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01-08-08 Item 6South Miami AlaMierlcaCty CITY OF SOUTH MIAMI OFFICE OF THE CITY MANAGER INTER - OFFICE MEMORANDUM 2001 To: The Honorable Mayor & Members of the City Commission Via: Yvonne S. McKinley, City Manager From: Carol M. Aubrun, aw Grants Writer and Administrator Date: January 8, 2007 Subject: Murray Park Swimming Pool Design Agenda Item No.: 6 Request: A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, AUTHORIZING THE CITY MANAGER TO EXECUTE FISCAL YEAR 2008 GRANT AGREEMENT WITH MIAMI -DADE COUNTY'S OFFICE OF COMMUNITY AND ECONOMIC DEVELOPMENT (OCED) FOR THE MURRAY PARK SWIMMING POOL DESIGN IN THE AMOUNT OF $276,000.00; AND PROVIDING FOR AN EFFECTIVE DATE Request: Authorizing the City Manager to execute an agreement with Miami -Dade County's Office of Community and Economic Development Reason/Need: The City of South Miami has been awarded a grant in the amount of $276,000.00 from Miami -Dade County's Office of Community and Economic Development (OCED). The attached resolution will allow the City Manager to execute the grant agreement with OCED for the Murray Park Swimming Pool Design. Cost: 5,1!0 Funding Source: N/A Backup Documentation: 0 Proposed Resolution O Grant Agreement Package RESOLUTION NO.: A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, AUTHORIZING THE CITY MANAGER TO EXECUTE FISCAL YEAR 2008 GRANT AGREEMENT WITH MIAMI -DADE COUNTY'S OFFICE OF COMMUNITY AND ECONOMIC DEVELOPMENT (OCED) FOR THE MURRAY PARK SWIMMING POOL DESIGN IN THE AMOUNT OF $276,000.00; AND PROVIDING FOR AN EFFECTIVE DATE WHEREAS, the Mayor and City Commission wish to accept the grant from Miami -Dade County's OCED; and WHEREAS, the grant agreement is for the Murray Park Swimming Pool Design in the amount of $276,000.00. 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's Office of Community and Economic Development for the Murray Park Swimming Pool Design Section 2: The attached exhibit is incorporated by reference into this resolution. PASSED AND ADOPTED this ATTEST: CITY CLERK READ AND APPROVED AS TO FORM: CITY ATTORNEY Include File Name and Path day of , 2008. MAYOR COMMISSION VOTE: Mayor Feliu: Vice Mayor Wiscombe: Commissioner Palmer: Commissioner Birts: Commissioner Beckman: MIAMI- AD e Carlos Alvarez, Mayor December 11, 2007 Mr. W. Ajibola Balogun Assistant City Manager City of South Miami 6130 Sunset Drive South Miami, FL 33143 Community & Economic Development 701 N.W. 1 st Court • 14th Floor Miami, Florida 33136 T 786 - 469 -2100 F 786469 -2170 �aLvn Yuc;Y r�'Ty � � 33IrS+ Subject: Contract Development Process for FY 2008 Activity Title: Murray Park Swimming Pool — Design Phase Activity I D: 20051346 Category: Capital Improvement Source: CDBG BCC Approval: $276,000 Dear Mr. Balogun: miamidade.gov On December 5, 2007, the Director. of Office of Community and Economic Development (OCED) advised you of your funding award for the above.mentioned project. Please find enclosed the documents required to execute your agreement with Miami -Dade County. Our office has scheduled a Contract Development Technical Assistance Workshop to be held on Friday, December 14, 2007 from 10:00 a.m. to 12:00 Noon in the Miami -Dade County Commission Chambers located at 111 NW 1st Street, '2nd Floor, Miami, Florida 33127. To prevent any delays in the execution of your agency's contract, please fill out and return all documents by December 21, 2007. Again, I would like to congratulate your agency on your FY 2008 award. If you should have any questions about the required documents, do not hesitate to contact me at 786 -469 -2220. CONTRACT DEVELOPMENT WORKSHOP LIST OF CONTENTS SAMPLE OF BOARD OF DIRECTOR'S RESOLUTION APPROVING THE FUNDED AMOUNT AND AUTHORIZING EXECUTION OF THE CONTRACT WITH OCED. • AUTHORIZED SIGNATURE FORM o MIAMI -DADE COUNTY AFFIDAVITS • AFFIDAVIT OF FINANCIAL AND CONFLICTS OF INTEREST • RELATED PARTIES DISCLOSURE STATEMENT • STATE OF FLORIDA PUBLIC ENTITY CRIMES AFFIDAVIT MIAMI -DADE COUNTY FAIR SUBCONTRACTING POLICIES • MIAMI -DADE COUNTY LIVING WAGE AFFIDAVIT • CODE OF BUSINESS ETHICS AFFIDAVIT • CERTIFICATION REGARDING LOBBYING • SAMPLE OF ACTION STEPS, SCOPE OF SERVICES, AND BUDGET FOR NON - CONSTRUCTION RELATED ACTIVITIES • SAMPLE OF ACTION STEPS, SCOPE OF SERVICES, AND BUDGET FOR C(, , SSTRUCTI_ ON RELATED ACTIVITIES • LIST OF REQUIRED DOCUMENTS TO BE SUBMITTED BY THE AGENCY C: /Contract Development Workshop /List of Contents/801anna SAMPLE OF BOARD OF DIRECTOR'S RESOLUTION APPROVING THE FUNDED AMOUNT AND AUTHORIZING EXECUTION OF THE CONTRACT WITH OCED C: /Contract Development Workshop/Ust of Contents /Brianna RESOLUTION AUTHORIZING EXECUTION OF A CONTRACT WITH MIAMI -DADE COUNTY AND FOR THE PROVISION WHEREAS, this Board desires to accomplish the objectives as outlined in the scope of service of the contract with Miami -Dade County. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF DIRECTORS of with Miami -Dade County for the maximum amount of $ approves one (1) contract for the provision of services for the Fiscal Year 2008 and authorizes to execute same for and on behalf of The foregoing resolution was offered by adoption, the motion was seconded by upon being put to a vote was as follows: and who moved its and The Chairperson /President thereupon declared this resolution duly passed and adopted this day of Signature- Chairperson or Secretary Agency Seal AUTHORIZED SIGNATURE FORM C: /Contract Development Warkshop/List of Contents /Mann AUTHORIZING SIGNATURES CONTRACTOR: DATE: This form certifies the names, titles and signatures of individuals authorized by the contractor's by -laws or board resolution to sign contracts, checks, budget revision requests, payment requests and any other requests, (e.g. purchase requisitions, purchase orders, receiving reports, direct bills) that are required by the Office of Community and Economic Development (OCED) for disbursement of funds. NAME TITLE SIGNATURE (Type or Print) (Type or Print) 1. Prime Contracts Subcontracts IL Checks (List Amount Limits) M. Budget Revision Requests NAME TITLE SIGNATURE (Type or Print) (Type or Print) IV. Payment Requests V. Other Administrative