HomeMy WebLinkAboutContract 52330-NC152330-NC1
Memorandum
Date: 4/27/2023
To: Assistant City Attorney
Return to: Tracy Walter — FMSNendor Management
Re: Omega Contracting Inc. to Omega Contracting, LLC - Name Change
Request
Prior Name: Omega Contracting Inc.
New Name: Omega Contracting, LLC
CSCO: 52330
Supplier Id: 7000000382
Reason for Name Change: Supplier has changed entity status however is
maintaining the same tax id number.
Reviewed & Approved by:
Andrea Phillip,4142 309:%IM
Asst. City Attorney
May 4, 2023
Date
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
OMEGA
CONTRACTING
2518 Chalk Hill Rd
Dallas TX 75212
PH: (214) 972-0612
www.azteca-omega.com
April 26, 2023
City of Fort Worth
Vendor Management
Supplier ID 7000000382
RE: Notice of Entity Change
Omega Contracting Inc. changed entity type from Incorporated to Limited Liability Company effective
January 1, 2022.
Should you have any questions or need anything further, please reach out to me. My contact
information is below.
Thank you for your help with this.
Karen Larson, Risk Manager
klarson@azteca-omega.com
(214) 418-3806
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Filing#: 126017900 Document#: 1106255110003 Filed On 12/28/2021 received by Upload
CERTIVICA,u OF
M
OMEGA. CONTRACTING, IN('.
(, Texas corporahop)
INTO
(WEGA. (74-.YN3:^RA(Yrryn LUC
(i 17exas limited fiabflit�r couipsany)
i-lurs"la.rit. to the of Sectiola 1 A 10 1 of fjhe Tlexas 13u,,inest� Orga-riizatioris Code,
ONAFGA CEYNTRAC."ISK! INQ a 1-`;�Xas; c'orpor,& ,tion cm- "r-n--tng lj;�Ieby, �adopc.,--;
this Cerfifkw�;,� of ConvosIn fbt- the purpose of corwertin.- U-MEGA (,'0N--TRAC7'1NG, INC,
firom -,, Texas corporation Am a Texas lAdvad AS& cornpany to bc- ka,,;.owl.- as C)ME(JA
C70hQT.-,-F'ACT'KG. ULC. hndWd bakht- Lii--n.ited
The AnwaNg Enti-iry cutifi.,-�S a-F, IffiHOWS:
1. The namef Me AnvuHng EMy? is 0-MIEGA C,'ONTRACTING, INC,
Z. The Q!�dic-11.,ion of formatio-n of the Clonvating EnSf isthe state of Texas.
1 The dwrte o!" of tht� Colivefting Ei,,.Iity i's February 1111 6, 1993.
4. The Bic mimber issuk to the Converting Endly by Me seaetay? of swe is
126017900.
T The Convert-,ng Entity nau.-j�,d 6bov- is convewing toa "Jil-nited i-J-aj-)flity companv,
the wne of the C.'�onverted ETmty.it; OMEG.A CONTR,V',`TING, LLC,
6. 11he Anvertod Wity iAiil] be oj.--J7e>--aS,
7. sio Instettachin-
g the plan of co-Aworn, the EentftIT cer.---i. fi.es to !:he
f6flo"vinwl ogfaS-katel'n;mts
A, A ,igneci plan cdff.�o-nversion is, cn file at the principad place of business of
le Cirivating EnApy. The addrcs� of -,he PT,-J•1Cip(.0 place ofl-61,1siless, ofme
Converting E'nfity W 8 Chalk Road, Daha.,,, 1'exas 75212.
B. A - iganed plwn of ;", be -.m file afftor the at the
principal place of business of' t1he The address o.F the
WRTIMIAME ()F CONVT-.�..RSJOIN, -i- O.NdIEGA C0N-FR-A.C'-r.'R-,,G, 1W,
principal place of business of the Converted Entity is 2518 Chalk Bill Toad,
Dallas, Texas 752:6 2.
C . A copy of the plan of conversion will be furnished on written request
without cost by.the Converting Entity before the conversion or by the
Converted Entity after the conversion to any owner or mere. ber of the
C:onverti Ig Entity or Converted Entity,
S. The Converted Entity is a "Texas limited liability company. The certificate of
formation of the Converted Entity is attached to this ccrti-ficate of conversion.
