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HomeMy WebLinkAboutPK04-132 - Original - King County Parks & Recreation Division - Upland Playfield - Youth Sports Facility Grant # D33337D - 03/05/2004 40 Records Management KENT Document WASNINOTON CONTRACT COVER SHEET This is to be completed by the Contract Manager prior to submission to City Clerks Office. All portions are to be completed, if you have questions, please contact Mary Simmons, City Clerks Office. Vendor Name: Contract Number: pKoq - l3a-bc I This Is assigned by Mary Simmons Vendor Number: Project Name: g4ko-& / — S GYM�S -# 03 333/7 :> Contract Effective Date: Contract Termination Date: Zii 3- 3 ALeO5 Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager. Department: ADCL7832 07/02 O King County Parks and Recreation Division Department of Natural Resources and Parks King Street Center Budding KSC-NR-0700 201 South Jackson Street Seattle,WA 98104-3855 206-296-8687 March 10, 2004 Shane Gilbertson,Project Manager Kent Parks and Recreation 220 4th Avenue South Kent, WA 98032 RE: Youth Sports Facility Grant, D33337D, $36,000 Dear Shane: Congratulations again on your grant award for Uplands Playfield This letter serves as an "Authorization to Proceed" with your project. Enclosed is an executed contract for you files Please keep me informed as the projects proceeds and nears completion Also, any project signage or promotional material should note King County and this program as a financial sponsor. Enclosed are plaques for this and past projects to be installed by Kent Parks. I hope this project serves your community well. Please feel free to invite to me to planning meetings or include me in design discussions. I can be reached at 206.263.6267 if you or project members have any questions. All the best, Butch Lovelace Program Manager tF�f a®2U2N k - 3 p [ ®King CounW Department of Natural Resources and Parks Parks and Recreation Division YOUTH SPORTS FACILITY GRANT CONTRACT—2004 Department/Division: Natural Resources and Parks / Parks Division Agency: Kent Parks and Recreation Project Title: Uplands Playfield Contract Amount: $36,000 Fund Code: 1638 Contract Period From: January 1,2004 To December 31,2005 Contract Number: D33337D THIS CONTRACT is entered into by KING COUNTY (the "County"), and Kent Parks and Recreation (the "Agency").,whose address is 220 4th Avenue South,Kent, WA 98032, WHEREAS,King County is the manager of the Youth Sports Facility Grant(YSFG)Program, WHEREAS,the grant recipient is either a public agency or a non-profit organization whose land or facility will provide recreational or athletic opportunities primarily to youth under 21 years of age; WHEREAS, King County has selected the identified agency to be awarded a Youth Sports Facility Grant to assist in capital improvements for increased recreational opportunities, WHEREAS, the grant recipients and/or landowner on whose property will receive these improvements will develop, program, operate, and maintain the facility to address a recreation need in King County, WHEREAS, King County has the authority under KC Ordinance 10454 to enter into agreements for the use of King County funds by public agencies and/or non-profit organizations to provide a service to the public, This form is available in alternate formats for people with disabilities upon request. 1 NOW THEREFORE, in consideration of payments, covenants, and agreements hereinafter mentioned, to be made and performed by the parties hereto,the parties covenant and do mutually agree as follows 1. SCOPE OF SERVICES The Agency shall provide services and comply with the requirements set forth hereinafter and in the following attached exhibits,which are incorporated herein by reference: ❑ Scope of Services Attached hereto as Exhibit I ❑ Budget Attached hereto as Exhibit II ❑ Tuneline Attached hereto as Exhibit III ❑ Invoice Voucher Attached hereto as Exhibit IV ❑ Design Documents Attached hereto as Exhibit V ❑ Insurance Certificate Attached hereto as Exhibit VI ❑ W-9 Attached hereto as Exhibit VII ❑ Use Agreement Attached hereto as Exhibit VIII ❑ Personnel Inventory Report(K.C.C. 12.16) NA ❑ Affidavit of Compliance(K.C.C. 12.16) NA ❑ Assurance of Compliance/Section 504 NA 2. DURATION OF CONTRACT This Contract shall commence on the 1 st day of January, 2004, and shall terminate on the 31 st day of December, 2005, unless extended or terminated earlier, pursuant to the terms and conditions of the Contract. 