Matters (e.g. Status Reports, Purchase Orders, Travel Requests) * These signatures authorized are retained by OGED for auditing purposes. * You are required to submit updates to this list as it becomes necessary. MIAMI -DADE COUNTY AFFIDAVITS C: /Contract Development Workshop /List of Contents/Brianno MIAMI -DADE COUNTY AFFIDAVITS The contracting individual or entity (government or otherwise) shall indicate by an "X" all affidavits that pertain to this contract and shall .indicate by an "NIA" all affidavits that do not pertain to this contract. All blank spaces must be filled. The MIAMI -DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT; MIAMI -DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT; MIAMI -DADE CRIMINAL RECORD AFFIDAVIT; DISABILITY NON - DISCRIMINATION AFFIDAVIT; and the PROJECT FRESH START AFFIDAVIT shall not pertain to contracts with the United States or any of its departments or agencies thereof, the State or any political subdivision or agency thereof; it shall however, pertain to municipalities of the State of Florida. All other contracting entities or individuals shall read carefully each affidavit to determine whether or not it pertains to this contract. being first duly sworn state: Affiant The full legal name and business address of the person(s) or entity contraction or transacting business with Miami -Dade County are (Post Office addresses are not acceptable): Federal Employer Identification Number (If none, Social Security) Name of Entity, Individual(s), Partners, or Corporation Doing Business As (If same as above, leave blank) Street Address . City State Zip Code 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. It 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 forgoing requirements shall not pertain to contracts with publicly - traded corporations or to contracts with the United States or any department or names and addresses are (Post Offices addresses are not acceptable): Full: Legal Name Address Ownership % % Page 1 of 5 2. The full legal names and business address of any other individual (other than subcontractors, material men, supplies, laborers, or lenders) who have, or will have, any interest (legal, equitable beneficial or otherwise) in the contract or business transaction with Dade County are (Post Office addresses are not acceptable): 3. Any person who willfully fails to disclose the information required herein, or who knowingly discloses false information in this regard, shall be punished by a fine of up to five hundred dollars ($500.00) or imprisonment in the County jail for up to sixty (60) days or both. 11. 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 dollar ($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 or any municipality of this State. 1. Does your firm havd a collective bargaining agreement with its employees? Yes No 2. Does your firm provide paid health care benefits for its employees? Yes No 3. Provide a current breakdown (number of persons) of your firm's work force and ownership as to race, national origin and gender. White:. Males Females Asian: Males Females Black: Males Females American Indian: Males Females Hispanics: Males Females Aleut (Eskimo): Males Females Males Females Males Females III. AFFIRMATIVE ACTIONINON- DISCRIMINATION OF EMPLOYMENT, PROMOTION AND PROCUREMENT PRACTICES (County Ordinances. 98 -30 codified at 2 -8.1.5 of the County Code) In accordance with County Ordinance No. 98 -30, entities with annual gross revenues in excess of $5,000,000 seeking to contract with the County shall, as condition receiving a County contract, have 1) a written affirmative action plan which sets forth the procedures the entity utilizes to assure that it does not discriminate in its employment and promotion practices; and ii) a written procurement policy which sets forth the procedures the entity utilizes to assure that it does not discriminate against minority and women - owned businesses in its own procurement of goods, supplies and services. Such affirmatives action plans and procurement. policies shall provide for periodic review to determine their effectiveness in assuring the entity does not discriminate in its employment, promotion and procurement practices. The foregoing notwithstanding, corporate entities whose boards of directors are representatives of the population make- up of the nation shall be presumed to have non - discriminatory employment and procurement policies, and shall not be required to have written affirmative action plans and procurement policies in order to receive a County contract. The foregoing presumption may be rebutted. The requirements of County Ordinance No. 98 -30 may be waived upon the written recommendation of the County Manager that it is in the best interest of the County to do so and upon approval of the Board of County Commissioners by majority vote of the members present. Page 2 of 5 The firm does not have annual gross revenues in excess of $5,000,000. The firm does have annual revenues in excess of $5,000,000; however, its Board of Directors is representative of the population make -up of the nation and has submitted a written, detailed listing of its Board of Directors, including the race of ethnicity of each board member, to the County's Department of Business Development, 175 NW I` Avenue, 281h Floor, Miami, Florida 33128. The firm has annual gross revenues in excess of $5,000,000 and the firm does have a written affirmative action plan and procurement policy as described above, which includes periodic review to determine effectiveness, and has submitted the plan and policy to the County's Department of Business Development, 175 NW 1$' Avenue, 28th Floor, Miami, Florida 33128. The firm does not have an affirmative action plan and/or a procurement policy as described above, but has been granted a waiver. IV. 