
application fees, and all other fees whenever possible.
• Not discriminate against Certified Customer in price or services, including the availability of
deferred payment plans, level or average payment plans, discount, budget, advance payment or
other credit plans.
• Not refuse to provide energy service or otherwise discriminate in the marketing and provision of
energy service to any Certified Customer because of race, creed, color, national origin, ancestry,
sex, marital status, lawful source of income, level of income, disability,financial status, location
2 Revised July 2022
of customer in an economically distressed geographic area, or qualification for low-income or
energy-efficiency services.
• Allow Agency forty-five days from the date of the pledge to forward payment to the Vendor.
Vendor agrees not to consider the portion of the Certified Customer's account to be paid by the
Agency delinquent if said payment is received within the above mentioned forty-five day period,
and Vendor is provided with a verbal or signed pledge from the Agency within forty-five days of
identifying a Certified Customer.
• Not interrupt service if Certified Customer is eligible under PUC regulations, or other state
agency regulations(as applicable), and enters into an agreement with the Vendor concerning
how the Certified Customer will pay the balance owed Vendor and the Certified Customer is
meeting the obligation under such agreement.
• If the Agency has paid for an initial deposit or similar refundable instrument, upon the
termination of service to the Certified Customer,the Vendor shall return funds including
interest(after any balance owed)to the Agency in accordance with PUC regulations or 10 Texas
Administrative Code§6.312(f)(as applicable).
The Agency will:
• Obtain written permission for Agency to request and have access to customer information,
including confidential or personal account information, credit and payment history, from
customers seeking Agency's assistance. Social Security numbers are not required for the CEAP
program and may not be disclosed to Agency.
• Provide to Vendor, at Vendor's request, customer's written permission for Agency's access to
customer information as stated above.
• Not provide pledges on behalf of a Certified Customer to Vendor without having adequate funds
to pay such pledge.
• Pay pledges within forty-five days of making pledge to Vendor.
• Determine if a customer is a Certified Customer within five daysof contacting Vendor.
• Provide Vendor a list of names, telephone numbers and e-mail addresses of Agency staff
designated to make pledges on behalf of the Agency and Certified Clients, if requested from
Vendor.
The terms of any confidential transaction under this agreement or any other information exchanged by
the Agency and Vendor relating to any transaction shall not be disclosed to any person not employed or
retained by the Agency or Vendor,their affiliates,or brokers,except to the extent disclosure is 1) required
by law; 2) necessary to disclose to the other party in connection with a dispute between the parties; 3)
otherwise permitted by written consent of the other party; 4) required by guarantors to be disclosed;
5) 3
Revised July 2022
information which must be disclosed to a third party to transmit energy; 6) to meet reliability council,
regulatory,administrative,judicial,governmental,or regulated commodity exchange requirements where
necessary; or 7) information which was or is hereafter in the public domain (except by breach of this
Agreement).
If vendor has fewer than 10 employees or the Agreement is for less than $100,000,this section does not
apply. Vendor acknowledges that in accordance with Chapter 2270 of the Texas Government Code, City
is prohibited from entering into a contract with a company for goods and services unless the contract
contains a written verification from the company that it: (1) does not boycott Israel; and (2) will not
boycott Israel during the term of the contract. The terms "boycott Israel" and "company" shall have the
meanings ascribed to those terms in Section 808.001 of the Texas Government Code. By signing this
Vendor Agreement, Vendor Certifies that Vendor's signature provides written verification to City that
Vendor: (1) does not boycott Israel;and (2)will not boycott Israel during the term of the Agreement.
Vendor agrees that City shall, until the expiration of three (3) years after final payment under the
Agreement, have access to and the right to examine any directly pertinent books,documents, papers and
records of Vendor involving transactions relating to the Agreement. Vendor agrees that City shall have
access during normal working hours to all necessary Vendor facilities and shall be provided adequate and
appropriate workspace in order to conduct audits in compliance with the provisions of this section. City
shall give Vendor reasonable advance notice of intended audits.