3. PREMISES This grant project is located at: Uplands Playfield,Kent 4. PARTIES All communication,notices,coordination, and other tenets of this agreement shall be managed by: On behalf of Kind?County: Butch Lovelace,YSFG Program Manager King County Department of Natural Resources and Parks 201 South Jackson St, Suite 701 Seattle, WA 98104-3855 Email: butch.lovelaceQmetrokc.gov Phone: 206.263.6267 2 On behalf of Mr. Shane Gilbertson,Project Manager Kent Parks and Recreation 220 4th Avenue South Kent, WA 98032 253.856.5115 silbertson@ci.kent.wa.us 5. COMPENSATION AND METHOD OF PAYMENT A. The County shall reimburse the agency for satisfactory completion of the services and requirements specified in this Contract after the agency submits an invoice and all accompanying reports as specified in the attached exhibits The County will initiate authorization for payment after approval of corrected invoices and reports. The County shall make payment to the Agency not more than 30 days after a complete and accurate invoice is received. B. The Agency shall submit its final invoice and all outstanding reports within 15 days of the date this Contract terminates. If the Agency's final invoice and reports are not submitted by the day specified in this subsection, the County will be relieved of all liability for payment to the Agency of the amounts set forth in said invoice or any subsequent invoice 6. OPERATING BUDGET When a budget is attached hereto as exhibit II, the Agency shall apply the funds received from the County under this Contract in accordance with said budget. The Agency shall request prior approval from the County for an amendment to this Contract when the cumulative amount of transfers among the budget categories, i.e. Project Tasks, is expected to exceed 10% of the Contract amount. Supporting documents necessary to explain fully the nature and purpose of the amendment must accompany each request for an amendment. 7. COMMUNICATION The Agency shall recognize King County Parks as a fiscal sponsor for the grant project in the following manner: A. Plaque: At the time of project completion or dedication, which ever comes first, the Agency shall install on or near the facility a 4" X 6" plaque provided by the County that notes King County as a fiscal sponsor. B. Events: The Agency shall invite and recognize King County Parks at all events promoting the project during construction,and at the final project dedication. C. Written material: The Agency shall recognize King County Parks as a fiscal sponsor in all brochures, banners, posters, and other promotional material. 3 ti S. PUBLIC ACCESS The Agency shall to the greatest extent reasonably possible make the project available for use by the general public without unreasonable requirements for use. Fees for use of the project shall be no greater than those generally charged by public operators of similar facilities in King County. 9. GREEN BUILDING King County is committed to promoting and using green building practices in construction projects. Though not required,King County strongly encourages practices that conserve resources, use recycled content materials,maximize energy efficiency,and otherwise consider environmental, economic and social benefits in the design and construction of a building project. 10. INTERNAL CONTROL AND ACCOUNTING SYSTEM The Agency shall establish and maintain a system of accounting and internal controls which complies with applicable, generally accepted accounting principles, and governmental accounting and financial reporting standards in accordance with Revised Code of Washington(RCW)Chapter 40.14. 11. MAINTENANCE OF RECORDS A. The Agency shall maintain accounts and records, including personnel, property, financial, and programmatic records and other such records as may be deemed necessary by the County to ensure proper accounting for all Contract funds and compliance with this Contract. B. These records shall be maintained for a period of six(6)years after termination hereof unless permission to destroy them is granted by the Office of the Archivist in accordance with Revised Code of Washington(RCW)Chapter 40.14. C. The Agency shall inform the County in writing of the location, if different from the Agency address listed on page one of this Contract, of the aforesaid books, records, documents, and other evidence and shall notify the County in writing of any changes in location within ten (10)working days of any such relocation. 12. RIGHT TO INSPECT King County at its discretion reserves the right to review and approve the performance of Agency with regard to this Contract. 13. COMPLIANCE WITH ALL LAWS AND REGULATIONS The Agency, in cooperation and agreement with the owners of the Premises, shall comply with all applicable laws, ordinances and regulations in using funds provided by the County including, to the extent applicable, those related to "public works," payment of prevailing wages and competitive bidding of contracts. The Agency specifically agrees to comply and pay all costs associated with achieving such compliance without notice from King County, and that King County, does not waive this section by giving notice of demand for compliance in any instance. The Agency shall indemnify and defend the County should it be sued or made the subject of an administrative investigation or hearing for a violation of such laws related to this Agreement 4 14. CORRECTIVE ACTION A. If the County determines that a breach of contract has occurred or does not approve of the aforementioned performance, it will give the Agency written notification of unacceptable performance. Agency then agrees to take convective action within a reasonable period of time, as defined by King County in the aforementioned written notification. B. The County may withhold any payment owed the Agency until the County is satisfied that corrective action has been taken or completed. 