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 of the date of this affidavit been convicted of a felony during the past ten (10) years. V. MIAMI -DADE 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 of 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 government entities. VI. MIAMI -DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT (County Ordinances 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 Dade County for each working day during each of twenty (20) or more calendar workweeks, shall provide the following information in compliance with all items in the aforementioned ordinance: Page 3 or 5 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 serious health condition without risk of termination of 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. VII. DISABILITY NON- DISCRIMINATION AFFIDAVIT (County Resolution R385 -95) That the above names firm, corporation or organization is in compliance with the 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 provisions 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. 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, the State or any political subdivision or agency thereof or any municipality of this State. VIII. MIAMI -DADE COUNTY REGARDING DELIQUENT AND CURRENTLY DUE FEES OR TAXES (Sec. 208.1 (c) of the County Code) Except for small purchase orders and sole source contracts, that above named firm, corporation, organization or individual desiring to transact business or enter 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 Dade County Tax Collector as well as Dade County issued parking tickets for vehicles registered in the name of the firm, corporation, organization or individual have been paid. IX. CURRENT OR ALL COUNTY CONTRACTS, LOANS AND OTHER OBLIGATIONS The individual entity seeking to transact business with the County is current in all its obligations to the County and is not otherwise in default or any contract, promissory note or other loan documents with the County or any of its agencies or instrumentalities. X. PROJECT FRESH START (Resolution R- 702 -98 and 358 -99) Any firm that has a contract with the County that results in actual payment of $500,000 or more shall contribute to Project Fresh Start, the County's Welfare to Work Initiative. However, if five percent (5 %) of the firm's work force consists of individuals who reside in Miami -Dade County and who have lost or will loose cash assistance benefits (formerly Aid to Families with dependent Children) as a result of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, the firm may request waiver from the requirement of R- 702098 and R- 358 -99 by submitting a waiver request affidavit. The foregoing requirement does not pertain to government entities, not for profit organizations or recipients of grant awards. Page 4 of 5 XI. DOMESTIC VIOLENCE LEAVE (Resolution 185 -00; 99 -5 Codified a# 11A -60 Et. Seq. of the Miami -Dade County Code). - The firm desiring to do business with the County is in compliance with Domestic Leave Ordinance, Ordinance 99 -5, codified at 11A -60 et. Seq. of the Miami -Dade County Code, which requires an employer which has in the regular course of business fifty (50) or more employees working in Miami -Dade County for each working day during each of twenty (20) or more calendar work weeks in the current or proceeding calendar years, to provide Domestic Violence Leave to its employees. I have carefully read this entire five (5) page document entitled Miami -Dade County Affidavits and have indicated by an °X" all affidavits that pertain to his contract and have indicated by an "N /A" all affidavits that do not pertain to this contract. By: (Signature of Affiant) (Date) SUBSCRIBED AND SWORN TO (or affirmed) before me this day of 20 by . He /She is personally known to me or has presented (Type of Identification) (Signature of Notary) (Print of Stamp of Notary) Notary Public -- State of (State) Page 6 of 5 as identification. (Serial Number) (Expiration Date) AFFIDAVIT OF FINANCIAL AND CONFLICTS OF INTEREST C: /Contract bevelopment Workshop/Ust of Contents/Brianna AFFIDAVIT OF FINANCIAL AND CONFLICTS OF INTEREST 1. Do you have any past due financial obligations with Miami -Dade County? YES NO Single Family House Loans Multi - Family Housing Rehab CDBG Commercial Loan Project U.S. HUD Section 108 Loan Other HUD Funded Programs Other (liens, fines, loans, Occupational licenses, etc.) If YES, please explain: ' 2. Do you have any past due financial obligations with Miami -Dade County? YES NO If YES, please explain: 3. Are you a relative of or do you have any business or financial interests with any elected Miami -Dade County official, Miami -Dade County Employee, or Member of Miami -Dade County's Advisory Boards? YES NO If YES, please explain: Any false information provided on this affidavit will be reason for rejection and disqualification of your project - funding request to Miami -Dade County. The answers to the foregoing questions are correctly stated to the best of my knowledge and belief. By: (Signature of Applicant) (Date) SUBSCRIBED AND SWORN TO (or affirmed) before me this day,of 20 By He /She is personally known to me or has presented as identification. (Type of Identification) (Signature of Notary) (Print or Stamp of Notary) Notary Public — Stamp of (State) (Serial Number) (Expiration Date) Notary Seal RELATED PARTIES DISCLOSURE STATEMENT C: /Contract Nveiopment Workshop /List of Contents/Brionnn SAMPLE AGENCY NAME DISCLOSURE ABOUT RELATED PARTIES (DATE) THERE ARE NO BOARD MEMBERS OF THE (AGENCY NAME) WHO HAVE ANY RELATIONSHIP OR HAVE MADE ANY TRANSACTION WITH OTHER ENTITIES THAT MIGHT RESULT IN A CONFLICT WITH (AGENCY NAME) OPERATIONS. STATE OF FLORIDA PUBLIC ENTITY CRIMES AFFIDAVIT C: /Contract Development Workshop /List of Contents/Brionno SWORN STATEMENT PURSUANT TO SECTION 287.133 (3) (a) FLORIDA STATUTES ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS 1. This form statement is submitted to by (Print individual's name and title) for (Print name of entity submitting sworn statement) whose business address is and if applicable its Federal Employer Identification Number (FEIN) is If the entity has not FEIN, include the Social Security Number of the individual signing this sworn statement. 2. 1 understand that a "public entity crime" as defined in paragraph 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to an directly related to the transactions of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to any bid or contract for goods or services to be provided to public entity or agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misinterpretation. 