Res. No. 002-09-12811RESOLUTION NO.: 02 -OY, -1 2811
A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF
SOUTH MIAMI, FLORIDA, AUTHORIZING THE CITY MANAGER TO EXECUTE A
GRANT AGREEMENT WITH MIAMI -DADE COUNTY BY AND THROUGH ITS
DEPARTMENT OF CULTURAL AFFAIRS IN AN AMOUNT OF $1,569.00 FOR THE
SOUTH MIAMI DR. MARTIN LUTHER KING (MILK), JR. PARADE PROGRAMMING;
AND PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, Miami -Dade County Department of Cultural Affairs has awarded a grant to
the City of South Miami; and
WHEREAS, the Mayor and City Commission wish to accept the grant with Miami -Dade
County Department of Cultural Affairs; and
WHEREAS, the grant agreement will allow the City to enhance its MLK, Jr. Parade; and
WHEREAS, the City Manager is authorized to execute the grant agreement in the amount of
$1,569.00.
NOW, THEREFORE, BE IT RESOLVED BY THE MAYOR AND CITY COMMISSION
OF THE CITY OF SOUTH MIAMI, FLORIDA THAT:
Section 1: The Mayor and City Commission authorize the City Manager to execute the
grant agreement with Miami -Dade County Department of Cultural Affairs for $1,569.00 for the
MLK, Jr. Parade.
Section 2: The attached exhibit is incorporated by reference into this resolution
ZA
PASSED AND ADOPTED this day of , 2009.
ATTEST:
APPROVED:
a t�Z' a,.
-ate., -)\°
"
CITY CLERK
MAYOR 0
READ AND APPROVED AS FORM:
COMMISSION VOTE:
4 -0
Mayor r
Yea
- —
Vice Mayor Beasley:
yea
Commissioner Palmer:
Yea
CIT ORNEY
Commissioner Beckman:
Yea
Include File Name and Path
south Miami
GII•HmedeaCfty
CITY OF SOUTH MIAMI r
OFFICE OF THE CITY MANAGER
INTER- OFFICE MEMORANDUM 2001
To: The Honorable Mayor & Members of the City Commission
Via: W. Ajibola Balogun, City Manager
From: Carol M. Aubrun
Grants Writer and Administrator
Date: January 6, 2009 Agenda Item No.:
Subject: City of South Miami's grant with Miami -Dade County Department of Cultural
Affairs for the Martin Luther King, Jr. Parade.
Request: A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF
SOUTH MIAMI, FLORIDA, AUTHORIZING THE CITY MANAGER TO
EXECUTE A GRANT AGREEMENT WITH MIAMI -DADE COUNTY BY AND
THROUGH ITS DEPARTMENT OF CULTURAL AFFAIRS IN AN AMOUNT OF
$1,569.00 FOR THE SOUTH MIAMI DR. MARTIN LUTHER KING (MILK), JR.
PARADE PROGRAMMING; AND PROVIDING FOR AN EFFECTIVE DATE.
Request: To authorize the City Manager to execute a grant agreement with Miami -Dade
County Department of Cultural Affairs for the MILK, Jr. Parade.
Reason/Need: The City of South Miami has been awarded funds for the MILK, Jr. Parade
from Miami -Dade County Department of Cultural Affairs as part of its
Community Grants Program. The event will take place in February 2009.
There is a 1:1 required match that will come from the City's special events
appropriation.
Cost:
N/A
Funding Source: Miami -Dade County Department of Cultural Affairs
Backup Documentation:
❑ Proposed Resolution
❑ Proposed Contract
COUNTY
The Miami -Dade County Department of Cultural Affairs and the Cultural Affairs Council, the Mayor and the Board of County
Commissioners are pleased to announce that Miami -Dade County has awarded a grant as described herein to City of South Miami.
(hereinafter referred to as the Grantee). The grant award, acknowledging that the Grantee is performing a public service through its
programs and projects, is awarded as follows:
1. GRANTEE
2, AMOUNT OF GRANT:
3, PROJECT:
4. ITEMIZED PROJECT BUDGET:
5. GRANT START DATE:
6. GRANT END DATE:
7, REPORT DEADLINE:
GRANTEE AND GRANT DESCRIPTION
City of South Miami(EIN# 596000431)
6130 Sunset Drive South Miami, FL 33143
$1,569
South Miami MLK Parade
(as described in the program application and any revisions attached hereto)
(as described in the Restatement of Project Budget attached hereto)
2/16/2009
2/16/2009
4/2/2009
The Parties hereto have executed this Agreement on the 2-5 day of kkxclhi , 20 OL.
MIAMI -DADE COUNTY, FLORIDA, by its BOARD OF COUNTY COMMISSIONERS:
f- * **
GRANTEE: ---J
Articles I, II, III, IV and V, together with their exhibits, the Restatement of Project Budget, original application and Universal Affidavit,
make up this grant award contract. In signing this article, the undersigned officials, on behalf of the Grantee, certify that they have read
and will abide by the terms and considerations set forth in the General Terms and Conditions for Grants (Articles II, III, IV and V) dated
April, 2008 as provided with the grant award package, and with those provisions outlined in the notarized and attached Universal
Affidavit. Further, the Grantee agrees that the funded project will be executed in substantially the form outlined in the original application
as approved for funding; in accordance with the program guidelines of the Community Grants Program program and within the scope of
budget submitted in the attached Restatement of Project Budget.
(Grantee's Corporate Seal)
LcAe�-C4�__
Approved for form and legal sufficiency by the Miami -Dade County Attorney (4/2008).
Clerk, Mi
A pF'p °�
i Dade County
Board of unty Commissioners
COUNTY
rn
C?
e
<p Rtp
�s
e
.
f- * **
GRANTEE: ---J
Articles I, II, III, IV and V, together with their exhibits, the Restatement of Project Budget, original application and Universal Affidavit,
make up this grant award contract. In signing this article, the undersigned officials, on behalf of the Grantee, certify that they have read
and will abide by the terms and considerations set forth in the General Terms and Conditions for Grants (Articles II, III, IV and V) dated
April, 2008 as provided with the grant award package, and with those provisions outlined in the notarized and attached Universal
Affidavit. Further, the Grantee agrees that the funded project will be executed in substantially the form outlined in the original application
as approved for funding; in accordance with the program guidelines of the Community Grants Program program and within the scope of
budget submitted in the attached Restatement of Project Budget.
(Grantee's Corporate Seal)
LcAe�-C4�__
Approved for form and legal sufficiency by the Miami -Dade County Attorney (4/2008).