15. TERAIINATION A. This Contract may be terminated by the County without cause, in whole or in part, prior to the date specified in Section II, by providing the Agency ten (10) days advance written notice of the termination. B. If the termination results from acts or omissions of the Agency, including but not limited to misappropriation, nonperformance of required services, or fiscal mismanagement, the Agency shall return to the County immediately any funds, misappropriated or unexpended, which have been paid to the Agency by the County. 16. FUTURE SUPPORT The County makes no commitment to support the services contracted for herein and assumes no obligation for future support of the activity contracted herein except as expressly set forth in this Contract. 17. HOLD HARMLESS AND INDEMNIFICATION The Agency agrees to indemnify and hold King County harmless as provided herein. Accordingly, The Agency agrees for itself, its successors, and assigns, to defend indemnify, and hold harmless King County, its appointed and elected officials, and employees from and against liability for all claims, demands, suits,and judgments, including costs of defense thereof for injury to persons, death, or property damage which is caused by, arises out of, or is incidental to any use of or occurrence on the Project that is the subject of this Contract or The Agency's exercise of rights and privileges granted by this Contract, except to the extent of the County's sole negligence. The Agency's obligations under this section shall include: A. The duty to promptly accept tender of defense and provide defense to the County at The Agency's own expense; B. Indemnification of claims made by The Agency's employees or agents; and C. Waiver of The Agency's immunity under the industrial insurance provisions of Title 51 RCW. but only to the extent necessary to indemnify King County, which waiver has been mutually negotiated by the parties. In the event it is necessary for the County to incur attorney's fees, legal expenses or other costs to enforce the provisions of this section, all such fees, expenses and costs shall be recoverable from The Agency. 5 b In the event it is determined that RCW 4.24.115 applies to this Contract, The Agency agrees to protect, defend, indemnify and save the County, its officers, officials, employees and agents from any and all claims, demands, suits, penalties, losses damages judgments, or costs of any kind whatsoever for bodily injury to persons or damage to property(hereinafter"claims"), arising out of or in any way resulting from The Agency's officers, employees, agents and/or subcontractors of all tiers, acts or omissions, performance of failure to perform the rights and privileges granted under this Contract, to the maximum extent permitted by law or as defined by RCW 4.24.115, now enacted or as hereafter amended. A hold harmless provision to protect King County similar to this provision shall be included in all Contractor or Subcontractor Agreements entered into by Agency in conjunction with this Contract. 18. INSURANCE A. Liability Insurance. Requirements Notwithstanding any other provision within this Agreement, Grant recipient shall procure and maintain the following Minimum Limits of Insurance for the duration of the term and shall require their contractors to procure and maintain: 1. Commercial General Liability. (to include Products-Completed Operations) insurance against claims for injuries to persons or damages to property that may arise from or in connection with the Concessionaire's use of the premises at the County Park site. General liability insurance shall be as broad as that provided by Commercial General Liability"occurrence"form CG0001 (Ed. 11/85). The insurance limits shall be no less than One Million dollars ($1,000,000) combined single limit per occurrence and Two million dollars ($ 2,000,000) in the aggregate for bodily injury and property damage 2. Automobile Liability. Insurance Services form number CA 00 01 (Ed. 1/80) any auto. If the grant includes the use of automobiles, the Limit of Liability shall be no less than One Million dollars($ 1,000,000)per occurrence. 