3. 1 understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in an federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, non jury trial, or entry of a plea of guilty or nolo contenders. 4. 1 understand that an "Affiliate" as defined in paragraph 287.133(1)(a), Florida Statutes means: 1. A predecessor or successor of a person convicted of a public entity crime, or 2. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers , directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares .constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 5. 1 understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States within the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or entity. The term person includes those officers, executives, partners, shareholders, employees, members, and agents who are active in management of an entity 6. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies.) Neither the entity submitting sworn statement, nor any of its officers, director, executives, partners, shareholders, employees, members, or'agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this sworn statement, or one or more. of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of the entity, or an affiliate of the entity had been charged with and convicted of a public entity crime subsequent to July 1, 1989, AND (please indicate which additional statement applies. The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, nor any affiliate of the entity has been charged with and convicted of a public entity crime subsequent proceeding before a Hearing Officer of the State of the State of Florida, Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (attach a copy of the final order). I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND THAT THIS FORM IS VALID THROUGH DECEMBER 31 OR THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THAT PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017 FLORIDA STATUTES FOR A CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. (Signature) Sworn to and subscribed before me this day of , 20 Personally known Or produced identification Notary. Public -State of (Type of identification) My commission expires (Printed, typed or stamped commissioned name of notary public) MIAMI -pADE COUNTY FAIR SUBCONTRACTING POLICIES C: /Contract Development Workshop/Ust of ContenftArianno MIAMI -DADE COUNTY OFFICE OF COMMUNITY AND ECONOMIC DEVELOPMENT PROVIDER'S DISCLOSURE OF SUBCONTRACTORS AND SUPPLIERS (Ordinance 97 -104) Name of Organization: Address: REQUIRED LISTING OF SUBCONTRACTORS ON COUNTY CONTRACT In compliance with Miami -Dade County Ordinance 97 -104, the Community Based Organization must submit the list of first their subcontractors or sub - consultants who will perform any part of the Scone of Services, if this Agreement is for $100,000 or more. The Community Based Organization must complete this information. If the Community Based Organization will not utilize subcontractors, then the Community Based Organization must state "No subcontractors will be used"; do not state "N /A." Name of Sg olier Address City and State REQUIRED LIST OF SUPPLIERS ON COUNTY CONTRACT In compliance with Miami -Dade County Ordinance 97 -104, the Community Based Organization must submit a list of suppliers who will supply materials for the Scope of Services to the Community Based Organization, if this Contract Agreement is $100,000 or more. The Community Based Organization must fill out this information. If the Community Based Organization will not use suppliers, the Community Based Organization must state "No suppliers will be used ", do not state "N /A." Name of Supplier Address City and State I hereby certify that the foregoing information is true, correct, and complete Signature of Authorized Representative: Title: Firm Name: Address: Date: Fed. ID No. City /State /Zip: Telephone: () Fax: L) - E -mail: MIAMI -DACE COUNTY LIVING WAGE AFFIDAVIT C: /Contract Development Workshop /list of Contents /Manna LIVING WAGE REQUIREMENT (Miami -Dade County Ordinance 99 -44) Effective November 11, 1999 the provisions of Miami -Dade County Ordinance 99 -44 and Section 2 -8.9 of the Code of Miami -Dade County shall apply to all service contracts involving the expenditure of over $100,000 per year for "Covered Services ". "Covered Services" are the type of services purchased by the County that are subject to the requirements of the Living Wage Ordinance which are one of the following: (1) County Service Contracts (i) food preparation and /or distribution (ii) security services (iii) routine maintenance services such as custodial, cleaning, refuse removal, repair, refinishing and recycling (iv) I clerical or other non - supervisory office work, whether temporary or permanent (v) transportation and parking services, including airport and seaport services (vi) printing and reproduction services (vii) landscaping, lawn and/or agricultural services In accordance with Miami -Dade County Ordinance 99 -44, all Service Contractors entering into a contract with Miami -Dade County to provide Covered Services as described above shall pay to all of its employees providing such Covered Services to the County a Living Wage of no less than $8.56 per hour plus Health Insurance as described in the aforementioned ordinance, or $9.81 per hour without Health Insurance. Such Health Benefits shall consist of payment of at least $1.25 per hour towards the provision of health care benefits for employees and their dependents. Proof of the provision of Health Insurance must be submitted to the County to qualify for the wage rate for employees with health benefits. The Service Contractor shall also agree to produce all documents and records relating to payroll and compliance with this Ordinance prior to award of a contract as a result of this solicitation upon request by the County. If records reflect that the Service Contractor is in violation of this Ordinance, the County has the right to sanction the Service Contractor to include but not limited to termination, fine and suspension. This Ordinance encompasses various responsibilities that must be accomplished by the successful proposer such as record keeping, posting and reporting. Upon the award of this contract, the successful proposer must be prepared to comply with these requirements as outlined in Ordinance 99 -44. 