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HomeMy WebLinkAboutCAG2023-227 - Original - Dana Lee & Deanna Mary Adams - Settlement Agreement, Subterranean Easement & Temporary Construction Easement - 04/07/2023 FOR CITY OF KENT OFFICIAL USE ONLY Sup/Mgr: Agreement Routing Form DirAsst: • For Approvals,Signatures and Records Management Dir/Dep: KENT This form combines&replaces the Request for Mayor's Signature and Contract Cover (optional) WASHINGTON Sheet forms. (Print on pink or cherry colored paper) Originator: Department: Cheryl Rolcik-Wilcox Public Works Date Sent: Date Required: c 03/30/2023 4/6/2023 QAuthorized to Sign: Date of Council Approval: Q �✓ Mayor or Designee 7/6/2021 Budget Account Number: Grant? Yes No�✓ Budget? Yes Type N/A M Vendor Name: Category: Dana Lee Adams and Deanna Mary Adams Contract Vendor Number: Sub-Category: Original 0 Project Name: S. 218th St./98th Ave. S. (from 94th PI. S. to S. 216th St.) oProject Details: Settlement Agreement, Subterranean Easement and Temporary c Construction Easement 40 c � Agreement Amount: �19 250.00 Basis for Selection of Contractor: GJ *Memo to Mayor must be attached Start Date: 41 /7/23 Termination Date: a Local Business? Yes F—]No*If meets requirements per KCC 3.70.100,please complete"Vendor Purchase-Local Exceptions"form on Cityspace. Business License Verification: ❑Yes In-Process F1 Exempt(KCC 5.01.045) FlAuthorized Signer Verified Notice required prior to disclosure? Contract Number: Yes ✓❑No CAG2023-227 Comments: Mayor Ralph - Please sign the attached Settlement Agreement (5th page of this packet) and the approval for the attached Subterranean Easement (9th c page of this packet) and Temporary Construction Easement (13th page of as *, this packet). Thx! Cheryl R-W 3 0 a Date Received:City Attorney: 3/30/23 Date Routed:Mayor's Office 3/30/23 6ity Clerk's Office 4/8/23 adccW22373_7_20 Visit Documents.KentWA.gov to obtain copies of all agreements rev.20221201 SETTLEMENT AGREEMENT KEN-50 S. 2181h St./98th Ave. S. from 94th PI. S. to S. 216th St. Project City of Kent Project Number: 17-3010 Owner: Dana Lee Adams and. Deanna Mary Adams King County Tax Parcel Number: 072205-9223 Address: 21647 98th Avenue S. This Settlement Agreement ("Settlement Agreement ) is between the City of Kent, a Washington municipal corporation ('City") and Dana Lee Adams and Deanna Mary Adams (collectively "the Adams"). Background A. The Adams own real property located at 21647 98th Avenue S. (the"Property"). B. To accommodate the City's S. 218th Street/98th Avenue S. from 94th Place S. to S. 216th Street Project ("Project"), the City must acquire from the Adams the following property and/or property rights: A permanent subterranean easement through a 598 square foot portion of the Property, as legally described in Exhibit A and depicted in Exhibit B to Attachment A to this Agreement (the "Subterranean Easement"), and a temporary easement over a 1,495 square foot portion of the property, as legally described in Exhibit A and depicted in Exhibit B to Attachment B to this Agreement (the "Temporary Easement" ). C. Construction of the Project requires displacement of installed landscaping improvements consisting of river rock within the Subterranean Easement and Temporary Easement Areas. The Project will also require the removal of a large tree at the southwest corner of the Property. D. The Adams have requested that the City preserve and collect any river rock that is displaced by the Project and reinstall it after the Project is completed. The Adams have also requested that the slope where the large tree will be removed be stabilized with a retaining structure to protect from future erosion, and if the gate and fencing on the west side of the Property is required to be removed as part of the Project, that the City replace them. E. The City would like to accommodate the Adams' requests as part of the settlement for acquisition of the above-referenced property rights. Adams Settlement Agreement - Page 1 of 4 The parties therefore agree as follows: Agreement 1. Settlement of Claims. The parties agree on the following as full and final settlement of all claims for just compensation and any other causes of action related in any way to the City's acquisition of property interest and use of the Property for its Project. 2. Preparation and Execution of the Easement. 2.1 The Adams will execute the Subterranean Easement document, attached as Attachment A, within 5 business days after the Effective Date of this Settlement Agreement. 