ARTICLE II
1. Parties: The parties to the Grant Award Agreement, which shall be referenced herein as the "Agreement,' are the
Grantee listed in Article 1.1, and Miami -Dade County, Florida, a political subdivision of the State of Florida. The Home Rule Charter
authorizes Miami -Dade County to provide for the uniform health and welfare of the residents throughout the County, and further
provides that all functions not otherwise specifically assigned to others under the Charter, shall be performed under the supervision of
the County Mayor or his designee. The County Mayor has delegated the responsibility of administering this grant to the Director of
the Miami -Dade County Department of Cultural Affairs, who shall be referred to herein as the "Director."
2. Amount and Payment of Grant Award: The total amount of the grant is specified in Article 1.2. By making this grant,
Miami -Dade County assumes no obligation to provide financial support of any type whatever in excess of the total grant amount. Cost
overruns are the sole responsibility of the Grantee. Grant funds will be supplied to the Grantee once the award is approved and
subject to the conditions and limitations as outlined in the Agreement and its accompanying articles and attachments.
Miami -Dade County's obligation to pay the award under the Agreement Is contingent upon an appropriation by the Miami -Dade
County Mayor and the Board of County Commissioners and on the availability of funds. in the event that County funds on which the
Agreement is dependent do not materialize or are withdrawn, the Agreement is terminated and the County has no further liability to
the Grantee, beyond that already incurred by the termination date. In the event of a County revenue shortfall, the total grant will be
reduced accordingly. Such termination or reduction of the total grant shall not affect the responsibility of the Grantee under the
Agreement as to those funds distributed.
3. Project Description: The Grantee may use the grant only for the purposes which are specifically described in Article
1.3, designated "Project," as documented In the Grantee's program application and in accordance with the published guidelines of the
grant program through which this grant is being awarded. Any necessary changes in the scope of the project are cited in the attached
Restatement of Project Budget. Further, it is expressly understood and agreed that the Grantee's program(s) supported by these
grant funds must be open and accessible to the public, provide public exposure and benefit the public unless otherwise noted under
Article V, "Special Conditions; of the Agreement.
Minor project revisions believed to be necessary for the purpose of completing the project, but which do not substantially alter the
original project, its quality, impact, or benefit to the organization, the County or its citizens, must be requested in writing to the Director
sufficiently prior to implementation of revisions for the Director's approval. Minor revisions include, but are not limited to those
affecting project scope, venue, timeframe and participants. The Director will make the final determination on revisions within fourteen
(14) business days of the date of receipt of the request in the Department of Cultural Affairs' offices.
4. Protect Budget: The Grantee agrees to demonstrate fiscal stability and the ability to administer grant funds
responsibly and in accordance with standard accounting practices by developing and adhering to a project budget that is based upon
reasonable revenue development and expenditures projected to accomplish the project covered under the Agreement. This budget is
referenced in Article 1.4 and is attached to the Agreement as the Restatement of Project Budget, and the Grantee agrees that all
expenditures will be subject to the terms of the Agreement and will not significantly deviate from the budget included as a part of the
Grantee's program application or funding request information provided to the Miami -Dade County Department of Cultural Affairs. The
Grantee agrees and expressly understands that any grant budget revisions Including line Item changes necessary for the
purpose of completing the project must be requested in writing to the Director for his consideration prior to the Grant End
Date stated in Article 1.6 and that any requested changes may not exceed twenty -five percent (25 %) of the total amount of
the grant award. The Director will approve or disapprove the Grantee's request in writing within fourteen (14) business days of the
date of receipt of the request in the Department's offices.
5. Grant End Date: The Grantee shall encumber all grant and matching funds on or before the Grant End Date as
outlined in Article 1.6. Any grant funds not encumbered by the Grant End Date or for which a project extension has not been
requested, or any encumbered funds not expensed within forty -five (45) days of the Grant End Date shall revert to the Department
and the Agreement shall be terminated in accordance with Article 11.14. A project extension may be requested in writing from the
Director at least thirty (30) business days prior to the Grant End Date. The Director, at his discretion, may grant an extension of up to
page i of 6 General Terms and conditions for Grants (412006)
one (1) year of the Grant End Date so long as such extension will not significantly alter the project including its quality, impact, or
benefit to the organization, the County or its citizens.
6. Report Deadline: To demonstrate that the Grantee has used the grant award for the project as approved (Article 1.3.)
and the Itemized Project Budget (Article 1.4.) as attached to the Agreement as the Restatement of Project Budget, and has met and
fulfilled all requirements as outlined in the Agreement, original application, and any other substantive materials as may be attached or
included as a condition to this grant award, the Grantee must submit to the Director or his designee, a written Final Report
documenting that the Grantee is meeting or has.fulfilled all project and financial requirements. This report is to be received by the
Director or his designee by the date specified in Article 1.7. in the form specific to the program through which this grant is being
awarded. The Grantee agrees and expressly understands that in making Final Report to the Department, any deviation from
the grant expense budget attached to the Agreement as the Restatement of Project Budget must be requested in writing to
the Director for his consideration prior to the Grant End Date stated in Article 1.6 and that any requested changes may not
exceed twenty-five percent (25 %) of the total amount of the grant award. The Director, at his sole discretion, may require the
Grantee to submit interim reports demonstrating progress on the project and accounting for project expenses to date. The Director
may also require that a compilation statement or independent financial audit encompassing the entire grant period and accounting for
the expenditure of grant funds be prepared by an independent certified public accountant at the expense of the Grantee.
With the exception of grants made through the Major Cultural Institutions Grants Program, the Grantee shall attach to the Final
Report, copies of original documentation conclusively demonstrating the expenditure of funds for the items indicated in the
Restatement of Project Budget as grant award expenses. Documentation shall include, but not be limited to, copies of original bills,
invoices, vouchers, receipts, and copies of canceled checks (front and rear) clearly designating payment for expenses associated
with the event. Cash transactions are not acceptable unless a copy of a contract, invoice, receipt or other documentation supporting
such cash payment is received, marked "paid" and signed by the recipient of the cash. The Director reserves the right to request
original documentation to substantiate grant expenditures.
In the case of grants made through the Major Cultural Institutions Grants Program, the Grantee shall submit an independent financial
audit of the fiscal year encompassing the grant period as part of its Final Report. If an audit is not prepared in time to meet the Final
Report deadline, a compilation statement encompassing the grant period prepared by an independent certified public accountant or
corporate financial officer, attesting to the Grantee's financial position as reported and to the Grantee's total compliance with the
provisions of the grant, may be submitted in the interim until such time as the final audit is available.
In the event that the Grantee fails to submit the required Final Report by the deadline date specified in Article 1.7., the Director may
terminate the Agreement in accordance with Article 11.14. Further, the Director or his designee must approve this report before the
Grantee is deemed to have met all conditions of the grant award.