5/01 1 of 2 FORM A -11 MIAMI -DADE COUNTY, FLORIDA MIAMI -DADE COUNTY LIVING WAGE AFFIDAVIT (Ordinance 99 -44 and Section 2 -8.9 of the Miami -Dade County Code) Solicitation No.: Title: 1, , being first duly sworn hereby state and certify that in compliance with Miami -Dade County Ordinance 99 -44 and Section 2 -8.9 of the Miami -Dade County Code, by accepting award of this contract, the bidder or proposer agrees to pay the living wage required by Miami -Dade County Ordinance 99 -44 to all employees assigned to this contract. The bidder or proposer further understands that the current living wage applied to this contract is $8.56 per hour plus health benefits as described in the ordinance, or $9.81 per hour without health benefits. M Signature of Affiant 20 Date ._.. Printed Name of Firm Address of Firm SUBSCRIBED AND SWORN TO (or affirmed) before me this day of 20_, by . He /She is personally known to me or has presented Affiant Type of Identification Signature of Notary Print or Stamp Name of Notary Notary Public — State of Rev. 1120100 as identification. 2 of2 Serial Number Expiration Date Notary Seal CODE OF BUSINESS ETHICS AFFIDAVIT C: /Contract Developme Workshop /List of Contents /86anna FORM A -12 CODE OF BUSINESS ETHICS In accordance with Section2- 8.1(i) of the Miami -Dade County Code, each person or entity that seeks to do business with the County shall adopt a Code of Business Ethics ("Code") and shall, prior to execution of any contract between the contractor and the County, submit an affidavit stating that the contractor has adopted a Code that complies with the requirements of Section 2 -8.1 (i) of the Miami -Dade County Code. Any person or entity that fails to submit the required affidavit shall be ineligible for contract award. The Code of Business Ethics shall apply to all business that the contractor does with the County and shall, at a minimum, require that the contractor: • Comply with all applicable governmental rules and regulations including, among others, the Miami -Dade County Conflict of Interest and Code of Ethics Ordinance and the False Claims Ordinance. • Comply with all applicable rules and regulations regarding Disadvantaged Business Enterprises, Black Business Enterprises, Hispanic Business Enterprises and Women Business Enterprises (hereinafter collectively Minority Business Enterprises, "MBEs ") and Community Small Business Enterprises (CSBEs) and shall specifically prohibit the following practices: o Pass-through Reauirements: The Code shall prohibit pass- throughs whereby the prime fire requires that the MBE or CSBE firm accept payments as a MBE or CSBE and pass through those payments or a portion of those payments to another entity including, but not limited to the owner /operator of the prime firm; o _Rental Space Equipment or Flat Overhead Fee Requirements. The Code shall prohibit rental space requirements, equipment requirements, and /or flat overhead fee requirements, whereby the prime firm requires the MBE or CSBE firm to rent space or equipment from the prime firm or charges a flat overhead fee for the use of space, equipment, secretary, etc; o Staffing Requirements. The Code shall prohibit the prime firm from mandating, as a condition to inclusion in the project, that a MBE or CSBE hire, fire, or promote certain individuals not employed by the prime firm, or utilize staff employed or previously employed by the prime firm. o MBE or CSBE Staff Utilization. The Code shall prohibit the prime firm from requiring the MBE or CSBE firm to provide more staff than is necessary and then utilizing the MBE or CSBE staff for other work to be performed by the prime firm. o Fraudulently creating, operating or representing MBE or CSBE. The Code shall prohibit a prime firm including, but not limited to, the owners /operators thereof from fraudulently creating, operating or representing an entity as a MBE or CSBE for purposes of qualifying for certification as a MBE or CSBE. The Code shall also require that on any contract where MBE or CSBE participation is purported, the contract shall specify essential terms including, but not limited to; a speck statement regarding the percent of participation planned for MBEs or CSBEs, the timing of payments and when the work is to be performed. M The failure of a contractor to comply with its Code of Business Ethics shall render any contract between the contractor and the County voidable, and subject violators to debarment from future County work pursuant to Section 90- 38(h)(2) of the Code. The inspector General shall be authorized to investigate any alleged Violation by a contractor of its Code of Business Ethics. Signature of Afriant Printed Name and Title of Affiant Printed Name of Firm Address of Firm 20 Date Federal Employer Identification Number SUBSCRIBED AND SWORN TO (of affirmed) before me this day of ,20 He /She is personally known to me or has presented as identification. Type of Identification Signature of Notary Print or Stamped Name of Notary Notary Public, State of Serial Number Expiration Date CERTIFICATION RE6ARDIN6 LOBBYING C: /Contract bevelopment Workshop /List of Contents/Briaana ATTACHMENT E CERTIFICATION REGARDING LOBBYING Certification for Contracts, Grants, Loans and Cooperative Agreements The undersigned certifies, to the best of his or her knowledge and belief, that: 1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the malting of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. 2. If any of the funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. 3. The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreement in excess of $100,000) and that all subrecipients shall certify and disclose accordingly. 4. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. By: r (Signature of Authorized Representative) Print: (Print Name of Firm and Authorized Representative) Title: Date: SAMPLE OF ACTION STEPS, SCOPE OF SERVICES, AND BUDGET FOR NON - CONSTRUCTION RELATED ACTIVITIES C: /Contract Development Worlcahop/Ust of Contents /9rianna a 3 m O Z rn 'v m S 0 3 }r ['� D nt m r O 3 m A 1 r GOU�ITY '. Agency Name FY 2008 Scope of Services January 1, 2008 — December 31, 2008 1. - ACTIVITY TITLE: Employment and Training Program r 2. - ACTIVI'T'Y DESCRIPTION: Employment training for 100 people countywide in FY 2008 3. - APPROVED BY BCC: $50,000 4. - SOURCE: CDBG 2008 5. - HUD INFORMATION: 5a. — HUD matrix code: 05H 5b. — Title: Employment Training_ 5c. — Eligibility 570.201(e) 6. - ACCOMPLISHMENTS: 6a. —Number of Units: 100 w. 6b. — Type: People 7. -NATIONAL OBJECTIVE: 570.208 (A)(2) --- Low/Mod. Income Clientele (LMC) 8. - ACTIVITY ADDRESS: 4343 W. Flagler Street, Ste. 300 Miami, Florida 33134 9. - LOCATION: Entitlement Ci (Miami) ➢ CO: Evan Best PLANNED John Know It All ■ . _ SAMPLE BUDGET SUMMARY FOR NOWCONSTRUC IQN RELATED PROJECTS NAME OF AGENCY, INC. ABC PROGRAMMING CDBG FY 2008 SUMMARY BUDGET JANUARY 1, 2008 — DECEMBER 31, 2008 CATEGORIES Non -OCED CDBG 2007 TOTAL ALL SOURCES I. PERSONNEL 119,236 23,169 $ 142,405 11. CONTRACTUAL SERVICES 9,500 9,500 $ 19,000 111. OPERATING SERVICES 6,750 6,750 $ 13,500 IV. COMMODITIES 800 800 $ 1,600 V. CAPITAL OUTLAY 0 0 $ 0 TOTAL BUDGET $136,286 $40,219 $176,505 OTHER FUNDING SOURCES (Non- OCED): ABC Grant $50,000 BL Grant $86.286 Total $136,286 SAMPLE BUDGET FOR NON_CQNSTRIICTION RELATED PROJECTS AGENCY NAME, INC. CDBG FY 2008 [PROJECT NAME] DETAIL BUDGET January 1, 2008 thru December 31, 2008 04010 grin a Benefits Fica:11 000 x .0620 = 628 x 100% PP Non OCED OCED TOTAL OCED TOTAL ALL SOURCES 04010 PERSONNEL - Em to ee $800 1,530 5,665 11.43 42.34 297 1,101 $1,827 $6,766 Regular - Salaries $0.00 13Y.736 Bi -Week! 2,669 $16,405 Executive Director 26 38,000 0 0 $38,000 De u Director 26 47,000 0 0 $47,000 Case Manager 26 12,500 480.77. 12,500 $25,000 Tutor 26 8,000 307.69 8,000 $16,000 Subtotal Salaries 105,500 788.46 20,500 $126,000 04010 grin a Benefits Fica:11 000 x .0620 = 628 x 100% 6,541 48.88 1,271 $7,812 Mica: 11,000 x.01 45 =160 Worker's Compensation $800 1,530 5,665 11.43 42.34 297 1,101 $1,827 $6,766 Subtotal Fringe $0.00 13Y.736 102.66 2,669 $16,405 22350 Bottled Water $800 0 0.00 0 $0.00 Total Personnel 1 1 119,236 891.12 1 $142,405 Pnn#m&#ai21 CarA -ac 21011vv'Extemai Audit 2,000 0.00 2,000 $4,000 21020 Accounting Services $800 0 0.00 0 $0.00 21030 Other Professional Svc. $0.00 0 0.00 0.00 $0.00 22350 Bottled Water $800 0 0.00 0 $0.00 25330 Rent Co ter $1600 1,500 0.00 1,500 $3,000 25511 Building Rental 6,000 0.00 6,000 $12,000 Total Contractual 9,500 0.00 9,500 1 $19,000 17- flnaraHnn Ovnanan 22010 Electrical Services 2-YO-0-0 0.00 2,000 $4.000 23210 General Liability Insurance $800 1,500 0.00 1,500 $3,000 23220 Automobile Liability Insurance $0.00 1,250 0.00 1,250 $2,500 31011 Telephone R ular $800 1,250 0.00 1,250 $2,500 31011 Telephone Long Distance $1600 150 0.00 150 $300 31610 Postage 600 0.00 600 1 $1,200 31420 Advertising Radio 0.00 0.00 0.00 $0.00 - Total Operating Expense 6,750 0.00 6,750 $13,500 Commodities 31510 Outside Printing 400 0.00 400 $800 95020 Computer Purchase 0.00 0 0.00 0 $0.00 47010 Office SupplieslOutside Vendors 400 0.00 400 $800 Total Commodities 1 800 0.00 800 $1600 Ca iialOutlay 0.001 0.00 1 0.00 Total Capital Outla 0.00 0.00 1 0.00 1 0.00 TOTAL BUDGET $136,286 1 0.00 1 $40,219 List of all other funding sources and corresponding amounts as indicated below: ABC Grant $50,000 BL Grant $86.28 Total $136,286 SAMPLE OF ACTION STEPS, SCOPE OF SERVICES, AND BUDGET FOR CONSTRUCTION RELATED ACTIVITIES C: /Contract bevelopment Workshop/Ust of Contents /Brianna D 'S m m O m 0 N yOy n b� r .n O o= .'✓00 w O is �O p Z o= ro a �W d O C �a D Q O� a! �m LL'] W O t ��(Q� (]� ��•.������zOi�yl�.,' q yy ���'c��.::$mOz���p c � 2� -i - tL77�D �nn C � � [7 R O m 2 cS y c —mm are; ,i O z z sy S p -op y�oo 2.= � a�a_C S2 m A p E E p mj .. .. 0 8F 3r[Z l r NyC ON, "i;; C5,. 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'�L YLh .�kL •( k i (.) od l 41L t- 2 � .'uL• t F7 �1 � y�'.R 3 i �sw^ f ti �.�..{��ij- F(N S Ji^si hY pY 4.�.;1`�} r.tF S.tR F} s.o.. t4 M€lI L J F rc++ny,. `•. $ <} t 2•T SC TS � l 1Hfz�l_. a a'g'\tt- '4irfi� is = fYl S x=t O S �' "" `° -� y. ����� .fin'✓; ' t`�:� ,�`�k9��j tit it :sL' � c EGyrJf� �. .>! $Y E' .fF r''�s,�s sF�•;�aa._ r }+. .� � Q m l�jC,k' y z,`'.+:7�.,.+%: '.;2_...�.m. - �Cii'�,:T. i�E_ n...:E.nr'. - .- .�.�.. sl,..TMr,',A7J•i�,ri ..f/�.,,.i�.. .,s tS.,.. .. -s i. ryi ..vr,.•., yy i x y� r... zr�yu� t• �p1 � iLYr 1. D 'S m m O m 0 N yOy n b� r .n O o= .'✓00 w O is �O p Z o= ro a �W d O C �a D Q O� a! �m LL'] W !� 1AM !•�E Agency Name FY 2008 Scope of Services January 1, 2008 — December 31, 2008 1. - ACTIVITY TITLE: ABC Community Center 2. - ACTIVITY DESCRIPTION: The construction of a Community Center - downtown 3. - APPROVED BY BCC: $250,000 4. - SOURCE: CDBG 2008 5. - HUI) INFORMATION: 5a. — ffLJD matrix code: 03E 5b. -- Title: Neighborhood Facilities 5c. — Eligibility 570.201(c) 6. - ACCOMPLISHMENTS: 6a. -- Number of Units: 1 6b. — Type: Facility 7. - NATIONAL OBJECTIVE: 570.208(A)(1j — Low/Mod. Income Area ( era.. a nnun i■ 8. - ACTIVITY ADDRESS: 1234 W. Flagler Street Ste. Miami Florida 33134 9. - LOCATION: Entitlement City (Miami) ➢ CO: Evan Best PLANNER: Johnny Know It All -a 0 s m X z v z G) ca -n v m � ti W G) Z 0 n = m v oo C CA A W N -� C ac n ' O m o 0 0 � o v o co W N G) N rt n O to fp G) �• 0 w m x 0 c m o a © ° o o Q g CD cm 0 ° p v O z o 40 o n oo -j g O Z o ° CD CD CIP Cl rn v w o zo o w A $ w v 4 C31 o CD o o c �� C t- m -n G) m ya. N c ° 00 C ac n ' O m o 0 � � v o co W G) z 0 m 0 v ao c> v O v m ft A s m z m r m 0 z CA I c n 0 z w c v G) 4 -n 0 mc O rm m 0 M 0 v w G) m C z v OTHER FUNDING SOURCES (Non -OCED) ABC Grant $30,000 First Bank Loan $30,360 Total $60,360 SAMPLE C_ ONST U, R CTION BUDGET FOR HOME OR CDBG FUNDS Agency Name OCED FY 2007 January 1, 2008 - December 31, 2008 SUB OBJECT DESCRIPTION HOME or CDBG OTHER AMT TOTAL AMT AMOUNT -.. .e.., Executive Director $0, $23,Q77 $23,077 ' Housing Assistant $0 $0 $0 FICAIMICA $0 $1,883 $1,883 Total Personnel $0 $24,960 $24,960 20 Contractual Services 21010 Audit External $10,000 $0 $0 $3,600 $10,000 $3,600 23210. Accounting Services General Liability Insurance $1,000 $0 . $1,000 23220 Auto Liability $1,000. $0 $0 $1,000 $1,000 23620 Other Insurance Expense: $1,000 Builders Risk 61613 Flood Title Insurance $5,000 $0 $5,000 21030 Construction Manager (Consultant) $25,000 $0 $25,000 21420 Appraisal & Surveying Services $7,000 $0 $7,000 24421 _ Property Maintenance $5,000 $0 $0 $5,000 $5,000 21210 Attorney's Fees $5,000 $10,000 $0 $10,000 31420 Marketing Total Contractual $70,000 $3,600 $73,600 R Electric/Telephone $0 $7,400 $7,400 MOM- Water & Sewer Services $0 $1,000 $1,000 Total Operating Expenses $0 $8,400 $8,400 Supplies $0 $1,400 $1,400 NffOffice Office Equipment $0 $5,000 $5,000 Rent $0 $12,000 $12,000 Total Commodities $0 $18,400 $18,400 90 Capital Outlay 91090 Purchase Price of Land $75,000 $0 $75,004 91012 Environmental $5,000 $0 $0 $5,000 $5,000 91021 Site Preparation $5,000 $2,000 $0 $2,000 91111 Fence Installation $0 $0 4210 Prime Contractor - Construction $0 $5,000 $5,000 32250 Property Taxes Building Permits $10,000 $0 $10,000 61626 Architect Fees $13,000 $20,000 $0 $0 $13,000 $20,000 26250 Impact Fees Total Capital Outlay $130,000 $5,000 $135,000 TOTALS $200,000 ' $60,360 $260,360 OTHER FUNDING SOURCES (Non -OCED) ABC Grant $30,000 First Bank Loan $30,360 Total $60,360 LIST OF REQUIRED DOCUMENTS TO BE SUBMITTED BY THE AGENCY C: /Contract bevelopmnt Warlmhop/List of Contents/Monm REQUIRED DOCUMENTS FOR CONTRACT DEVELOPMENT TO BE PROVIDED BY THE AGENCY 1. LIST OF CURRENT BUSINESS ASSOCIATIONS 2. MOST CURRENT ARTICLES OF INCORPORATION 3. MOST CURRENT BYLAWS 4. MOST CURRENT BOARD OF DIRECTOR'S ROSTER 5. MOST CURRENT IRS TAX EXEMPT STATUS DETERMINATION LETTER b. MOST CURRENT IRS FORM 994 7. MOST CURRENT STATE OF FLORIDA CORPORATE CERTIFICATE S. CERTIFICATE OF GOOD STANDING FROM DEPARTMENT OF STATE Enter your TIN in the appropriate box. The T!N provided must match the name given on Line 1 to avoid Soeiat setxirlty 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 your employer identification number (EIN). It you do not have a number, see Now to get a TiN on page 3. or 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. i LL I I 1 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 numberlo 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 fanure 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. person (Including a U.S. resident alien). 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 retum. 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 ORA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct T1N. (See the instructions on page 4.) Sign signature of Here u.s. person ► Date ► Purpose of Form A person who Is required to file an information return with the IRS, must obtain your correct taxpayer identification number (rIN) 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. U.S. person. Use Form W -9 only if you are a U.S. person (ncluding 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 a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S, exempt payee. In 3 above, 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. For federal tax purposes, you are considered a person if you are: cat. • An individual who is a citizen or resident of the United States, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, or • Any estate (other than a foreign estate) or trust. See Regulations sections 301.7701 -6(a) and 7(a) for additional Information. 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, tf 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 establish €ng 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 foilowing cases: • The U.S. owner of a disregarded entity and not the entity, Vo. 10231X Form W -9 (Rev. 11-20(15) W"9 Request for Taxpayer Give form to the Form (Rev. November 2005) identification Number and Certification requester. °° not send to the IRS. Department of the Treasury Internal Revenue Service N Name (as shown on your income tax return) m CD m CL Business name, if different from above c 0 w O Individual/ ❑ Corporation ❑ Partnership ❑ Other ► Exempt from backup ❑ °' ""' ❑ withholding Check appropriate bolt Sole proprietor w C Address (number, street, and apt or suite no.) Requester's name and address (optional) � tE V City, state, and ZIP code List account number(s) here (optional) Enter your TIN in the appropriate box. The T!N provided must match the name given on Line 1 to avoid Soeiat setxirlty 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 your employer identification number (EIN). It you do not have a number, see Now to get a TiN on page 3. or 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. i LL I I 1 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 numberlo 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 fanure 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. person (Including a U.S. resident alien). 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 retum. 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 ORA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct T1N. (See the instructions on page 4.) Sign signature of Here u.s. person ► Date ► Purpose of Form A person who Is required to file an information return with the IRS, must obtain your correct taxpayer identification number (rIN) 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. U.S. person. Use Form W -9 only if you are a U.S. person (ncluding 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 a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S, exempt payee. In 3 above, 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. For federal tax purposes, you are considered a person if you are: cat. • An individual who is a citizen or resident of the United States, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, or • Any estate (other than a foreign estate) or trust. See Regulations sections 301.7701 -6(a) and 7(a) for additional Information. 