[Signature page follows]
4 Revised July 2022
Authorized Vendor Signature Date
A410 c�AlllDf�25 3e. <S-V;C WC0,'V,0J7WA7r
Typed Name of Authorized Signature Title
Vendor(Area Code)Telephone Number
,4CC40NTsASaBAZKZZ7-(!iV-(!AV Cory!
Vendor Email Address
J u 1 22, 2022
Authorized Agency Signature Date
Victor Turner Director
Typed Name of Authorized Signature Title
817-392-7540
Agency(Area Code)Telephone Number
CITY OF FORT WORTH,TEXAS:
*Victor Turner has been delegated the
proper authority to execute this
document on behalf of the City pursuant
to an Interoffice Memorandum from the
City Manager dated July 20, 2021.
RECOMMENDED:
By:
Sonia Singleton
Assistant Neighborhood Services Director
APPROVED AS TO FORM AND LEGALITY:
By:
Jessika willliams OFFICIAL RECORD
Assistant City Attorney I
CITY SECRETARY
FT. WORTH, TX
5
ATTEST: o°00 01
0
Ono
By:
J ette S.Goodall(Ju128,202216: DT) O j.*'41�1�
o
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Jannette Goodall d� °° 0
00000000 ICY
City Secretary ��tl'4 Samoa
Contract Authorization:
M&C: N/A
Date Approved: N/A No M&C required.Ordinance No. 24161-04-2020
CONTRACT COMPLIANCE MANAGER:
By signing below, I acknowledge that I am the person responsible for the monitoring and administration of
this contract, including ensuring all performance and reporting requirements.
A—�10
Sonia Singleton
Assistant Neighborhood Services Director
6 R OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Form W'9 Request for Taxpayer
Give Form to the
(Rev.October2018) Identification Number and Certification requester.Do not
Department of the Treasury send to the IRS.
Internal Revenue Service ►Go to wwwJrs.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.
Brooklet Energy Distribution, LLC
2 Business name/disregarded entity name,if different from above
dba Acacia Energy
(D 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
m following seven boxes.
a certain entities,not individuals;see
o ❑ Individual/sole proprietor or El Corporation El Corporation ❑ Partnership ElTrust/estate instructions on page 3):
fn single-member LLC
pp, p Exempt payee code(if any)
.i�` ❑✓ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)► P
o 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
in LLC if the LLC Is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
a another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that code(if any)
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
V El� Other(see instructions)►
f/toP!!os to accounts malnfvned oulsldo the U.S.)
5 Address(number,street,and apt.or suite no.)See instructions.
Requester's name and address(optional)
11011 Brooklet Drive
6 City,state,and ZIP code
Houston,TX 77099
7 List account number(s)here(optional)
Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid 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 m
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.
To -En 5 2 5 9
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
2.1 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
3.1 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 de t,contributions to an individual retirement arrangement(IRA),and generally,payments
other than interest and dividends,you are not required to sign t c rtification,but you must provide your correct TIN.See the instructions for Part 11,later.
Sign Signature of
Here U.S.person► Date►
f f
General Instructions •Form 1099-DIV(dividends,including those from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise noted, .Form 1099-MISC(various types of income,prizes,awards,or gross
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 1099-S(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 TIN,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 Request for Taxpayer
Give Form to the
(Rev.October2018) 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.
Brooklet Energy Distribution, LLC
F Business name/disregarded entity name,if different from above
dba Snap Energy
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
rn following seven boxes. certain entities,not individuals;see
m
a
o
ElIndividual/sole proprietor or El Corporation ❑ S Corporation El Partnership ❑Trust/estate instructions on page 3):
c single-member LLC
a o Exempt payee code(if any)
✓❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)► P
o 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)
is disregarded from the owner should check the appropriate
ppro rlate box for the tax classification of its owner.
❑ Other(see instructions)►
(Applios to accounts mainlainod oulsldo(ha U.S.)
fn 5 Address(number,street,and apt.or suite no.)See instructions.