9. The plan of conversion has been approved as required by the laves of 'Texas and the
governing doc;urnents of the Converted Entity.
1.0. In lieu of providing the tax certificate, the limited liability company as the
Converted Entity is liable for the payment of any Franchise taxes.
1 ] . This document becomes effective at a later elate, which is not more than n.inet", (90)
clays froin the date of signing, The delayed effective elate is January 1, 2022.
The { ndersi.n peel sigixs this c ocurnent su' "ect to the penalties imposed by la\�, for the
submissions of a materially false of fraudulent instTu rent.
Dated.- December 28, 2021
; 6}A
OMEGA CONTRACTING, IIC.
Luis S. Spinola l e ident
CERTIFICATE OF CONI ERSTC)N -2- OMEGA COOT-RACTII1G.11vC.
CERTIFICATE OF FORNIATION
OF
I, the undersigned niiatffdl DCrs0rr., a^.t-hIg as organ zer 0>1"OMEEGA CONT1 ACTINIG, LLCM.
limited liability company (the "Com.na riv" a Under the Texas B-asiriess Organizations Code i the
Name. The name of the Company is Cal` E fA CCU �I�'�r'�C'�"IA�C3, LLC,
2. Conversion, The entity is bc: irtg forrried pursuant to a pars of corniersion. The converting
e,rtit<y`s rrar€iis C�i111 C _ `.. �'u`i'i C'1`fl*'_G, a. r.,€rrali rE formed. ander the laws of
the State of Texas on February I6, 1993, rider tile; nurribeb 12601 900. The tnailing and
street address of CiN-IEGA, CONTRACTING, TNC. is'218 Chalk: MY: Road, Dallas, Texas
75-21 '.
Qura}i.oi . T'he period of dx,, tion of the Corrrpar y xs perpctual unless the Company is
earlier ; oijrAd lap in accord arxce with the prov i.siens of its Comp 3..rry a greelnen- t.
4, 'l°eMg::Le., The �3ur� ose or vvl"zS.ci w. Company :?1�lc3"�y4' {g 3.r:ja:37 .i d 1 LZ ^or�
us ne�,s. €o rt niote any lawful pumose. and to engage ri. arI , i.awhil act or act`vIli y' Bor
wbic:h tita:ited liability companies may be er9anized under. I.: the Texas Limited ability
Corrpau f Law (ei-e "".i 1A.X.'JL ').
6. .gwers. The Company ,hall have the powers provided 1'or a limited iiability company
Lmder the TxIBOC.
6. Classes
es q r � 1S.f.Ct The � orn and shall r 111- aufl.S..to �Y L` i -s,-ue TINTO 'CIM ..>OS
i..y_C�.:3:9� .3: .'�vlet'lI ers am ro .i" ~ Y '''` 7.Cea��.. s 1 zt T ti` i MSS
OS
F` rsl en bra- ship units, t-0 be designated, i"G:ipoct.''.vely, voting 5:iernber _hip kmits and Tion .
voting men"bership units. All inembership units ofi tire Co-fripany shall have identical rights
and privileges in every respect, except that :he holders of voting ineribership units, shall be
entitled to vote u13p�'�:'? all rnatters :9,a� r lifted to a vote of i:ae n;crnbe,rs of flee � ornmaniv.
{i+'3;.y\s'yl+�dye�rs ,:�s{3AV(t��i]irs:"(�F�{luny }(g y$u?�.eyr (�i��L�..yrsy�y�i1:�?(��-nits A'ehall-y�n.ot 1be onfitiled.otherwise
^t��4�f�y vote C.�y?�4yi'n �:,�d�.f{;�f(yi r�('sL�.iL �1
)t.l.•�t ifted �Lgl3 a vote of he S_•lF..te L`✓ers o the �Flon-iyfany, oxc+ yept as oiher l�Y'i se pi-o- Y,-. od Ltt the
t..orrlpan yr .A.greement or rCi2lui d by l.t` -w .
�.3erLillL w; <3Lct 3vr3i t lei at's'�' voting is expressly? deiil{1'.
S& >` o l"reerrt. fi}r 1:t,4. Preerr fli'll c rights dk j n:3t exist.