7. Program Monitoring and Evaluation: The Director or his designee may monitor and conduct an evaluation of the
Grantee's operations and the project for which this grant is provided, which may include visits by County representatives to: observe
the project or Grantee's programs, procedures, and operations; discuss the Grantee's programs with the Grantee's personnel; and /or
evaluate the public impact of these funded events and activities.
Upon request, the Grantee shall provide the Director with notice of all meetings of its Board of Directors or governing board, general
activities and project - related events. In the event the Director or his designee conclude, as a result of such monitoring and/or
evaluation, that the Grantee is not in compliance with the terms of the Agreement, is not fulfilling other program requirements or
stipulations for which this Grant has been provided or for other reasons which significantly impact on the Grantee's ability to fulfill the
conditions of this grant award, the Director or his designee must provide in writing to the Grantee, within thirty (30) days of the date of
said monitoring /evaluation, notice of the inadequacy or deficiencies noted which may significantly impact on the Grantee's ability to
complete the project or fulfill the terms of the Agreement within a reasonable time frame. if Grantee refuses or is unable to address
the areas of concern within thirty (30) days of receipt of such notice, the Director, at his discretion, may take other actions, which may
include the withholding, reduction or rescission of grant funds until such time as the Grantee can demonstrate that such issues have
been corrected.
Further, in the event that the Grantee refuses or is unable to address the areas of concern and the grant award has been disbursed in
full or in part, then the Director may request the return of the full or partial grant payment. At the Director's sole discretion, a Grantee
found to be deficient or in default of a previous grant contract may be declared permanently ineligible to apply to the Department of
page 2 of 6 General Terms and conditions for Grants (42006)
Cultural Affairs' grants programs. Reinstating the Grantee's eligibility to apply is also at the Directors sole discretion, and may only
be considered subsequent to all deficient areas on prior grants having been addressed to the satisfaction of the Director.
If Grantee is not in compliance with the conditions of any other County agreement, the Director, at his discretion, may take other
actions, which may include the withholding, reduction or rescission of grant funds until such time as the Grantee can demonstrate that
such issues have been corrected.
8. Bank Accounts: Monies received pursuant to the Agreement shall be kept in accounts in established Florida banks,
credit unions or savings and loan associations whose identity shall be disclosed in writing, with the identity and title of individuals
whom the Grantee authorizes to withdraw or write checks on grant funds from the banking institution identified on the "Bank Account
Disclosure" form submitted by the Grantee. These accounts need not be accounts which are segregated from other accounts
maintained by the Grantee. However, it is highly recommended that the Grantee maintain a separate account for these grant funds.
9. Accounting and Financial Review: The Grantee must keep accurate and complete books and records for all receipts
and expenditures of this grant award and any matching funds required in conformance with reasonable general accounting
standards. These books and records, as well as all documents pertaining to payments received and made in conjunction with this
grant; such as vouchers, bills, invoices, receipts and canceled checks, shall be retained in Miami -Dade County in a secure place and
in an orderly fashion by the Grantee for at least two (2) years after: the Grant End Date specified in Article 1.6.; the expiration of an
extended grant period as approved by the Director; the completion of a County requested or mandated audit or compliance review;
the conclusion of a legal action involving the grant award, the Grantee and /or project or activities related to the grant award.
The Director or his designee may examine these books, records and documents at the Grantee's offices or other approved site under
the direct control and supervision of the Grantee during regular business hours and upon reasonable notice. Furthermore, the
Director may, upon reasonable notice and at the County's expense, audit or have audited all financial records of the Grantee,
whether or not purported to be related to this grant.
10. Publicity and Credits: The Grantee must include the following credit line in all promotional and marketing materials
related to this grant including web sites, news and press releases, public service announcements, broadcast media, event programs,
and publications: Will the support of the Miami -Dade County Department of Cultural Affairs and the Cultural Affairs Council, the
Miami -Dade County Mayor and Board of County Commissioners" The grantee must also use the Department's logo in marketing
and publicity materials whenever possible. Please call the Department to request an electronic logo file or download it from our
website (www.miamidadearts.orM.
By accepting County funds, the grantee is required to recognize and acknowledge Miami -Dade County's grant support in a manner
commensurate with all contributors and sponsors of its activities at comparable dollar levels.
Grantees through the Department's All Kids Included initiative, Summer Arts and Science Camps for Kids (SAS -C), Youth Arts
Enrichment program (YEP), and Youth Arts Miami (YAM) grants programs must include The Children's Trust logo (available for
download at www.thechildrenstrust.org/MediaKR asp) and the following statement in all materials related to the grant project,
Including but not limited to newsletters, press releases, brochures, fliers, websites or any other materials for dissemination to the
media or general public:
"The (insert event/program name) is funded by The Children's Trust. The Trust is a dedicated source of revenue
established by voter referendum to improve the lives of children and families in Miami -Dade County."
Note: in cases where funding by The Children's Trust represents only a percentage of the grantee's overall
funding, the above language can be altered to read: "The (insert event/program name) is funded in part by The
Children's Trust ...........
11. Liability and Indemnification: It is expressly understood and intended that the Grantee, as the recipient of grant
funds, is not an officer, employee or agent of Miami -Dade County, its Board of County Commissioners, its Mayor, the Department of .
Cultural Affairs or the Cultural Affairs Council. Further, for purposes of the Agreement and the grant project or activity, the parties
hereto agree that the Grantee, its officers, agents and employees are independent contractors.
page 3 of 6 General Terms and conditions for Grants (4/2008)
The Grantee shall take all actions as may be necessary to ensure that its officers, agents, employees, assignees and/or
subcontractors shall not act as nor give the appearance of that of an agent, servant, joint venturer, collaborator or partner of the
Department of Cultural Affairs, the Cultural Affairs Council, the Miami -Dade County Mayor, the Miami -Dade County Board of County
Commissioners, or its employees.
The Grantee agrees to be responsible for all work performed and all expenses Incurred in connection with the project. The Grantee
may subcontract as necessary to perform the services set forth in the Agreement, including entering into subcontracts with vendors
for services and commodities, provided that it is understood by the Grantee that Miami -Dade County shall not be liable to the
subcontractor for any expenses or liabilities incurred under the subcontract, and that the Grantee shall be solely liable to the
subcontractor for all expenses and liabilities incurred under the subcontract.