2.2 The Adams will execute the Temporary Easement document, attached as Attachment B, within 5 business days after the Effective Date of this Settlement Agreement. 3. City Payment. 3.1 The City will pay the Adams the amount of $1,800.00 (one thousand eight hundred dollars) as total just compensation for the Subterranean Easement. 3.2 The City will pay the Adams the amount of $2,650.00 (two thousand six hundred and fifty dollars) as total just compensation for the Temporary Easement. 3.2 The City will pay the Adams the amount of $14,800.00 (fourteen thousand eight hundred dollars) as total just compensation for the value of improvements that will be displaced during construction of the Project. 3.4 The City will make all payments set forth in this Section 3 no later than 20 business days after the Effective Date of this Agreement, except that the City is not obligated to make these payments if the Adams have not fulfilled the obligations within Section 2 and this Section 3.4. To facilitate the City's payment, the Adams will deliver to the City, no later than 5 days after the Effective Date of this Settlement Agreement, a completed Vendor Set-up Form and W-9 in the forms attached as Attachment C. 4. Landscaping and Wall. The City will preserve and collect any river rock that is displaced by the Project and will reinstall it in the Subterranean Easement Area Adams Settlement Agreement - Page 2 of 4 after the Project is completed. After the large tree is removed, the City will install a wall to support the fill and prevent erosion at the southwest corner of the Property. If the gate and any portion of the fencing on the west side of the Property is removed as part of the Project, the City will replace the gate and that portion of the fencing. The approximate locations of these improvements are depicted in Attachment D. 5. Successors and Assigns. This Settlement Agreement shall bind and inure to the benefit of the parties and their respective successors and assigns. 6. Amendments. This Settlement Agreement may only be amended in writing, signed by all parties. 7. Severability. If any term, covenant, condition or provision contained in this Settlement Agreement is determined to be invalid, voided or otherwise unenforceable, by any court of competent jurisdiction, such determination shall in no way affect the validity or enforceability of any other term, covenant, condition, or provision contained in this Settlement Agreement. 8. Execution in Counterparts. This Settlement Agreement may be executed in counterparts and/or transmitted electronically, and copies so executed or transmitted will be deemed originals. 9. Entire Agreement. This Settlement Agreement, together with all exhibits constitutes the entire agreement between the parties with respect to the subject matter of this agreement. This Settlement Agreement is specifically intended by the parties to supersede all prior agreements whether written or oral. Adams Settlement Agreement - Page 3 of 4 10.Effective Date. The effective date of this Agreement is the last date signed below. CITY OF KENT By: Dana Ralnh By: Dana Lee Adams Title: Mayor Date: _ "7 7 7 Date: 04/07/2023 n I v\� By: Deanna Maw Adams Date: Attachment List A - Subterranean Easement B - Temporary Easement C - Vendor Set-Up Form and W-9 D - Diction of Improvements Adams Settlement Agreement - Page 4 of 4 ATTACHMENT A WHEN RECORDED RETURN TO: City Clerk City of Kent 220 Fourth Avenue South Kent, Washington 98032 Grantor: Dana Lee Adams and Deanna Mary Adams Grantee: City of Kent Abbreviated Legal Description: Ptn Lot 2 Less Co Rd., KC SP No. 1284005, Rec. No. 86121512117 Additional Legal Description on: Exhibit "A" Assessor's Tax Parcel ID No.: 072205-9223 STR: 07-22-05 Project Name: KEN 50 S 218th St/98th Ave S from 94th PI S to S 216th St. SUBTERRANEAN EASEMENT The Grantors, Dana Lee Adams, as a separate estate, and Deanna Mary Adams, presumptively subject to the community interest of her spouse or registered domestic partner, if married or a registered domestic partner, as their interests may appear of record (collectively "Grantor"), for and in consideration of Ten Dollars and No/100 ($10.00) and/or other valuable consideration, receipt of which is hereby acknowledged, grants to City of Kent, a Washington municipal corporation ("Grantee"), a permanent subterranean easement ("Easement") over, under, through, across and upon the portion of the property situated in King County, Washington, specifically described in Exhibit "A" and