9. Com arry Agreenient, The; initial Corrpay. ; _ greernent veil' be adopted by he ,ne.-n-bers..
The powers to alter, .xrrlend, or repeal the; Corripa.rrt Ag eemerit or adept a new CCerr parry
Ag-reement is "vested in the ineinbers, except as etherwlw pro%sided in the Company
Agreement,
C.:�iR 'l'r'1.('1' iTE OF2�1�i�t.s��e N. 1t-.i.' "i- 5..i:�b�l El.7.A �,�?:.'V�V.f`�.'1��21�A `i.�i', 11�� �-,
10. Indemnification. The Company shall have the power and authority to indemnify any
person, including members and managers, to the fullest extent permitted by law.
11. Release of Liability. To the full extent permitted by Texas law, no manager of the
Company shall be liable to the Company or its members for monetary damages for an act
or omission in such manager's capacity as a manager of the Company, except that this
Article does not eliminate or limit the liability of a manager to the extent the manager is
found liable for (i) a breach of the manager's duty of loyalty to the Company or its
members; (ii) an act or omission not in good faith that constitutes a breach of duty of the
manager to the Company or an act or omission that involves intentional misconduct or a
knowing violation of the law; (iii) a transaction from which the manager received an
improper benefit whether or not the benefit resulted from an action taken within the scope
of the manager's office; or (iv) an act or omission for which the liability of a manager is
expressly provided by an applicable statute. Any repeal or amendment of this Article by
the managers or members of the Company shall be prospective only and shall not adversely
affect any limitation on the liability of a manager of the Company existing at the time of
such repeal or amendment. In addition to the circumstances in which the manager of the
Company is not liable as set forth in the preceding sentences, the manager shall not be
liable to the fullest extent permitted by any provision of the statutes of Texas hereafter
enacted that further limits the liability of a manager or of a director of a corporation. The
foregoing elimination of the liability to the Company or its members for monetary damages
shall not be deemed exclusive of any other rights or limitations of liability or indemnity to
which a manager may be entitled under any other provision of the Certificate of Formation
or the Company Agreement of the Company, contract or agreement, vote of members of
the Company, or otherwise.
12. Transferability Restrictions. The membership units of the Company will be subject to
restrictions on transferability as set out in the Company Agreement of the Company, or in
separate agreements (one or more) among the members, all of which will be kept with the
records of the Company. The Company will provide a copy of the Company Agreement
and any separate agreement(s) among the members without charge to any record holder of
a membership unit upon written request addressed to the Company at its principal office
or its registered agent's address.
13. Registered Agent and Mailimz Address. The street address of the initial registered office
of the Company and its principal office is 2518 Chalk Hill Road, Dallas, Texas 75212 and
the name of its initial registered agent at such address is Luis S. Spinola. The initial mailing
address of the Company is 2518 Chalk Hill Road, Dallas, Texas 75212.
CERTIFICATE OF FORMATION -2- OMEGA CONTRACTING, LLC
1.4, Ini.tial Manager. The Company ;,viil be managed by managers. The name and address of
the initial manager is as follows:
L IS S. SPIItiOLA
25.18 ClIalk Hill Road
Dallas, Texas 75212
15. Organizer. The organizer is age 18 years or snore, and the name and address of the
organizer is:
LUIS S. SP NO � k
2518 Chalk Hill Road
Dallas, Texas 752-12
16. Electiveness ofFilin .. This document becomes effective at a later date., which is not more
than ninety (90) days from the date of signing. The delayed effective date is JanuM 1..
.022.
It undersigned affirms that tho person designated as registered agent: has consented to the
appointment. The undersigned signs this document subject -to the penalties imposed by law for the
submission of materially false or fraudulent instrument and certifies under penalty of periary that
the undersigned is authorized to execute the film instrument.
T WITNESS WHEREOF, I have hereuEato set my hand on December -?8, 202I
366699_
TIZACf1NU,
CERTI-1.1C TEOFFOR FORMATION -�- OMEGA CON
WM9
Request for Taxpayer
Give Form to the
Form
(Rev. October2018)
Identification Number and Certification
requester. Do not
Department of the Treasury
send to the IRS.
Internal Revenue Service
1► Go to www,7rs,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.
Omega Contracting LLC
2 Business name/disregarded entity name, If different from above
Omega Contracting Inc.
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check onty one of the
4 Exemptions (codes apply only to
following seven boxes.
certain entities, not Individuals; see
Q.
o
❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
Instructions on page 3):
single member LLC
Exempt payee code (if any)
[✓ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► S
o
Note: Check the appropriate box In the Iine 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
code if an
( y)
a o
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.
y
❑ Other (see instructions) )•
fM^�' foP�+accounts mainfafned ouistda the U.S.)