The Grantee shall indemnify and hold harmless the County and its officers, employees, agents and instrumentalities from any and all
liability, losses or damages, including attorneys' fees and costs of defense, which the County or its officers, employees, agents or
instrumentalities may incur as a result of claims, demands, lawsuits, causes of actions or proceedings of any kind or nature arising
out of, relating to or resulting from the performance of the Agreement by the Grantee or its employees, agents, servants, partners,
principals or subcontractors. The Grantee shall pay all claims and losses in connection therewith and shall investigate and defend all
claims, suits, or actions of any kind or nature in the name of the County, where applicable including appellate proceedings, and shall
pay all costs, judgments, and attorneys' fees which may issue thereon. The Grantee expressly understands and agrees that any
insurance protection required by the Agreement or otherwise provided shall in no way limit the responsibility to indemnify, keep and
save harmless, and defend the County or its officers, employees, agents and instrumentalities as herein provided.
12. Assignment: The Grantee is not permitted to assign this grant award or any portion thereof. Any purported assignment
Will render this grant null and void and the Grantee shall be subject to immediate rescission of the full amount of the grant award and
reimbursement by the Grantee of its full value to the County.
13. Compliance with Laws: it shall be a contractual obligation of the Grantee hereunder, that during the term of the
Agreement, the Grantee agrees to abide by and be governed by all applicable federal, state and county laws and the terms of grants
made to Miami -Dade County and the Miami -Dade County Department of Cultural Affairs and Cultural Affairs Council, of which this
grant is a sub grant, including, but not limited to the following Miami -Dade County Ordinances, Resolutions, sections of the County
Code and federal laws:
(a} County Ordinance No. 72 -82 - Miami -Dade County's Conflict of interest and Code of Ethics Ordinance - as
amended, which is incorporated herein by reference as if fully set forth herein;
(b) Section 2 -8.1- of the Miami -Dade County Code - Ownership Disclosure;
(c) County Ordinance No. 90 -133- Amending Sec. 2 -8.1; (d)(2) - Employment Disclosure;
(d) Section 2 -8.6 -of the County Code - Criminal Record;
(e) County Resolutions R- 202 -96, R- 206 -96, R- 13211 -99;
(f) County Ordinance No. 92 -15 codified as Section 2 -8.1.2 of the County Code - Employment Drug -free
Workplace;
(g) County Ordinance No. 142 -91 codified as Section 11A -29 et. seq. of the County Code — Family Leave;
County Resolution R- 385-95 - Miami -Dade County Disability Nondiscrimination Affidavit, incorporating the
following Federal laws and Acts:
(1) The Americans with Disabilities Act of 1990 (ADA), Pub.L. 101 -336, 104 Stat. 327, 42 U.S.C.
12101 -12213 and 47 U.S.C. Sections 225 and 611 including Title I, Employment;
(2) Title II, Public Services;
(3) Title III, Public Accommodation and Services Operated by Private Entities; and Section 504 of the
Rehabilitation Act of 1973;
(4) Title IV, Telecommunications;
(5) Title V, Miscellaneous Provisions: The Rehabilitation Act of 1973,29 U.S.C. Section 794; The
Federal Transit Act, as amended 49 U.S.C. Section 1612; The Fair House Act as amended, 42
U.S.C. Section 3601 - The foregoing requirements of this section shall not pertain to contracts
with the United, States or any department or agency thereof, or the State or any political
subdivision or agency thereof or any municipality of this State;
(h) Section 2 -8.1 (c) of the County Code regarding Delinquent and Currently Due Fees or Taxes;
page 4 of 6 General Terms and Conditions for Grants (412008)
Resolution RA206 -97 regarding Welfare Reform Work Participation.
The Grantee has certifiably indicated compliance with these laws, ordinances and resolutions by properly executing the affidavits
attached hereto.
Further, all funded activities must provide equal access and equal opportunity in employment and services, and may not discriminate
on the basis of race, color, religion, ancestry, national origin, sex, pregnancy, age, disability, marital status, familial status, sexual
orientation or physical ability, in accordance with Title VI and Title VII of the Civil Rights Act of 1964, the Age Discrimination Act of
1975, Title IX of the Education Amendments of 1972 as amended (42 U.S.C. 2000d at seq.), the Americans with Disabilities Act
(ADA) of 1990, Section 504 of the Rehabilitation Act of 1973, and Miami -Dade County ordinances No. 97 -170, § 1, 2 -25 -97 and No.
98 -17, § 1,12 -1.98.
14. Remedies: in the event the Grantee shall fail to materially conform with any of the provisions of the Agreement or its
attachments referenced herein, the Director may withhold or cancel all, or any, unpaid installments of the grant upon giving five (5)
calendar days written notice to the Grantee, and the County shall have no further obligation to the Grantee under the Agreement.
Further, in the event of a material breach of any term or condition of the Agreement, upon five (5) calendar days written demand by
the Director, the Grantee shall repay to Miami -Dade County all portions of the grant which have been received by the Grantee, but
which have not actually been disbursed by the Grantee as of the date that the written demand is received.
In the event this grant is canceled or the Grantee is requested to repay grant funds because of a breach of the Agreement, the
Grantee may be declared, permanently ineligible to apply to the Department of Cultural Affairs' grants programs. Reinstating the
Grantee's eligibility to apply is also at the Director's sole discretion, and may only be considered subsequent to all deficient areas on
prior grants having been addressed to the satisfaction of the Director. Further, the Grantee will be liable to reimburse Miami -Dade
County for all unauthorized expenditures discovered after the expiration of the grant period. The Grantee will also be liable to
reimburse the County for all lost or stolen grant funds.
Grant funds which are to be repaid to Miami -Dade County pursuant to this Section or other Sections in the Agreement, are to be
repaid by delivering to the Director a certified check for the total amount due, payable to the Miami -Dade County Board of County
Commissioners.
These provisions do not waive or preclude the County from pursuing any other remedy, which may be available to it under the law.
15. Indulgence Will Not Be A Waiver of Breach: The indulgence of either party with regard to any breach or failure to
perform any provision of the Agreement shall not be deemed to constitute a waiver of the provision or any portion of the Agreement
either at the time the breach or failure occurs or at any time throughout the term of the Agreement.
16. Written Notices: Any written notices required under the Agreement will become effective when delivered in person or
upon the receipt of a certified letter addressed to the Grantee at the address specified in Article 1.1 of the Agreement, and to the
Director when addressed as follows: Director, Miami -Dade County Department of Cultural Affairs, 111 NW First Street, Suite 625,
Miami, Florida 33128.
17. Captions Used in the Agreement: Captions as used in the Agreement are for convenience of reference only and
should not be deemed or construed as in any way limiting or extending the language or provisions to which such captions may refer.
18. Contract Represents Total Agreement: The Agreement, including its special conditions and attachments, represents
the whole and total agreement of the parties. No representations, except those contained within the Agreement and its attachments,
are to be considered in construing its terms. Other than as specified in this agreement, no modifications or amendments may be
made to the Agreement unless made in writing, signed by both parties, and approved by appropriate action by the Miami -Dade
County Board of County Commissioners and Mayor.
