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Home My WebLink AboutContract 53699-NC1CSC No. 53699-NC1 FORTWORTH MEMORANDUM Date: 11 /3/2023 To: Assistant City Attorney From: Tracy Walter — FMS/Vendor Management Re: Name Change Only: Cl Technologies Inc. to Cl Technologies LLC Prior Name: CI Technologies Inc. New Name: CI Technologies LLC Supplier id: 0000015759 CSCO: 53699 Note: Supplier updated name only and the tax id (EIl) number remained the same. APPROVED BY: Assistant City Attorney Nov 3, 2023 OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX Delaware Page The First State I, JEFFREY W. BULLOCK, SECRETARY OF STATE OF THE STATE OF DELAWARE, DO HEREBY CERTIFY THE ATTACHED ARE TRUE AND CORRECT COPIES OF ALL DOCUMENTS ON FILE OF "CI TECHNOLOGY, LLC" AS RECEIVED AND FILED IN THIS OFFICE. THE FOLLOWING DOCUMENTS HAVE BEEN CERTIFIED: CERTIFICATE OF CONVERSION, FILED THE TWENTY—FOURTH DAY OF FEBRUARY, A.D. 2023, AT 2:32 O'CLOCK P.M. CERTIFICATE OF FORMATION, FILED THE TWENTY—FOURTH DAY OF FEBRUARY, A.D. 2023, AT 2:32 O'CLOCK P.M. AND I DO HEREBY FURTHER CERTIFY THAT THE AFORESAID CERTIFICATES ARE THE ONLY CERTIFICATES ON RECORD OF THE AFORESAID LIMITED LIABILITY COMPANY, "CI TECHNOLOGY, LLC" 7316705 8100H SR# 20231086434 dummy YI SkPIRKh. SecMary W SWm Authentication: 202969138 Date: 03-21-23 DocuSign Envelope ID: B2BDA65C-D249-4FFD-86EA-40199898045C STATE OF DELAWARE CERTIFICATE OF CONVERSION FROM A NON-DELAWARE CORPORATION TO A DELAWARE LIMITED LIABILITY COMPANY PURSUANT TO SECTION 18-214 OF THE LIMITED LIABILITY ACT 1. The jurisdiction where the corporation first formed is the State of Florida. 2. The jurisdiction immediately prior to filing this Certificate is the State of Florida. 3. The date the corporation first formed is September 2, 1998. 4. The name of the corporation immediately prior to filing this Certificate is Cl TECHNOLOGIES, INC. 5. The name of the limited liability company as set forth in the Certificate of Formation is CI TECHNOLOGY, LLC. IN WITNESS WHEREOF, the undersigned has executed this Certificate on the 23rd day of February, 2023. CI TECHNOLOGIES, INC., a Florida corporation DocuSigned by: By: �... Name: Tim Conner Title: President State of Delaware Secretary of State Division of Corporations Delivered 02:32 PM, 02/24/2023 FILED 02:32 PM 02/24/2023 SR 20230689217 - File Number 7316705 DocuSign Envelope ID: B2BDA65C-D249-4FFD-86EA-40199898045C STATE OF DELAWARE CERTIFICATE OF FORMATION OF LIMITED LIABILITY COMPANY The undersigned authorized person, desiring to form a limited liability company pursuant to the Limited Liability Company Act of the State of Delaware, hereby certifies as follows: 1. The name of the limited liability company is Cl TECHNOLOGY, LLC. 2. The Registered Office of the limited liability company in the State of Delaware is located at: 108 Lakeland Ave., in the City of Dover, County of Kent, 19901. The name of the Registered Agent at such address upon whom process against this limited liability company may be served is Capitol Services, Inc. IN WITNESS WHEREOF, the undersigned has executed this Certificate of Formation as of this 23 day of February, 2023. DncuSigned by: 1 INA6#k� (h"kr -►J I J,IJ J2h1J:1... Authorized Person State of Delaware Secretary of State Division of Corporations Delivered 02:32 PM, 02/24/2023 FILED 02:32 PM 02/24/2-023 SR 20230689217 - File Number 7316705 Request for Taxpayer Give Form to the Form (Rev. October2018) ■wv.•�nwwa.v.■ .�w...ww. ...... �.......�........ ---- - -- - 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. Cl Technology, LLC 2 Business name/disregarded entity name, if different from above c0 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 cufollowing seven boxes. certain entities, not individuals; see a instructions on page 3): C 0 ❑✓ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate c single -member LLC Exempt payee code (if any) ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► `p 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 .3`. 0 c LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is code if an ( y) a another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. d❑ Other (see instructions) ► (Applies to accounts maintained outside the U.S.) y5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) 109 Ponemah Road, Unit H 6 City, state, and ZIP code Amherst, New Hampshire 03031 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 - 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. 579 - 3 15 14 4 i 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 certification, but you must provide your correct TIN. See the instructions for Part 11, later. Sign Signature of __ /�� Here I U.S. person ► ► r�� Date 0-/" I t`� 27, V �` 3 General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018)