0)
5 Address (number, street, and apt. or suite no.) See Instructions.
Requester's name and address (optional)
m
2518 Chalk Hill Rd
6 City, state, and ZIP code
Dallas, TX, 75212
7 List account number(s) here (optional)
111111MM
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 wlien, sole
For individuals, this Is generally your social security number (Sate). However, for a - m -
resident alien, sole proprietor, or disregarded entity, see the Instructions for Part 1, later. For other
entitles, it Is your employer identification number (EIN). If you do not have a number, see Now 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.
7 5 W 2 4 6 �714 M47
FMII 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 pald,
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 U.S. person 11o,
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.lrs.gov/FormIN9.
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
ISSN), 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)
Date ►
• 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)
Form W-9 (Rev. 10-2018)
Page 2
By signing the filled -out form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt
payee. If applicable, you are also certifying that as a U.S. person, your
allocable share of any partnership Income from a U.S. trade or business
is not subject to the withholding tax on foreign partners' share of
effectively connected income, and
4. Certify that FATCA code(s) entered on this form (if any) indicating
that you are exempt from the FATCA reporting, is correct. See What Is
FATCA reporting, later, for further information.
Note: If you are a U.S. person and a requester gives you a form other
than Form W-9 to request your TIN, you must use the requester's form if
it is substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who Is a U.S. citizen or U.S. resident alien;
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States;
• An estate (other than a foreign estate); or
+ A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to pay a withholding
tax under section 1446 on any foreign partners' share of effectively
connected taxable income from such business. Further, in certain cases
where a Form W-9 has not been received, the rules under section 1446
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
that is a partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to establish your
U.S, status and avoid section 1446 withholding on your share of
partnership income.
In the cases below, the following person must give Form W-9 to the
partnership for purposes of establishing its U.S. status and avoiding
withholding on Its allocable share of net income from the partnership
conducting a trade or business in the United States.
• In the case of a disregarded entity with a U.S. owner, the U.S. owner
of the disregarded entity and not the entity;
• In the case of a grantor trust with a U.S. grantor or other U.S. owner,
generally, the U.S. grantor or other U.S. owner of the grantor trust and
not the trust; and
• In the case of a U.S. trust (other than a grantor trust), the U.S, trust
(other than a grantor trust) and not the beneficiaries of the trust.
Foreign person. If you are a foreign person or the U.S. branch of a
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
Pub. 515, Withholding of Tax on Nonresident Aliens and Forelgn
Entities).
Nonresident alien who becomes a resident alien. Generally, only a
nonresident alien individual may use the terms of a tax treaty to reduce
or eliminate U.S. tax on certain types of income. However, most tax
treaties contain a provision known as a "saving clause." Exceptions
specified in the saving clause may permit an exemption from tax to
continue for certain types of Income even after the payee has otherwise
become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an exemption
from U.S. tax on certain types of Income, you must attach a statement
to Form W-9 that specifies the following five Items.
1. The treaty country. Generally, this must be the same treaty under
which you claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the
saving clause and its exceptions.
4. The type and amount of Income that qualifies for the exemption
from tax.
5. Sufficient facts to justify the exemption from tax under the terms of
the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an
exemption from tax for scholarship income received by a Chinese
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
the United States exceeds 6 calendar years. However, paragraph 2 of
the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows
the provisions of Article 20 to continue to apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of the first
protocol) and is relying on this exception to claim an exemption from tax
on his or her scholarship or fellowship income would attach to Form
W-9 a statement that includes the Information described above to
support that exemption.
If you are a nonresident alien or a foreign entity, give the requester the
appropriate completed Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons making certain payments to you
must under certain conditions withhold and pay to the IRS 24% of such
payments. This is called "backup withholding." Payments that may be
subject to backup withholding include interest, tax-exempt Interest,
dividends, broker and barter exchange transactions, rents, royalties,
nonemployee pay, payments made in settlement of payment card and
third party network transactions, and certain payments from fishing boat
operators. Real estate transactions are not subject to backup
withholding.
You will not be subject to backup withholding on payments you
receive If you give the requester your correct TIN, make the proper
cortiflcaVons, and report all your taxable interest and dividends on your
tax return.