ARTICLE III - INSURANCE
The Grantee must maintain and shall furnish upon request to the Director or his designee, certificates of insurance indicating that
insurance has been obtained which meets the requirements as outlined below:
page 6 of 6 General Terms and Condtlons for Grants (412006)
1. Workers' Compensation Insurance for all employees of the Grantee as required by Chapter 440 Florida
Statutes.
2. Public Liability Insurance on a comprehensive policy in an amount not less than $300,000 combined single
limit per occurrence for bodily injury and property damage.
3. Automobile Liability Insurance covering all owned, non -owned and hired vehicles used in connection with
the project, in an amount not less than $300,000 combined single limit per occurrence for bodily injury
and property damage.
The insurance policies required above shall be issued by companies authorized to do business under the laws of the State of Florida,
with the following qualifications:
1. The Company must be rated no less than "B" as to the management, and no less than "Class V" as to
financial strength by the latest edition of Best's Insurance Guide, published by A.M. Best Company,
Oldwick, New Jersey, or its equivalent, subject to the approval of the County Risk Management Division;
or,
2. The Company must hold a valid Florida Certificate of Authority as shown in the latest "List of All Insurance
Companies Authorized or Approved to Do Business in Florida," issued by the State of Florida Department
of Insurance, and is a member of the Florida Guaranty Fund.
Certificates must indicate that no modification or change in insurance shall be made without thirty (30) days advance written notice to
the certificate holder.
Modification or waiver of any of the aforementioned insurance requirements is subject to the approval of the County's Risk
Management Division. The Grantee shall notify the County of any intended changes in insurance coverage, including any renewals of
existing policies.
ARTICLE IV- TERMINATION
If, for any reason, the Grantee shall fail to fulfill in a timely and proper manner its obligations under the Agreement, or should violate
any of the covenants, agreements, or stipulations of the Agreement, the County shall thereupon have the right to terminate the
Agreement by giving written notice to the Grantee of such termination and specifying the effective date thereof, at least five (5) days
before the effective date of such termination.
Notwithstanding the above, the Grantee shall not be relieved of liability to the County by virtue of any breach of the Agreement by the
Grantee, and the County may withhold any payments to the Grantee until such time as the exact amount of damages due to the
County from the Grantee is determined.
ARTICLE V - SPECIAL CONDITIONS
Indirect costs may not be assigned to, charged against or debited from County grant funds.
page 6 or 6 General Terms and Conditions for Grants (412008)
Fiscal Year I Program: 2008/2009 Community Grants 2nd QTR
Organization Name: City of South Miami
Project Title: Dr. Martin Luther King, Jr Parade
Dates of Activities: 2/16/09
Necessary changes in the project (if any):
N/A
Itemize cash expenses to be expended from the grant award. Expenditures must equal the total amount of the grant award as listed on
the Grant Award Agreement. Round amounts to the nearest dollar (do not show cents). NOTE: The items specified in this budget must
correspond with the Grant Dollars Allocated column of the project Expense Budget on your original application form.
GRANT AWARD
PERSONNEL
ADMINSTRATNE:
ARTISTIC:
TECHNICAL:
OUTSIDE ARTISTIC FEES: 800.00
OUTSIDE OTHER FEES:
MARKEnNGIPUBLICrrY
PRINTING
POSTAGE
IN COUNTY TRAVEL
OUT OF COUNrY TRAVEL
EQUIPMENT RENTAL 769.00
EQUIPMENT PURCHASE
SPACE RENTAL
INSURANCE
UTILmES
SUPPLIESIMATF.RIALS
OTHER COSTS (ITEMIZE):
TOTAL GRANT AWARD: 1569.00
Restatement ofProjed Budgd (912004) Page i of
List cash and in -kind expenses and revenues specifically identified with your projectlseason. Round amounts to the nearest dollar (do
not show cents). NOTE: Total project expenses and revenues must equal.
CASH
CASH
EXPENSES
IN -KIND -
REVENUES IN -KIND
PERSONNEL
ADMISSIONS
ADMINISTRATIVE:
CONTRACTED SERVICES
ARTISTIC:
TUITIONS
TECHNICAL:
4,068 CORPORATE SUPPORT
6,143 4,588
OUTSIDE ARTISTIC FEES:
4,100
FOUNDATION SUPPORT
OUTSIDE OTHER FEES:
250
PRIVATE/INDIVIDUAL SUPPORT
1,300
MARKETINGIPUBLICITY
350
250.00 GOVERNMENT GRANTS:
PRINTING
250.00 FEDERAL
POSTAGE
STATE
INCOUNTYTRAVEL
LOCAL
OUT OF COUNTY TRAVEL
APPLICANT CASH ON HAND
- 248
EQUIPMENT RENTAL
4,060
OTHER REVENUES (ITEMIZE):
EQUIPMENT PURCHASE
SPACE RENTAL
INSURANCE
UTILITIES
SUPPLIESIMATERIALS
OTHER COSTS (ITEMIZE):
Youth Monitors
150
GRANT AWARD
1,569.00
Un -Sung Heroes
350
SUB TOTALS: 9,260 4,588
TOTAL EXPENSES: 13,848
Prepared by:
SUB TOTALS: 9,260 4,588
TOTAL REVENUES: 13,848
SIGNATURE W j,"��'�6� , DATE 1/8/09
TYPEDIPRINTED NAME W. Ajibola Balogun TITLE City Manager
Restatement of Project Budget 1912904) Page 2 of 2
MIAMI -DADE COUNTY DEPARTMENT OF CULTURAL AFFAIRS
UNIVERSAL AFFIDAVIT
Each section of this form must be read, and initiated indicating acceptance and /or compliance with the County's policy related to the particular affidavit.
For affidavit sections that you do not believe are applicable to your organization, please indicate this by placing "N /A" in the blank and your initials next
to the "N /A." ALL SECTIONS MUST BE COMPLETED, either with your initials indicating compliance or "N /A" indicating non - applicable. Sections not
completed on the Affidavit will render the entire Universal Affidavit null and void and it will be returned to you for completion.
The MIAMI -DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT, MIAMI -DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT, MIAMI -
DADE COUNTY CRIMINAL RECORD AFFIDAVIT, and MIAMI -DADE COUNTY DISABILITY NONDISCRIMINATION AFFIDAVIT shall not pertain to
contracts with the United States or any departments or agencies thereof, the State of Florida or any political subdivision or agency thereof, or any
municipality of this State. The MIAMI -DADE COUNTY FAMILY LEAVE AFFIDAVIT shall not pertain to contracts with the United States or any of its
departments or agencies, the State of Florida or any political subdivision or agency thereof, it shall, however, pertain to municipalities of the State of
Florida.
I, W.