3. Workers Compensation/SW Gap. If the recipient or its contractors has employees, parties shall provide Statutory Workers Compensation coverage and Stop Gap Liability for a limit no less than One Million dollars($1,000,000) 4. Professional Liability. If the grant includes the use of Professional Services, a Per Claim/Aggregate Limit of$ 1,000,000. shall be provided. B. If the grant involves the construction of a capitol project or involves the purchase of equipment greater than$ 5,000. in value,Grant Recipient shall provides "All Risk"Builders Risk or Property" coverage for the full replacement value of the project/property built/purchased. King County shall be listed as a Loss payee. C. King County and its officers, officials, employees and agents shall be covered as additional insured with respect to liability arising out of activities performed by the grant recipient and its contractors. Additional Insured status shall include Products-Completed Operations. D. To the extent of the grant recipient or its contractor's negligence,their insurance respectively shall be primary insurance with respect to the County, its officers, employees and agents. Any insurance or self-insurance maintained by the County, and its officers, officials, 6 » S ' employees or agents shall not be subjected to contribution in favor of the Grant recipient or its contractors insurance and shall not benefit their in any way. Grant Recipient and Contractors insurance shall apply separately to each insured against whom a claim is made or a lawsuit is brought, subject to the limits of the insurer's liability. E. Coverage shall not be suspended, voided, canceled, reduced in coverage or in limits except by the reduction of the applicable aggregate limit by claims paid, until after thirty (30) days' prior written notice has been given to and change in coverage accepted by King County. F. The insurance provider must be licensed to do business in the State of Washington and maintain a Best's rating of no less than A VIII. The Grant Recipient must provide a Certificate of Insurance and Additional Insured Endorsement to the (Exhibit VII), and upon written request of the County, provide a duplicate of the policy as evidence of insurance protection. Grant recipient shall be responsible for the maintenance of their contractors insurance documentation. G. If the Agency is a Municipal Corporation or an agency of the State of Washington and is self-insured for any of the above insurance requirements, a certification of self-insurance shall be attached hereto and be incorporated by reference and shall constitute compliance with this section. 19. NONDISCRIMINATION AND EQUAL EMPLOYMENT OPPORTUNITY A. Nondiscrimination in Employment Provision of Services King County Code Chapter 12.16 is incorporated by reference as if fully set forth herein and such requirements apply to this Contract. During the performance of this Contract, neither the Agency nor any party subcontracting under the authority of this Contract shall discriminate or tolerate harassment on the basis of race, color, sex, religion, national origin, marital status, sexual orientation, age, or the presence of any sensory, mental, or physical disability in the employment or application for employment or in the administration or delivery of services or any other benefits under this Contract. B. Nondiscrimination in Subcontracting Practices King County Code Chapter 12.17 is incorporated by reference as if fully set forth herein and such requirements apply to this Contract. During the solicitation, award and term of this Contract,the Agency shall not create barriers to open and fair opportunities to participate in County contracts or to obtain or compete for contracts and subcontracts as sources of supplies, equipment, construction and services. In considering offers from and doing business with subcontractors and suppliers, the Agency shall not discriminate against any person on the basis of race, color, religion, sex, age, national origin, marital status, sexual orientation or the presence of any mental or physical disability in an otherwise qualified disabled person. C. Fair Employment Practices King County Code Chapter 12.18 is incorporated by reference as if fully set forth herein and such requirements apply to this Contract. During the performance of this Contract, neither the Agency nor any party subcontracting under the authority of this Contract shall engage to unfair employment practices. 7 D. Compliance with Laws and Regulations The Agency shall comply fully with all applicable federal, state and local laws, ordinances, executive orders and regulations that prohibit discrimination. These laws include, but are not limited to, RCW Chapter 49.60, Titles VI and VII of the Civil Rights Act of 1964, the Americans with Disabilities Act,and the Restoration Act of 1987. E. Sanctions for Violations Any violation of the mandatory requirements of the provisions of this Section shall be a material breach of contract for which the Agency may be subject to damages, withholding payment and any other sanctions provided for by the Contract and by applicable law. F. Repoortm 1. The Agency entering into a contract or agreement with King County valued at$25,000 or more shall submit with this Contract a total Personnel Inventory Report providing employment data for minorities,females,and persons with disabilities. Subject to the provisions of KCC Chapter 12.16.060, the Agency's Personnel Inventory Report shall be effective for two years after the date on which the report was submitted. 