Payments you receive will be subject to backup withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the instructions for
Part II for details),
3. The IRS tells the requester that you furnished an incorrect TIN,
4. The IRS tells you that you are subject to backup withholding
because you did not report all your interest and dividends on your tax
return (for reportable interest and dividends only), or
5. You do not certify to the requester that you are not subject to
backup withholding under 4 above (for reportable interest and dividend
accounts opened after 1983 only).
Certain payees and payments are exempt from backup withholding.
See Exempt payee code, later, and the separate Instructions for the
Requester of Form W-9 for more Information.
Also see Special rules for partnerships, earlier.
What is FATCA Reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a
participating foreign financial institution to report all United States
account holders that are specified United States persons. Certain
payees are exempt from FATCA reporting. See Exemption from FATCA
reporting code, later, and the Instructions for the Requester of Form
W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you
claimed to be an exempt payee If you are no longer an exempt payee
and anticipate receiving reportable payments In the future from this
person. For example, you may need to provide updated Information if
you are a C corporation that elects to be an S corporation, or if you no
longer are tax exempt. In addition, you must furnish anew Form W-9 if
the name or TIN changes for the account; for example, if the grantor of a
grantor trust dies.
Penalties
Failure to furnfsh TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such failure
unless your failure Is due to reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding, If you
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. 10-201B)
Page 3
Criminal penalty for falsifying Information. Willfully falsifying
certifications or affirmations may subject you to criminal penalties
including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of
federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Line 1
You must enter one of the following on this line; do not leave this line
blank. The name should match the name on your tax return.
If this Form W-9 is for a joint account (other than an account
maintained by a foreign financial institution (FFI)), list first, and then
circle, the name of the person or entity whose number you entered in
Part I of Form W-9, If you are providing Form W-9 to an FFI to document
a joint account, each holder of the account that is a U.S. person must
provide a Form W-9.
a. Individual. Generally, enter the name shown on your tax return. If
you have changed your last name without informing the Social Security
Administration (SSA) of the name change, enter your first name, the last
name as shown on your social security card, and your new last name.
Note: ITIN applicant: Enter your Individual name as it was entered on
your form W-7 application, line 1 a. This should also be the same as the
name you entered on the Form 1040/1040A/1040EZ you filed with your
application.
b, Sole proprietor or single -member LLC. Enter your individual
name as shown on your 1040/1040A/1040EZ on line 1. You may enter
your business, trade, or "doing business as" (DBA) name on line 2,
c. Partnership, LLC that is not a single -member LLC, C
corporation, or 5 corporation, Enter the entity's name as shown on the
entity's tax return on line 1 and any business, trade, or DBA name on
line 2.
d. Other entities. Enter your name as shown on required U.S. federal
tax documents on line 1. This name should match the name shown on the
charter or other legal document creating the entity. You may enter any
business, trade, or DBA name on line 2.
e. Disregarded entity. For U.S. federal tax purposes, an entity that is
disregarded as an entity separate from its owner Is treated as a
"disregarded entity." See Regulations section 301.77011-2(c)(2)(14). Enter
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
name shown on the Income tax return on which the income should be
reported. For example, if a foreign LLC that is treated as a disregarded
entity for U.S. federal tax purposes has a single owner that is a U.S.
person, the U.S. owner's name is required to be provided on line 1. If
the direct owner of the entity is also a disregarded entity, enter the first
owner that is not disregarded for federal tax purposes. Enter the
disregarded entity's name on line 2, "Business name/disregarded entity
name." If the owner of the disregarded entity Is a foreign person, the
owner must complete an appropriate Form W-8 instead of a Form W-9.
This is the case oven if the foreign person has a U.S. TIN.
Line 2
If you have a business name, trade name, DBA name, or disregarded
entity name, you may enter it on line 2.
Line 3
Check the appropriate box on line 3 for the U.S. federal tax
classification of the person whose name is entered on line 1. Check only
one box on line 3.
IF the entity/person on line 1 Is
THEN check the box for . , .
a(n) ...
• Corporation
Corporation
• Individual
Individual/sole proprietor or single-
• Sole proprietorship, or
member LLC
• Single -member limited liability
company (LLC) owned by an
Individual and disregarded for U.S.
federal tax purposes.
