HomeMy WebLinkAboutContract 53279-NC153279- N C 1
Memomndum
Date: 11/13/2024
To: Hye Won Kim, Assistant City Attorney
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To: Joanne Hinton, Human Resources Manager JH
Holly Moyer, Asst. Human Resources Director fiH
Re: Virgin Pulse, Inc to Personify Health, Inc — Name change Only
Prior Name: Virgin Pulse, Inc
New Name: Personify Health, Inc
CSCO: 53279
Name change only, tax id number remains the same.
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APPROVED BY:
Hye Won Kim, Assistant City Attorney
APPROVAL DATE: Nov 15, 2024
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
DocuSign Envelope ID: 54B6B52E-DB8F-4046-8006-7E2F1DOE9871
Form
Request for Taxpayer Give form to the
(Rev. March 2024) Identification Number and Certification requester. Do not
Department of the Treasury Go to www.irs.gov/F`orrnW9 for instructions and the latest information. send to the IRS.
Internal Revenue Service
Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.
1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner's name on line 1, and enter the business/disregarded
entity's name on line 2.)
Personify Health, Inc.
2 Business name/disregarded entity name, if different from above.
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3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check
4 Exemptions (codes apply only to
0
only one of the following seven boxes.
certain entities, not individuals;
a
C
❑ Individual/sole proprietor ❑✓ C corporation ❑ S corporation ❑ Partnership ❑ Trust/estate
see instructions on page 3):
0
❑ LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) . . . .
Exempt payee code (if any)
a o
Note: Check the "LLC" box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax
�classification
of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate
for its
Exemption from Foreign Account Tax
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box the tax classification of owner.
Compliance Act (FATCA) reporting
L=
❑ Other (see instructions)
code (if any)
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3b If on line 3a you checked "Partnership" or "Trust/estate," or checked "LLC" and entered "P" as its tax classification,
(%tP accounts maintained
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and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check
tsidea the United States.)
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this box if you have any foreign partners, owners, or beneficiaries. See instructions . . . . . . . . . Elouu
5 Address (number, street, and apt. or suite no.). See instructions. Requester's name and address (optional)
75 Fountain Street, Suite 310
6 City, state, and ZIP code
Providence, RI 02902
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 or
TIN, later.
Employer identification number
Note: If the account is in more than one name, see the instructions for line 1. See also What Name and
Number To Give the Requester for guidelines on whose number to enter. M2O - 2 5 4 7 4 8 0
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 certification, but you must provide your correct TIN. See the instructions for Part II, later.
uuwmgned uy:
Sign Signature of , •a
Here U.S. person �(,t Date 6�20�2024
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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/F6rmW9.
What's New
Line 3a has been modified to clarify how a disregarded entity completes
this line. An LLC that is a disregarded entity should check the
appropriate box for the tax classification of its owner. Otherwise, it
should check the "LLC" box and enter its appropriate tax classification.
New line 3b has been added to this form. A flow -through entity is
required to complete this line to indicate that it has direct or indirect
foreign partners, owners, or beneficiaries when it provides the Form W-9
to another flow -through entity in which it has an ownership interest. This
change is intended to provide a flow -through entity with information
regarding the status of its indirect foreign partners, owners, or
beneficiaries, so that it can satisfy any applicable reporting
requirements. For example, a partnership that has any indirect foreign
partners may be required to complete Schedules K-2 and K-3. See the
Partnership Instructions for Schedules K-2 and K-3 (Form 1065).
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS is giving you this form because they
Cat. No. 10231X Form W-9 (Rev. 3-2024)
-.personify"
HEALTH
Virgin Pulse is now Personify Health
Dear Customer:
We are excited to inform you that Virgin Pulse, Inc. is now officially Personify Health, Inc.
Effective immediately, please update your records to reflect our new name.
No other changes have been made.
Our headquarters is still located at:
75 Fountain Street
Suite 310
Providence, RI 02902-0050
Our E I N is still: 20-2547480
Our banking information remains the same as well:
Bank Payment Instructions:
Account Name: Personify Health, Inc.
Please Remit Checks To:
Bank Name: Bank of America
Personify Health, Inc
ACH Routing Number: 011500010
PO Box 411549
Account Number: 394005722468
Boston, MA 02241-1549
Please find an updated W-9 reflecting our name change attached and reach out to
Invoicing@VirainPulse.com if additional documentation is needed.
Thank you for your business - we appreciate it very much.
Sincerely,
Personify Health, Inc.
Invoicinu@Vire.inPulse.com
*Please note- our Invoicing@VirginPulse.com email address will be transitioning to
Invoicing@PersonifyHeaIth.com.
V
2024 Personify Health'" All rights reserved
person ifyhealth.com