2. The Agency entering into a contract with King County valued at more than $25,000, or contracts which in the aggregate have a value to the Agency of more than $25,000 should submit an Affidavit of Compliance in the form provided by the County, demonstrating commitment to comply with the provisions of KCC Chapter 12.16 in accordance with paragraph A of this Section XV. 20. SECTION 504 AND AMERICANS WITH DISABILITIES ACT The Agency shall complete a 504/ADA Self-Evaluation Questionnaire for all programs and services offered by the Agency (including any services not subject to this Contract) and shall evaluate its services, programs and employment practices for compliance with Section 504 of the Rehabilitation Act"of 1973, as amended ("504") and the Americans with Disabilities Act of 1990 ("ADA"). The Agency shall complete a 504/ADA Assurance of Compliance, and corrective action plan as needed for structural,programmatic, and/or service changes necessary at each of its premises within the State of Washington to comply with 504 and the ADA, and it is attached as an exhibit to this Contract and incorporated herein by reference. 21. CONFLICT OF INTEREST KCC Chapter 3.04 is incorporated by reference as if fully set forth hence, and the Agency agrees to abide by all conditions of said chapter. Failure by the Agency to comply with any requirement of said KCC Chapter shall be a material breach of contract. 22. POLITICAL ACTIVITY PROHIBITED None of the funds, materials, property, or services provided directly or indirectly under this Contract shall be used for any partisan political activity or to further the election or defeat of any candidate for public office. 8 wt rr 23. EQUIPMENT PURCHASE,MAINTENANCE,AND OWNERSHIP A. The Agency shall be responsible for all such property, including the proper care and maintenance of the equipment. B. The Agency shall establish and maintain inventory records and transaction documents (purchase requisitions, packing slips, invoices, receipts) of equipment purchased with Contract funds. 24. NOTICES Whenever this Contract provides for notice to be provided by one(1)party to another, such notice shall be: A. In writing; and B. Directed to the person specified in Section IV of this Contract Any time within which a party must take some action shall be computed from the date that the notice is received by said party. 25. ASSIGNMENT The Agency shall not assign any portion of rights and obligations under this Contract or transfer or assign any claim arising pursuant to this Contract without the written consent of the County. Said consent must be sought in writing by the Agency not less than fifteen(15)days prior to the date of any proposed assignment. 26. CONTRACT AMENDMENTS Either party may request changes to this Contract. Proposed changes that are mutually agreed upon shall be incorporated by written amendments to this Contract. 9 { 27. ENTIRE CONTRACT/WAIVER 4F DEFAULT The parties agree that this Contract is the complete expression of the terms hereto and any oral or written representations or understandings not incorporated herein are excluded. Both parties recognize that time is of the essence in the performance of the provisions of this Contract. Waiver of any default shall not be deemed to be a waiver of any subsequent default. Waiver or breach of any provision of the Contract shall not be deemed to be a waiver of any other or subsequent breach and shall not be construed to be a modification of the terms of the Contract unless stated to be such through written approval by the County, which shall be attached to the original Contract. KING COUNTY AGENCY NAME HERE FOR 00 King tatinty Executive Signa VIAM-QA 5 P 7.0O4- 1"r, 1 Date NAME(Please type or print),Ti le Date 10 @ King County Exhibit i Department of Natural Resources and Parks Parks and Recreation Division Youth Sports Facility Grant Scope of Services Please detail the scope of work to be performed under this contract as described in the YSFG application. You may use and expand upon the application text. Please be thorough in your description of both the entire project and how the YSFG,grant will assist you in your project. SCOPE OF WORK: YSFG Funds will be used to create an ADA accessible route to two youth baseball/softball fields, replace fence fabric, install an automatic irrigation system, and provide site furniture, for an existing City of Kent park, Uplands Playfield. Uplands Playfield currently is ADA accessible from the parking lot to the Interurban Trail. At the time when the park was originally constructed, an ADA accessible route was not required from the trail to each ball field. Youth Sports Facility funds will be used to construct new sidewalks and/or ramps from the existing trail to the ball field back stops which will provide ample area to access the field or to just park in a wheel chair and enjoy a game at either field. The City of Kent will hire a professional Land Surveyor to perform a topographic survey. The completed survey will ensure that proper grades are constructed to meet current ADA accessibility standards. Currently, the maintenance staff has to drag hoses and water the fields by hand because an automatic irrigation system does not exist. This task is labor-intensive