• LLC treated as a partnership for
Limited liability company and enter
U.S, federal tax purposes,
the appropriate tax classification,
• LLC that has filed Form 8832 or.
(P= Partnership; C= C corporation;
2553 to be taxed as a corporation,
or S= S corporation)
or
• LLC that is disregarded as an
entity separate from Its owner but
the owner is another LLC that Is
not disregarded for U.S. federal tax
purposes.
• Partnership
Partnership
• Trust/estate
Trust/estate
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting,
enter in the appropriate space on line 4 any code(s) that may apply to
you.
Exempt payee code.
• Generally, Individuals (including sole proprietors) are not exempt from
backup withholding.
• Except as provided below, corporations are exempt from backup
withholding for certain payments, Including Interest and dividends.
• Corporations are not exempt from backup withholding for payments
made in settlement of payment card or third party network transactions.
• Corporations are not exempt from backup withholding with respect to
attorneys' fees or gross proceeds pal to attorneys, and corporations
that provide medical or health care services are not exempt with respect
to payments reportable on Form i099-MISC.
The following codes identify payees that are exempt from backup
withholding. Enter the appropriate code in the space in line 4.
1—An organization exempt from tax under section 501(a), any IRA, or
a custodial account under section 403(b)(7) if the account satisfies the
requirements of section 401(f)(2)
2—The United States or any of Its agencies or Instrumentalities
3—A state, the District of Columbia, a U.S. commonwealth or
possession, or any of their political subdivisions or instrumentalities
4—A foreign government or any of its political subdivisions, agencies,
or instrumentalities
S--A corporation
6—A dealer in securities or commoditles required to register in the
United States, the District of Columbia, or a U.S. commonwealth or
possession
7—A futures commission merchant registered with the Commodity
Futures Trading Commission
8—A real estate Investment trust
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. fo-2018)
Page 4
The following chart shows types of payments that may be exempt
from backup withholding. The chart applies to the exempt payees listed
above, i through 13.
1F the payment is for ...
THEN the payment is exempt
for...
Interest and dividend payments
All exempt payees except
for 7
Broker transactions
Exempt payees 1 through 4 and 6
through 1 i and all C corporations.
S corporations must not enter an
exempt payee code because they
are exempt only for sales of
noncovered securities acquired
prior to 2012.
Barter exchange transactions and
Exempt payees 1 through 4
patronage dividends
Payments over $600 required to be
Generally, exempt payees
reported and direct sales over
1 through 52
$5,000,
Payments made In settlement of
Exempt payees 1 through 4
payment card or third party network
transactions
1 See Form 1099-MISC, Miscellaneous Income, and Its Instructions.
2 However, the following payments made to a corporation and
reportable on Form 1099-MISC are not exempt from backup
withholding: medical and health care payments, attorneys' fees, gross
proceeds paid to an attorney reportable under section 6045(f), and
payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes Identify
payees that are exempt from reporting under FATCA. These codes
apply to persons submitting this form for accounts maintained outside
of the United States by certain foreign financial institutions. Therefore, if
you are only submitting this form for an account you hold in the United
States, you may leave this field blank. Consult with the person
requesting this form if you are uncertain If the financial institut€on is
subject to these requirements. A requester may Indicate that a code is
not required by providing you with a Form W-9 with "Not Applicable" (or
any similar indication) written or printed on the line for a FATCA
exemption code.
A —An organization exempt from tax under section 501(a) or any
individual retirement plan as defined in section 7701(a)(37)
B—The United States or any of its agencies or instrumentalities
C—A state, the District of Columbia, a U.S. commonwealth or
possession, or any of their political subdivisions or instrumentalities
D—A corporation the stock of which is regularly traded on one or
more established securities markets, as described in Regulations
section 1.1472-1(c)(1)(i)
E—A corporation that is a member of the same expanded affiliated
group as a corporation described In Regulations section 1.1472-1(c)(1)(i)
F--A dealer In securities, commodities, or derivative financial
Instruments (Including notional principal contracts, futures, forwards,
and options) that Is registered as such under the laws of the United
States or any state
G—A real estate investment trust
H--A regulated Investment company as defined in section 851 or an
entity registered at all times during the tax year under the Investment
Company Act of 1940
I —A common trust fund as defined in section 584(a)
J—A bank as defined in section 581
K—A broker
L—A trust exempt from lax under section 664 or described in section
4947(a)(1)
M—A tax exempt trust under a section 403(b) plan or section 457(g)
plan
Note: You may wish to consult with the financial institution requesting
this form to determine whether the FATCA code and/or exempt payee
code should be completed.
