HomeMy WebLinkAboutContract 57800-NC1Memorandum CSC No. 57800-NC1
Date: 8/8/2025
To: Hye Won Kim, Assistant City Attorney
To: Keith Morris — Assistant Police Director KICM
Re: Name Change Only: Operation Blue Shield to One CommunityUSA
Prior Name: Operation Blue Shield
New Name: One CommunityUSA
CSCO: 57800
Entity change from Inc to LLC only. TIN remained the same.
F ���
APPROVED BY:
Hye Won Kim, Assistant City Attorney
APPROVAL DATE: 08/14/2025
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Farm W-9 Request for Taxpayer Give form to the
(Rev. March 2024) 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.
Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.
1 Name of entityAndividual. 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.)
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One CommunityUSA
2 Business name/disregarded entity name, if different from above.
3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check
only one of the following seven boxes.
❑ Individual/sole proprietor ❑ C corporation ❑ S corporation ❑ Partnership ❑ Trust/estate
❑ LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) . . . .
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
box for the tax classification of its owner.
❑✓ Other (see instructions) Nonprofit corporation exempt under IRS Code Section 501(C)(3)
3b If on line 3a you checked "Partnership" or "Trust/estate," or checked "LLC" and entered "P" as its tax classification,
and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check
this box if you have any foreign partners, owners, or beneficiaries. See instructions . . . . . . . . . ❑
5 Address (number, street, and apt. or suite no.). See instructions.
8226 Douglas Ave., Ste. 648
6 City, state, and ZIP code
Dallas, TX 75225
7 List account number(s) here (optional)
i::ialg Taxpayer Identification Number (TIN)
4 Exemptions (codes apply only to
certain entities, not individuals;
see instructions on page 3):
Exempt payee code (if any)
Exemption from Foreign Account Tax
Compliance Act (FATCA) reporting
code (f any)
(Applies to accounts maintained
outside the United States.)
Requester's name and address (optional)
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 genera[ly your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other I — —
entities, it is your employer identification number (EIN). If you do not have a number, see Now 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. M47 - 14 18 9 16 4 0 14 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,
ou are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign I signature of
Here U.S. person rate
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)
Form 401 \\` �. of
Secretary of State Filed in the Office of the
P.O. Box 13697 Secretary of State of Texas
Austin, TX 78711-3697 Filing #: 802278251 05/27/2025
FAX: 512/463-5709 Document #: 1484547190003
Statement of Change of Image Generated Electronically
Filing Fee: See Instructions Registered Office/Agent for Web Filing
Entity Information
The name of the entity is
One CommunitvUSA
The file number issued to the entity by the secretary of state is: 802278251
The registered agent and registered office of the entity as currently shown on the records of the secretary of state are:
TONI C. BRINKER
5949 Sherry Lane. Suite 1162. Dallas. TX. USA 75225
Change to Registered Agent/Registered Office
The following changes are made to the registered agent and/or office information of the named entity:
Registered Agent Change
i-A. The new registered agent is an organization by the name of:
OR
I-B. The new registered agent is an individual resident of the state whose name is:
Ian Feuer
Registered Office Change
I C. The business address of the registered agent and the registered office address is changed to:
8226 Douglas Avenue. Suite 648. Dallas. TX. USA 75225
The street address of the registered office as stated in this instrument is the same as the registered agent's business
address.
Consent of Registered Agent
rA. A copy of the consent of registered agent is attached.
I B. The consent of the registered agent is maintained by the entity.
Statement of Approval
The change specified in this statement has been authorized by the entity in the manner required by the BOC or in the
manner required by the law governing the filing entity, as applicable.
Effectiveness of Filing
A. This document becomes effective when the document is filed by the secretary of state.
B. This document becomes effective at a later date, which is not more than ninety (90) days from the date of its
filing by the secretary of state. The delayed effective date is:
Execution
The undersigned signs this document subject to the penalties imposed by law for the submission of a materially false
or fraudulent instrument.
Date: Mav 27. 2025 Ian Feuer
Signature of authorized person(s)
FILING OFFICE COPY
�i� one
usa
One CommunityUSA
8226 Douglas Ave., Ste 648
Dallas TX 75225
July 30, 2025
Jaycee Shane
CCPD Partners Manager
Police Department
505. W. Felix St.
Fort Worth TX 7b 1 15
Hi Jaycee,
America's Community Partner
Please accept this letter as documentation of the One CommunityUSA updates that we discussed.
Timeline
- August 21, 20 I S: Operation Blue Shield Certificate of Formation filed.
- December 3, 2015: IRS granted 501(c)(3) status.
- July I, 2019: TX Office of the Secretary of State issued a Certificate of Filing of Operation Blue
Shield Assumed Name One CommunityUSA.
May 2, 2023: Legal name changed from Operation Blue Shield to One CommunityUSA.
- May 27, 2025:
a Business address changed FROM 5949 Sherry Lane, Suite 1 162, Dallas TX 75225 TO 8226
Douglas Ave., Suite 648, Dallas TX 75225.
o Registered Agent changed from Toni Brinker to Ian Feuer.
Please let me know if you have any questions regarding these details.
Thank you for making these updates to our profile.
Best regards,
lakewer
President &CEO, One CommunityUSA
OneCommunityUSA.org 1 214.851.4872 1 info@OneCommunityUSA.org
Form 424
Secretary of State Filed in the Office of the
P.O. Box 13697 Secretary of State of Texas
Austin, TX 78711-3697 Filing #: 802278251 05/02/2023
FAX: 512/463-5709 Document #: 1243247190003
Certificate Image Generated Electronically
Filing Fee: See instructions Of Amendment for Web Filing
Entity Information
The filing entity is a: Domestic Nonprofit Corporation
The name of the filing entity is: Operation Blue Shield
The file number issued to the filing entity by the secretary of state is: 802278251
Amendment to Name
The amendment changes the formation document of the filing entity to change the article or provision that names the
entity. The article or provision is amended to read as follows:
The name of the filing entity is:
One CommunitvUSA
A letter of consent, if applicable, is attached.
Statement of Approval
The amendment has been approved in the manner required by the Texas Business Organizations Code and by the
governing documents of the entity.
Effectiveness of Filing
A. This document becomes effective when the document is filed by the secretary of state.
rB. This document becomes effective at a later date, which is not more than ninety (90) days from the date of its
filing by the secretary of state. The delayed effective date is:
Execution
The undersigned signs this document subject to the penalties imposed by law for the submission of a materially false
or fraudulent instrument and declares under penalty of perjury that the undersigned is authorized under the Texas
Business Organizations Code to execute the filing instrument.
Date: Mav 2, 2023 Toni Brinker
Signature of authorized person
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