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, tf 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 establish €ng 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 foilowing cases: • The U.S. owner of a disregarded entity and not the entity, Vo. 10231X Form W -9 (Rev. 11-20(15) Form W -9 (Rev. 11 -20057 Page 2 e The U.S. grantor or other owner of a grantor trust and not the trust, and a 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 treaties contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the recipient 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 follow_ ing 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. taw, 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 28% of such payments (after December 31, 2002). This is called "backup withholding." Payments that may be subject to backup withholding include 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 11 instructions on page 4 for details), 3. The IRS tells the requester that you furnished an incorrect TIN, 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See the instructions below and the separate Instructions for the Requester of Form W -9. Also see Special rules regarding 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 (DBA)" name on the "Business name" line. Limited liability company (LLC). If you are a single- member LLC (Including a foreign LLC with a domestic owner) that is disregarded as an entity separate from its owner under Treasury regulations section 301 .7701 -3, enter the owner's name on the "Name" line. Enter the LLC's name on the "Business name" line. Check the appropriate box for your filing status (sole proprietor, corporation, etc.), then check the box for "Other" and enter "LLC" in the space provided. 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 DBA name on the "Business name" line. Note. You are requested to check the appropriate box for your status (individual /sole proprietor, corporation, etc.). Exempt From Backup Withholding If you are exempt, enter your name as described above and check the appropriate box for your status, then check the "Exempt from backup withholding" box in the fine following the business name, sign and date the form. Form W-9 (Rev. 11 -2005) 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. Exempt payees. Backup withholding is not required on any payments made to the following payees. 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(1)(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, 8. 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 recipients listed above, 1 through 15. IF the payment is for - .. T14EN the payment is exempt for.... Interest and dividend payments All exempt recipients except for 9 Broker transactions Exempt recipients 1 through 13. Also, a person registered under the Investment Advisers Act of 1940 who regularly acts as a broker Barter exchange transactions Exempt recipients 1 through 5 and patronage dividends Payments over $600 required Generally, efempt recipients to be reported and direct 1 through 7 sales over $5,000' See Form 1099 -MISC, Miscellaneous income, and its instructions. 4However. the following payments made to a corporation (vnciuding gross proceeds paid to an attorney under section 6045(1), 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' fees; 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, IoTiur TIN is your IRS individual taxpayer identification number N). 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 -owner LLC that is disregarded as an entity separate from its owner (see Limited liability company (LLC) on page 2), enter your SSN (or EIN, if you have one). if the LLC is a corporation, partnership, etc., 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.socialsecurity.gov. You may also get this form by calling 1 -800- 772 -1213. Use Form W -7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS -4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at wwwdrs.gov /businesses and clicking on Employer ID Numbers under Related Topics. 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 Form 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. Writing "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. Form W -8 (Rev. 11 -2005) Page 4 Part 11. 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 recipients, see Exempt From Backup Withholding 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. 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). 6. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuMon 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 tills type of account: Give name and SSN of: 1. Individual The individual 2. Two or more individuals Qoint The actual owner of the account account) or, if combined funds, the first individual on the account' 3. Custodian account of a minor The minor 2 (Uniform Gift to Minors Act) 4. a. The usual revocable The grantor - trustee' savings trust (grantor is also trustee) b. So- called trust account The actual owner' that is not a legal or valid trust under state law 5. Sole proprietorship or The owner' single -owner LLC For this type of account: Give name and EIN of: 6. Sole proprietorship or The owner 3 single -owner LLC 7. A valid trust, estate, or Legal entity " pension trust 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 multi- member The partnerahip LLC 11 _ A broker or registered The broker or nominee nominee 12. Account with the Department The public entity of 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 first and circle the name of the person whose number you fumish. If only one person on a joint account has an SSN, that person's number must be fumished. 2Gircle the minor's name and famish the minor's SSN. ' You must show your individual name and you may also enter your business or "DBA" name on the second name line. You may use either your SSN or GN (d you have one). If you are a sole proprietor, IRS encourages you to use your SSN. 'List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules regarding parMerships on page 1. Note. If no flame is circled when more than one name is listed, the number will be considered to be that of the first name listed. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct 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.