Ail, 614L '60JONk, being first duly swom state:
(Name of Affiant / Authorized Official)
The full legal name and business address of the person(s) or entity contracting or transacting business with Miami -Dade County are (Post Office
addresses are not acceptable):
Federal Employer Identification Number
cAly cc 5)A HI6 m I
Name of Entity, Individual(s), Partners, or Corporation
Street Address
omb
City
Zip Code
I. MIAMI -DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2 -8.1 of the County Code)
1. if the contract or business transaction is with a corporation, the full legal name and business address shall be provided for each
officer and director and each stockholder who holds directly or indirectly five percent (5 %) or more of the corporation's stock. If the
contract or business transaction is with a partnership, the foregoing information shall be provided for each partner. If the contract or
business transaction is with a trust, the full legal name and address shall be provided for each trustee and each beneficiary. The
foregoing requirements shall not pertain to contracts with publicly traded corporations or to contracts with the United States or any
department or agency thereof, the State of Florida or any political subdivision or agency thereof or any municipality of this State. All
such names and addresses are (Post Office addresses are not acceptable):
Full Legal Name Address Ownership
N) A Rio
Rio
Rio
2. The full legal name and business address of any other individual (other than subcontractors, material men, suppliers, laborers,
or lenders) who have, or will have, any interest (legal, equitable, beneficial or ofherwise) in the contract or business transaction
With Miami -Dade County are (Post Office addresses are not acceptable):
MW
3. Any person who willfully fails to disclose the information required herein, or who knovringly discloses false information in this
regard, shall be punished by a fine of up to five hundred dollars ($500) or imprisonment in the County jail for up to sixty (60) days
or both.
Universal Affidavits (212007) Page I of 4
W A II. MIAMI -DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT (County Ordinance No. 90 -133. Amending sec. 2.8 -1:
Subsection (d)(2) of the County Code).
Except where precluded by federal or State laws or regulations, each contract or business transaction or renewal thereof which involves
the expenditure of ten thousand dollars ($10,000) or more shall require the entity contracting or transacting business to disclose the
following information. The foregoing disclosure requirements do not apply to contracts with the United States or any department or
agency thereof, the State or any political subdivision or agency thereof or any municipality of this State.
1. Does your f m have a collective bargaining agreement with your employees?
Yes —No
2. Does your firm provide paid health care benefits for its employees?
c Yes _ No
3. Provide current breakdown (number of persons) of your firm's work force and ownership as to race, national origin and gender.
White: lh Males W Females
Black: Males Females
Hispanic: Males a1 Females
Native American: _ Males _ Females
Asian: _ Males _ Females
Aleut�Es�YY kirpo): Males _ Females
I Males D Females
k III. MIAMI -DADE COUNTY CRIMINAL RECORD AFFIDAVIT (Section 2 -8.6 of the County Code)
The individual or entity entering into a contract or receiving funding from the County _ has _ has not as of the date of this
affidavit been convicted of a felony during the past ten (10) years.
An officer, director, or executive of the entity entering into a contract or receiving funding from the County _ has X has not as of
the date of this affidavit been convicted of a felony during the past (10) years.
W A & IV. MIAMI -DADE COUNTY EMPLOYMENT DRUG -FREE WORKPLACE AFFIDAVIT (County Ordinance No. 92 -15 codified as
Section 2 -8.1.2 of the County Code)
That in compliance with Ordinance No. 92.15 of the Code of Miami -Dade County, Florida, the above named person or entity is providing
a drug -free workplace. A written statement to each employee shall inform the employee about:
1. danger of drug abuse in the workplace;
2. the firm's policy of maintaining a drug -free environment at all workplaces;
3. availability of drug counseling, rehabilitation and employee assistance programs;
4. penalties that may be imposed upon employees for drug abuse violations.
The person or entity shall also require an employee to sign a statement, as a condition of employment that the employee will abide by
the terms and notify the employer of any criminal drug conviction occurring no later than five (5) days after receiving notice of such
conviction and impose appropriate personnel action against the employee up to and including termination.
Compliance with Ordinance No. 92 -15 may be waived if the special characteristics of the product or service offered by the person or
entity make it necessary for the operation of the County or for the health, safety, welfare economic benefits and well -being of the public.
Contracts involving funding which is provided in whole or in part by the United States or the State of Florida shall be exempted from the
provisions of this ordinance in those instances where those provisions are in conflict with the requirements of those governmental
entities.
LA) V. MIAMI -DADE COUNTY EMPLOYMENT FAMILY LEAVE AFFIDAVIT (County Ordinance No. 142.91 codified as Section 11A -29
et. seq. of the County Code)
That in compliance with Ordinance No. 142 -91 of the Code of Miami -Dade County, Florida, an employer with fifty (50) or more
employees working in Miami -Dade County for each working day during each twenty (20) or more calendar work weeks, shall provide the
following information in compliance with all items in the aforementioned ordinance:
Universal Affidavits (2/2007) Page 2 of 4
An employee who has worked for the above firm at least one (1) year shall be entitled to ninety (90) days of family leave during any
twenty-four (24) month period, for medical reasons, for the birth or adoption of a child, or for the care of a child, spouse or other close
relative who has a serious health condition without risk of termination of employment or employer retaliation.
The foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof, or the State of
Florida or any political subdivision or agency thereof. It shall, however pertain to municipalities of this State.
VI. MIAMI -DADE COUNTY DISABILITY NONDISCRIMINATION AFFIDAVIT (County Resolution R- 385 -95)
That the above named firm, corporation or organization is in compliance with and agrees to continue to comply with, and assure that
any subcontractor, or third party contractor under this project complies with all applicable requirements of the laws listed below
including, but not limited to, those provisions pertaining to employment, provision of programs and services, transportation,
communications, access to facilities, renovations, and new construction in the following laws: The Americans with Disabilities Act of
1990 (ADA), Pub. L. 101 -336, 104 Stat. 327, 42 U. S. C. 12101 -12213 and 47 U. S. C. Sections 225 and 611 including Title I,
Employment; Title Il, Public Services; Title III, Public Accommodation and Services Operated by Private Entities; Title IV,
Telecommunications; and Title V, Miscellaneous Provisions: The Rehabilitation Act of 1973, 29 U.S.C. Section 794; The Federal
Transit Act, as amended 49 U S. C. Section 1612: The Fair Housing Act as amended, 42 U.S.C. Section 3601 -3631. The foregoing
requirements shall not pertain to contracts with the United States or any department or agency thereof, or the State or any political
subdivision or agency thereof or any municipality of this State.
WO) VII, MIAMI -DADE COUNTY AFFIDAVIT REGARDING DELINQUENT AND CURRENTLY DUE FEES OR TAXES (Sec. 2- 8.1(c) of the
County Code).