graphically depicted in Exhibit "B", both of which are attached and incorporated herein (the "Easement Area"). The Grantor agrees that this easement touches and concerns the lanb described in Exhibit A, and that this easement shall run with the land. Grantee intends to construct a permanent retaining wall ("Wall") utilizing an earth shoring system. This would require soil reinforcement within the Easement Area by drilling and inserting tiebacks ("Tiebacks"); or by excavation and installation of soil reinforcing grids. The subterranean easement includes a "no dig" area through Page 1 of 4 and under the portion of the Property needed to support the Wall to prevent any digging in the Easement Area and preserve the integrity of the Wall's shoring system. Grant. Grantor hereby grants, conveys and warrants to Grantee, subject to matters of record, a nonexclusive subterranean easement over, under, through, across, and upon the Easement Area. This Easement touches and concerns the land described in Exhibit A and runs with the land for the purposes of (1) drilling, excavating, installing, constructing, and maintaining the shoring system in connection with the construction of a retaining wall, and (2) preventing the erection of any structures on, digging or excavation in the Easement Area. Construction. Grantee shall ensure that the drilling, excavation, installation, construction, and maintenance of the shoring system shall not damage the property or any improvements, outside of the Easement Area. Grantee shall restore, as practicable, the Easement Area to as or better than the condition of the Easement Area prior to entering the Easement Area. Prior to any drilling, excavation, construction, and installation of the shoring system, Grantee shall immediately provide to Grantor any information obtained by Grantee regarding any underground storage tanks, unstable fill material, gravel substratum, utility facilities and other underground improvements within the property. Grantee's Obligations. Grantee agrees to retain, at its sole cost, the services of a licensed engineer to determine the exact specified locations of the underground shoring system. These locations shall be identified on drawings provided to Grantor before construction. Grantee shall provide to Grantor, upon completion of the shoring system and retaining wall, detailed as-built drawings showing the locations (including elevations) and dimensions of all Tiebacks or reinforcing grids, and other underground improvements that have been installed by Grantee within the Easement Area. Reservation of Rights. Grantor reserves for itself and its successors and assigns the right to use the Easement Area and the remainder of subject property for any lawful use not inconsistent with the Easement. Grantor shall retain the right to use the surface of this Easement Area, including the immediately adjacent incidental areas, so long as that use is not inconsistent with the purposes of the Easement and does not interfere with the Grantee's uses as described in this document. Under no circumstances shall Grantor and its successors conduct any digging or excavation in the Easement Area without prior express written approval of Grantee. Indemnity. Grantee accepts the Easement Area in its present physical condition, AS IS. Grantee does hereby release, indemnify and promise to defend and save harmless Grantor from and against any and all liability, loss, damage, expense, actions and claims, including costs and reasonable attorney's fees incurred by Grantor in connection therewith, arising directly on account of or out of the negligent exercise by Grantee, its servants, agents, employees and contractors of the rights granted in this Easement. Page 2 of 4 Binding Effect. This Easement and its terms and conditions set forth herein shall be a covenant running with the land, and shall bind Grantor's successors, heirs and assigns, and all future owners of the real property affected by this Easement. NTOR: Name: Dana Lee Adams Name: Deanna Mary Adams Date: Z Z0 '23 Date: STATE OF WASHINGTON ) ss. COUNTY OF KING ) I certify that I know or have satisfactory evidence that Dana Lee Adams is the person who appeared before me, and said person acknowledged that she signed this instrument and acknowledged it to be her free and voluntary act for the uses and purposes mentioned in the instrument. Dated:_ -Notary Seal Must Appear Within This Box- IN WITNESS WHEREOF, I have hereunto set my hand and official seal the day and ye&K.,("t%Qove