and prevents staff from completing other park duties. After a typical season with prolonged use and heavy exposure to the sun, the turf so stressed it is prone to disease and sometimes dies and may need to be re- seeded. This has prompted some teams to not want to play on these fields and forces us to shorten a season. With an automatic irrigation system installed, it will allow us to initiate a turf management program where we would fertilize and water the fields on a regular basis, keeping the turf green and healthily, long into the hot summer months extending our season. As part of the sponsor match, the Kiwanis Club of Kent has volunteered to backfill and re-sod all the newly installed automatic irrigation trench lines. The perimeter fence is the original fence that was constructed in 1972 and is in poor condition. Some fence areas are not functional because the fabric is simply non-existent. In several spots the fence is bowed out into the field of play, causing a safety hazard. The existing garbage cans, player benches, base line fencing and back stops are not as old as the perimeter fencing however, due to heavy use they are also in desperate need of replacing. Under the new fencing, we will install a concrete mow strip level with existing ground. The mow strip has a two fold purpose:first It will eliminate the need for weed eating or spraying herbicide along the fence line. This will save on labor hours and unsightly turf growing up into the fence, causing an aesthetic nuisance. Second, it will act as a barrier between the infield material and the turf. With the concrete border in place, it will stop the migration of infield material in to the turf, reducing the amount of infield material that has to be purchased and installed every year at the beginning of the season, saving time and money. w „dr ,� _-� 19 "-�lllllatl p .E rl( le I:- NO x x � .i N y i � � _ � bi'° „•'}y :fir �l p N y VI 44 PI- P t� -��"- �a; a�. a. M N V l} 9 N � a i� CD as4 i �;• ��l �a a L 4 TT u Jvp aaL$kR n� 1 t f yff{ N, • • F i • li, ,i • .r; i IT xxset �� aq R • ., fin' �, 3r �'�' ` 3 X 7 Q • i�� a�?'"� �iv N 3 King C,ouMy Exhibit III �r9 Department of Natural Resources and Parks Parks and Recreation Division Youth Sports Facility Grant Timeline Please provide a schedule of tasks. You may use the application timeline unless it has developed since June. If so,please provide an updated timeline. Below is an example. Tasks (Year One): 2004 Quarter 1 Quarter 2 Quarter 3 Quarter 4 example Jan. - March April -June Jul - Sept. Oct. - Dec. YSFG Contracting Complete February 5 Complete Design March 1 Construction Documents April 15 Apply for Permits April 20 Receive Permits July 14 Notice to Proceed August 15 50% Complete October 1 Project Complete November 10 YSFG Billing December 10 Tasks (Year Two): 2005 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Jan. -March April - June Jul - Sept. Oct. - Dec. OVA Insurance Authority P 0. Box 1165 Renton, WA 98057 29-Dec-03 Cert#: 3431 Phone 425-377-7237 King County Parks&Recreation Attn: Butch Lovelace Fax 425-277-7242 KSC-NR-0700, 201 S. Jackson Street Seattle,WA 98104-3855 RE: City of Kent KC Youth Sports Grant Funds for work on Uplands Playfield in Kent. Evidence of Coverage The above captioned entity is a member of the Washington Cities Insurance Authority (WCIA), which is a self insured pool of over 108 municipal corporations in the State of Washington. WCIA has at least$1 million per occurrence combined single limit of liability coverage in its self insured layer that may be applicable in the event an incident occurs that is deemed to be attributed to the negligence of the member. WCIA is an Interlocal Agreement among municipalities and liability is completely self funded by the membership. As there is no insurance policy involved and WCIA is not an insurance company, your organization cannot be named as an "additional insured'. Sincerely, Eric B. Larson Assistant Director cc: Christopher Hills Joan Broom cietter 1 aX6&+Ix i'anrri W-9 Request for Taxpayer Give this form to (`teV.September 1991) identification Number and Certification the requester. Do Oepannwna of the Treasury NOT send to IRS. hxem,.i rteverwe servee Name(It toml names,list lust and ctrde the name of the person or amity whose number you enter in Part I below See Instructions on page 2 a yaw name has Clanged) f e& S Business name(Sow proprietors we instructions on page 24 Address kaartDar and sweet► lnl acrxxM niiMner(s)here(opt" o S y7j% /}ul- d City.state,and ZIP oxide A W3)L • Taxpayer Identification Number IN For Payees Exempt From Enter your TIN In the appropriate box. For Backup Withholc(in9 (See individuals,this is your social security number nodal security number instructions on page?) (SSN).For sole proprietors,see the inst►uct(ons on page 2. For other entities. R is your employer identification number(EIN). If you do not have a OR number,see How To Obtain a TIN, below. Requester's name and address IoPlroi+aA Employer idsnd0ea*m number, Note:ff role account isIn irate then«te name. ! 