Except for small purchase orders and sole source contracts, the above named firm, corporation, organization or individual desiring to
transact business or enter into a contract with the County verifies that all delinquent and currently due fees or taxes — including but not
limited to real and property taxes, utility taxes and occupational licenses -- which are collected in the normal course by the Miami -Dade
County Tax Collector as well as Miami -Dade County issued parking tickets for vehicles registered in the name of the firm, corporation,
( /� organization or individual have been paid.
0A b VIII. MIAMI -DADE COUNTY WELFARE REFORM WORK PARTICIPATION AFFIDAVIT (Resolution R- 702 -98, as amended by
Resolution R- 358 -99).
Please check one of the following options:
This entity is a governmental entity and is therefore exempt from the provisions of Resolution No. R- 702 -98, as
amended by Resolution R- 358 -99.
_ This entity is a not - for - profit organization and is therefore exempt from the provisions of Resolution No. R -702-
98, as amended by Resolution R- 358 -99.
_ This entity is a recipient of a grant award and is therefore exempt from the provisions of Resolution No. R -702-
98, as amended by Resolution R- 358 -99.
_ This entity has a contract with the County that results in actual payment of less than $500,000 and is therefore
exempt from the provisions of Resolution No. R- 702 -98.
_ This entity can demonstrate that five percent (5 %) of its work force consists of individuals who reside in Miami -
Dade County and who have lost or who will lose cash assistance benefits (formerly Aid to Families with
Dependent Children or "AFDC") as a result of the Personal Responsibility and Work Opportunity Reconciliation
Act of 1996, and therefore, requests a waiver of the requirements of Resolution No. R- 702 -98, as amended by
Resolution R- 358.99.
This entity has a contract with the County that results in actual payment of $500,000 or more, and therefore,
will contribute to Project Fresh Start, the County's welfare - to-work initiative, based on the following scale:
If the entity has a contract with the County that results in actual payment of an amount between:
$500,000 to $1,000,000 then that entity shall contribute $5,000
$1,000,001 to $5,000,000 then that entity shall contribute $10,000
$5,000,001 to $10,000,000 then that entity shall contribute $20,000
$10,000,001 and over then that entity shall contribute $25,000
Universal Affidavits (212007) Page 3 of 4
( `-Ab IX. ATTESTATION REGARDING DUE AND PROPER ACKNOWLEDGEMENT OF COUNTY FUNDING SUPPORT
By initialing this subsection and accepting County funds, the above named firm, corporation, organization or individual agrees to abide by the grant
contract requirement to recognize and acknowledge Miami -Dade County's grant support in a manner commensurate with all contributors and sponsors
of its activities at comparable dollar levels.
I have carefully read this entire four (4) page document entitled, "Universal Affidavit" and have initialed all affidavits that pertain to this contract and
have indicated by "NA" all affidavits that do not pertain to this contract.
By: Ct Sd V' �� C J /•
(Signature o ant) (Date)
SUBSCRIBED AND SWORN TO (or affirmed) before me this C da)i df, 20� by
M / She: -r/�- 6 ( /
❑has produced as identification.
(Type of Identification)
I
x r rtJ Notary Public
(Signet re of Notary)
(Name of Notary Typed, Printed or Stamped)
State of Florida - County of
Universal Affidavits (2/2007) Page 4 of 4
PDH....... o. ..0e1.0 .................INOO..`
MARIAL GARCIA
...�••ep.0 Cemmri 000438883
expires 1002009
Bonded tare (800)482 -4280
a; t;P Florida Notary
Imp44idotary3eal.•`
W -9
Request for Taxpayer
Give form to the
Form
(Rev. October 2007)
Identification Number and Certification
requester. Do not
sand to the IRS.
oepmnmeM Of the Treasury
Internal Rmvenue Serviw
Name (as shown on your income tax return)
N
d
Business name, if different from above '
o.
c
0
a
Check appropriate box: ❑ Indivlduataote proprietor ❑ Corporation ❑ Partnership
Exempt
a.
El Limited liability company. Enter the tax classification (O= disregarded entity, C= corporation, P= partnershlp) 0. .....__
❑ payee
p
Other (see Instructions) ►
CAddress
(number, street, and apt. or suite no.)
Requester's name and address (optional)
City, state, and 21P code
a
y
List account number(s) here (optional)
Tax a er Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line t to avoid social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other entities, It is or
your employer identification number Phil. If you do not have a number, see How to get a TIN on page 3.
Note. If the account is In more than one name, see the chart on page 4 for guidelines on whose Employer Identification number
number to enter.
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).
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 on page 4.
sign signature of
Here u s
—nn ► Date ►' _......
General Instructions
Section references are to the Internal Revenue Code unless
otherwise noted.
Purpose of Form
A person who is required to file an information return with the
IRS must obtain your correct taxpayer Identification number (TIN)
to report, for example, income paid to you, real estate
transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
Use Form W -9 only if you are a U.S. person (including a
resident alien), to provide your correct TIN to the person
requesting it (the requester) and, when applicable, to: -
1. Certify that the TIN you are giving Is correct (or you are
waiting for anumber 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.
Note. If 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 on any foreign partners' share of Income
from such business. Further, In certain cases where a Form W -9
has not been received, a partnership is required to presume that
a partner is a foreign person, and pay the 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 withholding on your share of partnership
income.
The person who gives 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 is in the
following cases:
• The U.S. owner of a disregarded entity and not the entity,
10231X
Form W-9 (Rev. 10 -2007)
Form W -9 (Rev. 10 -2007)
• The U.S. grantor or other owner of a grantor trust and not the
trust, and
• The U.S. trust (other than a grantor trust) and not the
beneficiaries of the trust.
Foreign person. if you are a foreign person, do not use Form
W -9. Instead, use the appropriate Form W -8 (see Publication
515, Withholding of Tax on Nonresident Aliens and Foreign
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 trestles 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 5
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 not subject to
backup withholding, give the requester the appropriate
completed Form W -8.
What is backup withholding? Persons making certain payments
to you must under certain conditions withhold and pay to the
IRS 280A 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, 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 certifications, 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 Part II
Instructions on page 3 for details), ,
3. The IRS tells the requester that you fumished 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 the Instructions below and the separate
Instructions for the Requester of Form W -9.
Also see Special rules for partnerships on page 1.
Penalties
Failure to furnish 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.
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
Name
If you are an individual, you must generally enter the name
shown on your income tax return. However, if you have changed
your last name, for Instance, due to marriage without informing
the Social Security Administration of the name change, enter
your first name, the last name shown on your social security
card, and your new last name.
If the account is In joint names, list first, and then circle, the
name of the person or entity whose number you entered in Part I
of the form.