written. ��� �OLC/K lull p /� (Signature) NOTARY PUBLIC, in and for the State %.,� +ev�� �=`2: of Washington, residing at �11 �'`i�/�I o ® My appointment expires I P gN Additional notary acknowledgment on following page Page 3 of 4 STATE OF WASHINGTON ) ) ss. COUNTY OF KING ) I certify that I know or have satisfactory evidence that Deanna Mary Adams is the person who appeared before me, and said person acknowledged that she signed this instrument and acknowledged it to be her free and voluntary act for the uses and purposes mentioned in the instrument. Dated:_ I9,9 /,'"2D -Notary Seal Must Appear Within This Box- IN WITNESS WHEREOF, I have hereunto set my hand and official seal the day and year [kkq iP*gq written. ow4A,,, o�i� (Signature) v rim '�►n;'�'�'` �� NOTARY PUBLIC, in and for the State c, 1S697 of Washington, residing at :, My appointment expires 1i-9 -9 i(P ������IV1,091 s''��= ACCEPTED: CITY OF KENT By: Dana Ralph Title: Mayor Date: 04/07/2023 Page 4 of 4 EXHIBIT-A TAX LOT 0722059223 EASEMENT THE SOUTH 4.00 FEET OF LOT 2, KING COUNTY SHORT PLAT NUMBER 1284005, RECORDED UNDER RECORDING NUMBER 8612151217, RECORDS OF KING COUNTY, WASHINGTON, IN THE NORTHEAST QUARTER OF THE SOUTHEAST QUARTER OF SECTION 7, TOWNSHIP 22 NORTH, RANGE 5 EAST, WILLAMETTE MERIDIAN, CITY OF KENT, IN KING COUNTY, WASHINGTON. CONTAINING 598 SQUARE FEET, MORE OR LESS. + f y R�S •. ry 1 V 1 Y � tii NV113� t\f� ,r li } I §$)§®/22 � Em=m � rx �3 2 722§§R§Wq k q§\zG> $§2 = mz? mowg m-< P222> > k Uomm >E o z �\\k}q7 zTmk °< � q� $ )Q /(n k z 0 0 m o ( mƒ | mz ( §§§3 0- gy m ---- �iq§ a§\q �/(n CO) z£ � - , o m §g \ k o_ 3 m m k 7�� ]/' ] Co � v � o NG k § 7 § � ° zCA | 3 m 2 � « % ■ 4 ATTACHMENT B After recording return document to: City Clerk City of Kent 220 4th Avenue South Kent, WA 98032 Document Title: Temporary Easement Reference Number of Related Document: N/A Grantor(s): Dana Lee Adams and Deanna Mary Adams Grantee(s): City of Kent Legal Description: Ptn. Lot 2, Less Co Rd, KC SP No. 1284005, Rec No. 86121512117 Additional Legal Description is on Exhibit A of Document. Assessor's Tax Parcel Number: 072205-9223 TEMPORARY EASEMENT KEN-50 South 2181h Street/98th Avenue South from 94th Place South to South 216th Street Project The Grantor(s), Dana Lee Adams, as a separate estate, and Deanna Mary Adams, presumptively subject to the community interest of her spouse or registered domestic partner, if married or a registered domestic partner, as their interests may appear of record„ for and in consideration of TEN AND NO/100 ($10.00) DOLLARS, and other valuable consideration, conveys and grants unto the City of Kent, and its assigns, Grantee, under the imminent threat of the Grantee's exercise of its right of Eminent Domain,the right,privilege and easement over, upon, through and across the hereinafter described lands for the purpose of widening South 218th Street and 98th Avenue South(from 94th PL S to 99th Ave S)to three lanes and including paving, concrete curbs & gutters, sidewalks, paved shoulders, street lighting, storm drainage, sanitary sewer, water mains replacement, landscaping, and channelization. This project will also include undergrounding all the overhead utilities to a Joint Utility Trench. Said lands being situated in King County, State of Washington, and described in Exhibit A and depicted in Exhibit B, attached hereto and made a part hereof. FA No. LPA-325 Page 1 of(3)Pages Parcel Number: 122204-9085 Rev.5/2021 TEMPORARY EASEMENT The term of this Temporary Easement shall commence on the date of acceptance of this Temporary Easement by Grantee and shall terminate on October 31, 2024, hereinafter the "Term". Provided. however, that Grantee's use and occupancy of the easement area is limited to between August 1, 2023 and October 31, 2024. It is further agreed that this Temporary Easement may be extended by up to six months at the Grantee's option. The rate associated with this extension shall be at the same rate as the original Temporary Easement, or at the newly established rate determined by an updated administrative offer; whichever is higher. Grantee shall notify Grantor in writing prior to exercising this option. Grantee shall provide Grantor written notice no less than three days in advance of Grantee's intent to exercise its rights under this Temporary Easement. It is understood and agreed that delivery of this temporary easement is hereby tendered and that the terms and obligations hereof shall not become binding upon the City of Kent unless and until accepted and approved hereon in writing for the City of Kent, by its authorized agent. Dated: � � Grantor: na Lee Adams Deanna Mary Adams Accepted and Approved City of Kent By�L -- -- - Dana Ralph Mayor Date: 04/07/2023 Notary acknowledgments on following page LPA-325 Page 2 of(3)Pages Rev.5/2021 TEMPORARY EASEMENT STATE OF WASHINGTON ) ) ss. COUNTY OF KING ) I certify that I know or have satisfactory evidence that Dana Lee Adams is the person who appeared before me, and said person acknowledged that he/she signed this instrument and acknowledged it to be his/her free and voluntary act for the uses and purposes mentioned in the instrument. Dated: `2,-9G12?