Line 5
Enter your address (number, street, and apartment or suite number),
This is where the requester of this Form W-9 will mall your information
returns. If this address differs from the one the requester already has on
file, write NEW at the top. If a new address is provided, there is still a
chance the old address will be used until the payor changes your
address in their records.
Line 6
Enter your city, state, and ZIP code.
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. If you are a resident alien and
you do not have and are not eligible to get an SSN, your TIN is your IRS
Individual taxpayer Identification number (ITIN). Enter It in the social
security number box. If you do not have an ITIN, see Novo to get a TIN
below.
If you are a sole proprietor and you have an EIN, you may enter either
your SSN or EIN.
If you are a single -member LLC that Is disregarded as an entity
separate from Its owner, enter the owner's SSN (or EIN, if the owner has
one). Do not enter the disregarded entity's EIN. If the LLC is classified as
a corporation or partnership, enter the entity's EIN.
Note: See What Name and Number To Give the Requester, later, for
further clarification of name and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately.
To apply for an SSN, got Form SS-5, Application for a Social Security
Card, from your local SSA office or get this form online at
www.SSA.gov. You may also get this form by calling 1-800-772-1213.
Use Form W-7, Application for IRS Individual Taxpayer Identification
Number, to apply for an ITIN, or Form SS-4, Application for Employer
Identification Number, to apply for an EIN. You can apply for an EIN
online by accessing the IRS website at www.irs.govlBusinesses and
clicking on Employer Identification Number (EIN) under Starting a
Business. Go to www.irs.gov/Forms to view, download, or print Form
W-7 and/or Form SS-4. Or, you can go to www.frs.gov1OrdorForms to
place an order and have Form W-7 and/or SS-4 mailed to you within 10
business days.
If you are asked to complete Form W-9 but do not have a TIN, apply
for a TIN and write "Applied For" in the space for the TIN, sign and date
the form, and give it to the requester. For Interest and dividend
payments, and certain payments made with respect to readily tradable
Instruments, generally you will have 60 days to get a TIN and give it to
the requester before you are subject to backup withholding on
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
you provide your TIN to the requester.
Note: Entering "Applied For" means that you have already applied for a
TIN or that you intend to apply for one soon.
Caution: A disregarded U.S. entity that has a foreign owner must use
the appropriate Form W-8.
Part II, Certification
To establish to the withholding agent that you are a U.S. person, or
resident alien, sign Form W-9. You may be requested to sign by the
withholding agent even if item 1, 4, or 5 below Indicates otherwise.
For a joint account, only the person whose TIN Is shown in Part I
should sign (when required). In the case of a disregarded entity, the
person identified on line 1 must sign. Exempt payees, see Exempt payee
code, earlier.
Signature requirements. Complete the certification as indicated In
Items 1 through 5 below.
Form W-9 (Rev. 10-2018)
1. Interest, dividend, and barter exchange accounts opened
before 1084 and broker accounts considered active during 1983.
You must give your correct TIN, but you do not have to sign the
certification.
2. Interest, dividend, broker, and barter exchange accounts
opened after 1983 and broker accounts considered inactive during
1983. You must sign the certification or backup withholding will apply. If
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
certification before signing the form.
3. Real estate transactions. You must sign the certification. You may
cross out Item 2 of the certification.
4. Other payments. You must glvo your correct TIN, but you do not
have to sign the certification unless you have been notified that you
have previously given an incorrect TIN. "Other payments" include
payments made In the course of the requester's trade or business for
rents, royalties, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to
a nonemployce for services, payments made in settlement of payment
card and third party network transactions, payments to certain fishing
boat crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified tuition program
payments (under section 529), ABLE accounts (under section 529A),
IRA, Goverdoll ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct
TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account: I Give name and SSN of:
1. Individual
2. Two or more individuats (joint
account) other than an account
maintained by an FFI
3. Two or more U.S. persons
golnt account maintained by an FFI)
4. Custodial account of a minor
(Uniform Gift to Minors Act)
5. a. The usual revocable savings trust
(grantor is also trustee)
b. So-called trust account that Is not
a legal or valid trust under state law
6. Sole proprietorship or disregarded
entity owned by an individuai
7. Grantor trust filing under Optional
Form 1099 Filing Method 1 (sea
Regulations section 1.671-4(h)(2)@
(A))
The individual
The actual owner of the account or, if
combined funds, the first Individual on
the account'
Each holder of the account
The minar2
Page rJ
For this type of account: Give name and EIN of:
14, Account with the Department of The public entity
Agriculture In the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
15. Grantor trust filing under the Form The trust
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulations section 1.671-4(b)(2)0(13))
1 List first and circle the name of the person whose number you furnish.
If only one person on a joint account has an SSN, that person's number
must be furnished.