Sole proprietor. Enter your individual name as shown on your
income tax return on the "Name" line. You may enter your
business, trade, or "doing business as PEA)" name on the
"Business name" line.
Limited liability company (LLC). Check the "Limited liability
company" box only and enter the appropriate code for the tax
classification ("D" for disregarded entity, "C" for corporation, "P"
for partnership) in the space provided.
For a single - member LLC (including a foreign LLC with a
domestic owner) that is disregarded as an entity separate from
Its owner under Regulations section 301.7701 -3, enter the
owner's name on the "Name" line. Enter the LLC's name on the
"Business name" tine.
For an LLC classified as a partnership or a corporation, enter
the LLC's. name on the "Name" line and any business, trade, or
DBA name on the "Business name" line.
Other entities. Enter your business name as shown on required
federal tax documents on the "Name" line. This name should
match the name shown on the charter or other legal document
creating the entity. You may enter any business, trade, or IDEA
name on the "Business name" line.
Note. You are requested to check the appropriate box for your
status Qndividual /sole proprietor, corporation, etc.).
Exempt Payee
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status,
then check the "Exempt payee" box In the line following the
business name, sign and date the form.
Form W -9 (Rev. 10 -2007) Page 3
Generally, individuals (including sole proprietors) are not exempt
from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
withholding.
The following payees are exempt from backup withholding:
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 possession of the United
States, or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions,
agencies, or Instrumentalities, or
5. An international organization or any of Its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding
Include:
6. A corporation,
7. A foreign central bank of issue,
S. A dealer in securities or commodities required to register in
the United States, the District of Columbia, or a possession of
the United States,
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A real estate Investment trust,
11. An entity registered at all times during the tax year under
the Investment Company Act of 1940,
12. A common trust fund operated by a bank under section
584(a),
13. A financial institution,
14. A middleman known In the investment community as a
nominee or custodian, or
15. A trust exempt from tax under section 664 or described in
section 4947.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt payees listed above, 1 through 15.
IF the payment is for ...
THEN the payment is exempt
for...
Interest and dividend payments
All exempt payees except
for 9
Broker transactions
Exempt payees 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Barter exchange transactions
Exempt payees 1 through.5 .
and patronage dividends
Payments over $600 required
Generally, exempt payees
to be reported and direct
1 through 7
sales over $5,000'
'See Form 1099 -MISC, Miscellaneous Income, and its Instructions.
'However, the following payments made to a corporation (Including gross
proceeds paid to an attorney under section 6045(Q, even if the attorney is a
corporation) and reportable on Form 1099 -MISC are not exempt from
backup withholding: medical and health care payments, attorneys' foss, and
payments for services paid by a federal executive agency.
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 How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that you
use your SSN.
If you are a single - member LLC that Is disregarded as an
entity separate from Its owner (see Limited liability company
(LLQ on page 2), 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 the chart on page 4 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, get Form SS -5, Application
for a Social Security Card, from your local Social Security
Administration office or get this form online at www.wa.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 )TIN, or Forth 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.gov /businesses and clicking on Employer Identification
Number (EIN) under Starting a Business. You can get Forms W -7
and SS -4 from the IRS by visiting www.irs.gov or by calling
1- 800 - TAX -FORM (1- 800 -829- 3676).
If you are asked to complete Forth W -9 but do not have a TIN,
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 domestic 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 Items 1, 4, and 5 below Indicate
otherwise.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt payees, see Exempt
Payee on page 2.
Signature requirements. Complete the certification as indicated
in 1 through 5 below.
1. Interest, dividend, and barter exchange accounts
opened before 1984 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.
Form W -9 (Rev. 10 -2007)
3. Real estate transactions. You must sign the certification.
You may cross out item 2 of the certification.
4. Other payments. You must give 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
nonemployee for services, payments to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
S. Mortgage interest paid by you, acquisition or
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529), IRA,
Coverdell 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:
Give name and SSN of.
1. Individual
The individual
2. Two or more Individuals (joint
The actual owner of the account or,
account)
If combined funds, the first
individual on the account'
3. Custodian account of a minor
The minor'
(Uniform Gift to Minors Act)
4. a. The usual revocable savings
The grantor- tmstee'
trust (grantor Is also trustee)
b. So- called trust account that is
The actual owner
not a legal or valid trust under
state law
S. Sole proprietorship or disregarded
The owner'
entity owned by an individual
For this type of account:
Give name and EIN of.
6. Disregarded entity not owned by an
The owner
individual
7. A valid trust, estate, or pension trust
Legal entity'
8. Corporate or LLC electing
The corporation
corporate status on Form 8832
9. Association, club, religious,
The organization
charitable, educational, or other
tax - exempt organization
10. Partnership or mufti- member LLC
The partnership
11. A broker or registered nominee
The broke or nominee
12. 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
'List &st and circle the room of the person whose number you furnish. If only one person
on a joint account has an SSN, that pereon's number must be fumished.
eCircle the minor's name and furnish the minors SSN.
You must show your Individual name and you may also enter your business w "DW
name on the second name line. You may use either your SSN or EIN Of you have ono),
but the IRS encoumgee you to use your SSN.
° Dst that end circle the name of the Wet, estate, or pension bust. (DO trot famish the TIN
of the personal representative or trustee unless the legal ertlty Itself is not designated in
the account MO.) Also see spacfaf mtos for Pannemhlps on page t.
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
Page 4
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal
Information such as your name, social security number (SSN), or
other identifying information, without your permission, to commit
fraud or other crimes. An identity thief may use your SSN to get
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.
Call the IRS at 1 -80D -829 -1040 if you think your Identity has
been used Inappropriately for tax purposes.
Victims of Identity theft who are experiencing economic harm
or a system problem, or are seeking help In resolving tax
problems that 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 smalls or phishing
schemes. Phlshing is the creation and use of email and
websites designed to mimic legitimate business Smalls 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.
The IRS does not Initiate contacts with taxpayers via Smalls.
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 personal property to
the Treasury Inspector General for Tax Administration at
1- 800 - 366 -4484. You can forward suspicious Smalls to the
Federal Trade Commission at: spam ®uce.gov or contact them at
www.consumergov/idtheft or 1- 877- IDTHEFT(438. 4338).
Visit the IRS website at www.irs.gov 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 coned TIN to persons who must file information returns with the IRS to report Interest,
dividends, and certain other Income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for Identification purposes and to help verify the accuracy of your tax return.
The IRS may also provide this Information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal
nontax 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. Payers must generally withhold 28% of taxable Interest, dividend, and certain other
payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
O
s�uraootnu��
laarnumm
mommloommoklemom
swdok
NORM AM
MaMDUQOAIlIi PA
a
"ww
w