Requester's name and address(optional)
11011 Brooklet Drive
6 City,state,and ZIP code
Houston,TX 77099
7 List account number(s)here(optional)
Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid 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 —
m
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 Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
2 0 -EE5E T59
JIM 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
2.1 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
3.1 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 a ification,but you must provide your correct TIN.See the instructions for Part II,later.
Sign Signature of
Here U.S.person► /
Data► a
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 noted. ( types of income,prizes,awards,or gross
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 1099-8(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 TIN,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.10-2016)
Farm W-9 Request for Taxpayer
Give Form to the
(Rev.October2018) Identification Number and Certification requester.Do not
Department of the Treasury send to the IRS.
Internal Revenue Service to-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.
Brooklet Energy Distribution, LLC
2 Business name/disregarded entity name,if different from above
dba Now Power
a) 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
fallowing seven boxes,
a certain entities,not individuals;see
c instructions on page 3):
o ❑ Individual/sole proprietor or ❑ C Corporation El Corporation El Partnership ❑Trust/estate
fn single-member LLC
a o Exempt payee code(if any)
❑✓ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)► P
o ;? 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
y LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
I another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that code(if any)
(L °— is disregarded from the owner should check the ap
propriate ppropriate box for the tax classification of its owner.
❑ Other(see instructions)►
CL (Applies to acco (s mainfainod oulsido Me U.S.)
Cn
5 Address(number,street,and apt.or suite no.)See instructions.
Requester's name and address(optional)
rn 11011 Brooklet Drive
6 City,state,and ZIP code
Houston,TX 77099
7 List account number(s)here(optional)
RON Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid 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 T -
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.
E__EE
2 5 9
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
2.1 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
3.1 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 c cation,but you must provide your correct TIN.See the instructions for Part 11,later.
Sign Signature of
Here U.S,person► Date►
General Instructions •Form 1099-DIV(dividends,including those from stocks or mutual
Section references are to the Internal Revenue Code unless otherwise funds)
noted. •Form 1099-MISC(various types of income,prizes,awards,or gross
proceeds)
Future developments.For the latest information about developments
related to Form W-9 and its instructions,such as legislation enacted •Form 109s b (stock or mutual fund sales and certain other
transactions b
after they were published,go to www.irs.gov/FormW9. y brokers)
•Form 1099-S(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 TIN,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 Request for Taxpayer
Give Form to the
(Rev.October2018) Identification Number and Certification requester.Do not
Department of the Treasury send to the IRS.
Internal Revenue Service 0-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.
Brooklet Energy Distribution, LLC
2 Business name/disregarded entity name,if different from above
dba Vital Power
m 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
following seven boxes. certain entities,not individuals;see
a
rz o ❑ Individual/sole proprietor or El Corporation ❑S Corporation El Partnership ❑Trust/estate instructions on page 3):
rn single-member LLC Exempt payee code(if any)
a o
❑✓ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)► P
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
y LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
a another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that code(if any)
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
❑ Other(see instructions)►
(Applies to accounts maintained outside the U.S)
rn 5 Address(number,street,and apt.or suite no.)See instructions.
Requester's name and address(optional)
W 11011 Brooklet Drive
6 City,state,and ZIP code
Houston,TX 77099
7 List account number(s)here(optional)
Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding.For individuals,this is generally your social security number(S .However,for a -m -
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 Employer Identification number
Number To Give the Requester for guidelines on whose number to enter.
2 0 — 5 1 3 1 1 1 5 45 1 9
Certification
Under penalties of perjury,1 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
2.1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)1 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
3.1 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. ication,but you must provide your correct TIN.See the instructions for Part 11,later.
Sign Signature of
Here U.S.person► Date aca
►
General Instructions •Form 1099-DIV(dividends,including those from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise noted. .Form 1099-MISC(various types of income,prizes,awards,or gross
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 1099-S(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 TIN,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)