2 Circle the minor's name and furnish the minor's SSN.
3 You must show your Individual name and you may also enter your
business or DBA name on the "Business name/disregarded entity"
name line. You may use either your SSN or BIN (if you have one), but the
IRS encourages you to use your SSN.
4 List first and circle the name of the trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the
legal entity itself is not designated in the account title.) Also see Speclai
rules for partnerships, earlier.
*Note: The grantor also must provide a Form W-9 to trustee of trust.
Note: If no name is circled when more than one name is listed, the
number will be considered to be that of the first name listed.
Secure Your Tax Records From Identity Theft
Identity theft occurs when someone uses your personal information
such as your name, SSN, or other identifying information, without your
permission, to commit fraud or other crimes. An identity thief may use
your SSN to got a job or may file a tax return using your SSN to receive
a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax preparer.
The grantor -trustee' If your tax records are affected by identity theft and you receive a
notice from the IRS, respond right away to the name and phone number
The actual owner printed on the IRS notice or letter.
If your tax records are not currently affected by Identity theft but you
The owner3 think you are at risk due to a lost or stolen purse or wallet, questionable
credit card activity or credit report, contact the IRS Identity Theft Hotline
The grantor* at 1-800-908-4490 or submit Form 14039.
For this type of account: I Give name and EIN of:
B. Disregarded entity not owned by an
Individual
9. A valid trust, estate, or pension trust
10. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
11. Association, club, religious,
charitable, educational, or other tax-
exempt organt7aticn
12. Partnership or multi -member LLC
13. A broker or registered nominee
The owner
Legal enttty4
The corporation
The organization
The partnership
The broker or nominee
For more information, see Pub. 5027, Identity Theft Information for
Taxpayers.
Victims of Identity theft who are experiencing economic harm or a
systemic problem, or are seeking help in resolving tax problems chat
have not been resolved through normal channels, may be eligible for
Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
calling the TAS toll -free case intake line at 1-877-777-4778 or TTY/TDD
1-800-829-4059.
Protect yourself from suspicious emalls or phishing schemes.
Phishing is the creation and use of email and websites designed to
mimic legitimate business emails and websites. The most common act
Is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user Into surrendering
private Information that will be used for identity theft.
Form W-9 (Rev. 10-2018)
Page 6
The IRS does not initiate contacts with taxpayers via emails. Also, the
IRS does not request personal detailed Information through email or ask
taxpayers for the PIN numbers, passwords, or similar secret access
information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishing@irs.gov. You may also report misuse
of the IRS name, logo, or other IRS property to the Treasury Inspector
General for Tax Administration (TIGTA) at 1-800-366-4484. You can
forward suspicious emails to the Federal Trade Commission at
spam@uce.gov or report them at www.ftc.gov/complaint, You can
contact the FTC at www.ftc.gov/ldtheft or 877-IDTHEFT (877-438-4338).
If you have been the victfm of identity theft, see www.lder)tityTheff.gov
and Pub. b027.
Visit wwwJrs.govlldeWhyTheft to learn more about identity theft and
how to reduce your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your
correct TIN to persons (including federal agencies) who are required to
file information returns with the IRS to report interest, dividends, or
certain other income paid to you; mortgage Interest you paid; the
acquisition or abandonment of secured property; the cancellation of
debt; or contributions you made to an IRA, Archer MSA, or HSA. The
person collecting this form uses the information on the form to file
Information returns with the IRS, reporting the above information.
Routine uses of this information include giving it to the Department of
Justice for civil and criminal litigation and to cities, states, the District of
Columbia, and U.S. commonwealths and possessions for use in
administering their laws. The Information also may be disclosed to other
countries under a treaty, to federal and state agencies to enforce civil
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.
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