6 0 o 12 S y see the chart on page 2 for guidelines on whose number to enter. Certification.—Under penalties of perjury. I certify that (11 The number shown on this form its my correct taxpayer kientification number(or I am wading 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 back Lip withholding. 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 of underreporting interest or dividends on your tax return. For real estate transactions, Item(2)does not apply. For mortgage interest paid,the acquisition or abandonment of secured property,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.(Also see Signing the Certification on page 2.) Please Sign Here Signature ► Date ► (Section references are to the Informal Revenue 60 days to obtain a TIN and furnish it to the broker and barter exchange transactions,rents, Code.) requester.If the requester dozes not receive your royalties,nonemployee compensation,and Purpose of Form.--A person wfio is textured to TIN within 60 days,backup withholding,If certain payments from fishing boat operators, file an information return with the IRS must applicable,will begin and continue until you but do not include real estate transactions. obtain your correct TIN to report Income paid to furnish your TIN to the requester.For reportable It you give the requester your correct TIN, you.real estate transactions,mortgage Interest interest or dividend payments,the payer must make the appropriate certifications,and report you paid.the acquisition or abandonment of exercise one of the following options concerning all your taxable interest and dividends on your secured property,or contributions you made to backup withholding during this 60-day period. tax return,your payments will not be subject to an IRA. Use Form W-9 to furnish your correct Under option(1).a payer must backup withhold backup withholding.Payments you receive will TIN to the requester(the person asking you to on any withdrawals you make from your account be subject to backup withholding iF furnish your TIN)and,when applicable,(1)to after 7 business days after the requester 1.You do not fumish your TIN to the certify that the TIN you are furnishing is correct receives this form back from you.Under option requester,or (or that you are waning fora number to be rej•�ableyer must e Merest wbackup it vdend payments made 2.The IRS notifies the requester that you issued).wi to candy that you are not subject to t your account,regardless of whether make tunushed an incorrect TIN,or backup withholding,and(3)to claim exemption Y� re9 YW from backup withholding it you are an exempt any withdrawals.The backup withho iding under 3.You are notified by the IRS that you are payee Furnishing your correct TIN and making option(2)must begin no later than 7 business subject to backup withholding because you the appropriate certifications will prevent certain days after the requester receives this form back. failed to repot all your interest and dividends on payments from being subject to backup Under option(2),the payer is required to refund your tax return(for reportable interest and withholding the amounts withheld d your certified TIN is dividends only),or Note,if a requester gives you a form other than feceived within the 60-day period and you were 4.You fad to certify to the requester that you a W-9 to request your 7/N,you must use the not subject to backup withholding during that are not subject to backup withholding under(3) requester's form period above(for reportable interest and dividend Now To Obtain a TIN.—If you do not have a Note,writing"Applied for'on the form means accounts opened after 1983 only),or TIN,apply for one immediately.To apply,get that you have already applied for a 77N OR that 5.You fail to certify your TIN.This applies only Form SS-5,Application fa a Social Security you intend to apply for one in the near future, to reportable Merest,dividend,broker,or barter Number Card(for individuals),from your local As soon as you receive your TIN,complete exchange accounts opened after 1983,or broker office of the Social Security Administration,or another Form W-9,include your TIN,sign and accounts considered inactive in 1983. Form SS-4,Application for Employer date the form,and give it to the requester Except as explained in(5)above,other Identification Number(for businesses and all What Is Backup Withholding?—Persons making reportable payments are subject to backup other entities),from your local IRS office certain payments to you are required to withhold withholding only if(1)or(2)above applies. To complete Form W-9 it you do not have a and pay to the IRS 20%of such payments Certain payees and payments are exempt from TIN,write"Applied for"in the space for the TIN under certain conditions This is called "backup backup withholding and information reporting in Part 1 sgn and date the form.and give it to withholding"Payments that could be subject to See Payees and Payments Exempt From the requester Generally,you will then have backup withholding include interest,dividends, Cat.No 10231X Forth W-g (Rev.9-91)