� -Notary Seal Must Appear Within This Box- IN WITNE\` ko`f REOF,I have hereunto set my hand and official seal the day and year first above written. �.��X\p1.CJK.I III,, m�r i i�� ��l�l u✓�� s•IF'r p14AA4k '� ���`� �i (Printed Name) Cc'h d'cJ 1 R C GU olci k-W j 1 V o ? NOTARY PUBLIC in and for the State �0 996974 of Washington,residing at '� 2 cn�'ii� ;B�� �F AO = My appointment expires I 1 1 09 7UF � WA 1. STATE OF WASH' ' ) ss. COUNTY OF KING ) I certify that I know or have satisfactory evidence that Deanna Mary Adams is the person who appeared before me, and said person acknowledged that he/she signed this instrument and acknowledged it to be his/her free and voluntary act for the uses and purposes mentioned in the instrument. Dated: '� 3 -Notary Seal Mzrst Appear Within This Box- IN WITNESS WHEREOF, I have hereunto set my hand and official seal the day and year first above written. �zzl�jkO LCIk 1II11 VZ`— p A ,, 0. (Printed Name) Chc i34I 20IC1 V — LUi I CO S '� % %NOTARY PUBLIC,in and for the State 199978 i °"_. of Washington,residing at /:A / ,013 �1�R .;:My appointment expires LPA-325 Page 3 of(3)Pages Rev.5/2021 EXHIBIT A TAX LOT 0722059223 TEMPORARY CONSTRUCTION EASEMENT THE SOUTH 10.00 FEET OF LOT 2, KING COUNTY SHORT PLAT NUMBER 1284005, RECORDED UNDER RECORDING NUMBER 8612151217, RECORDS OF KING COUNTY, WASHINGTON, IN THE NORTHEAST QUARTER OF THE SOUTHEAST QUARTER OF SECTION 7, TOWNSHIP 22 NORTH, RANGE 5 EAST, WILLAMETTE MERIDIAN, CITY OF KENT, IN KING COUNTY, WASHINGTON. CONTAINING 1,495 SQUARE FEET, MORE OR LESS. ♦♦♦t*tuuultty s � � M 2 1 I � f !tlll!!tltttttt♦♦ EXHIBIT B $±\§ §/7 ƒ % -n - g k«_Eq § § \2 «§7 � k = = z / �0 ~ /ƒ §§/ §§ me > g a m «9 >$ ® > > § m =zo = $ «« >°® § §\/ ® /\ /zzo \ z2m ƒ � { 3 \ ) % z jf z c / | oa | /7 \\ - - - - ma � a cn\/\/ co 5\\\ 45« \ } � 10 00 c , r � � ® $ o co / o_ . on / � ee � to Ul 2 cn P o in o y > n m > O 2 > CDm z — ca O | ? § \ k | ~ G CO) ` ? © * q_ w | Om 2 � m � » 0 @ m m m � Z w ATTACHMENT C ❑ New Vendor ❑ Reactivate Vendor KENT Vendor Set-up Form ❑ Address Change WASHINGTON To be filled out by Vendor ONLY Vendor Number FINANCE 220 Fourth Avenue South • Kent,WA 98032-5895 • Phone: (253) 856-5235 • Fax: (253)856-6200 An incomplete form will create a delay in our payment(s)to you and your payment(s) could bes =ybject to the IRS required back-up withholding. ill 4yl s Name, as it will appear on check (NO ABBREVIATIONS) Doing Business As(If different than name on check) Payment Address Business Address City State Zip City State Zip ( ) CA5 Lt— Sa`hq Phone Number Accounts Receivable Contact .. • check the appropriate box ❑ Corporation ❑ Government Agency ndividual/Sole Proprietor ❑ Non-Profit ❑ Partnership This business is ❑ Minority Owned ❑ Women Owned ❑ Both Minority and Women Owned ❑ Neither Will you provide medical services to the City of Kent? ................................................................Yes No Will you provide legal services to the City of Kent? ....................................................................Yes No Will you provide services other than medical or legal to the City of Kent?....................................Yes No Will you provide parts, supplies or materials to the City of Kent?..................................................Yes No Do you pay sales tax to the State of Washington?........................................................................Yes No if exempt from Form 1099 reporting, and check your qualifying exemption reason below: ❑ 1. Corporation, except there is no exemption for medical and healthcare payments or payments for legal services ❑ 2. Tax Exempt Charity under 501(a), or IRA ❑ 3. The United States or any of its agencies or instrumentalities ❑ 4. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions ❑ 5. A foreign government or any of its political subdivisions Name(Owner of the Tax Payer Identification Number(EIN or SSN) as name appears on IRS or Social Security Administration Records): Lfe e, 610Q M Social Security#: or Federal TIN: Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me) and, 2. 1 am not srhe ' Cfto ba up withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by Internal evenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all iest or div' ends, or(c)t e IRS has notified me that I am no longer subject to backup withholding. • /Signature It ► ` 20 2— fics2727 Indd-2104 Form Request for Taxpayer Give Form to the (Rev.October2018) Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. Internal Revenue Service ►Go to www.irs.gov/F`ormWg for instructions and the latest information. 1 Namebashown on your income tax return).Nam�j is required on this line;do not leave this line blank. c^t c/LE t-C� �UGL M S 2 Business name/disregarded entity name,if different from above M 3 Check a hate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions s(codes apply only to d pp � certain entities,not individuals;see afollowi seven boxes. instructions on page 3): p Individual/sole proprietor or ElC Corporation ElS Corporation El Partnership El Trust/estate c single-member LLC Exempt payee code(if any) 2 ► ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership) p L Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is code(if any) another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that 0 is disregarded from the owner should check the appropriate box for the tax classification of its owner. w ❑ (4ppiestoaccounts maintained outside the U.S.) Other(see instructions)► M5 Address(number,street,and apt.or suite no.)See instructions. Requester's name and address(optional) a) 6 City,state,and ZIP code V1' vv't�l' C� 7 List account number(s)here(optional) Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number backup withholding.For individuals,this is generally your social security number(SSN).However,for a resident alien,sole proprietor,or disregarded entity,see the instructions for Part I,later.For other entities,it is your employer identification number(EIN).If you do not have a number,see How to get a TIN,later. or Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. Certification Under penalties of perjury,I certify that: 1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and 2.1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholding;and 3.1 am a U.S.citizen or other U.S.person(defined below);and 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct. Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid, acquisition or abandon o ured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than i;U.S. an dividends, u are not required to sign the certification,but you must provide your correct TIN.See the instructions for Part II,later. Sign a of Here erso `cur Date Do- _Zi /z_C� •Form 1099-DIV(dividends,including those from stocks or mutual General Instructions funds) Section references are to the Internal Revenue Code unless otherwise .Form 1099-MISC(various types of income,prizes,awards,or gross noted. proceeds) Future developments.For the latest information about developments a Form 1099-B(stock or mutual fund sales and certain other related to Form W-9 and its instructions,such as legislation enacted transactions by brokers) after they were published,go to wwwJrs.gov/FormW9. .Form 1099-S(proceeds from real estate transactions) Purpose of Form •Form 1099-K(merchant card and third party network transactions) An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(student loan interest), information return with the IRS must obtain your correct taxpayer 1098-T(tuition) identification number(TIN)which may be your social security number •Form 1099-C(canceled debt) (SSN),individual taxpayer identification number(ITIN),adoption .Form 1099-A(acquisition or abandonment of secured property) taxpayer identification number(ATIN),or employer identification number (EIN),to report.on an information return the amount paid to you,or other Use Form W 9 only if you are a U.S.person(including a resident amount reportable on an information return.Examples of information alien),to provide your correct TIN. returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might •Form 1099-INT(interest earned or paid) be subject to backup withholding.See What is backup withholding, later. Cat.No.10231X Form W-9(Rev.10-2018) ATTACHMENT C ❑ New Vendor ❑ Reactivate Vendor NS �,KNT Vendor Set-up Form ❑ Address Change 7 W A 9 H I N G T O N To be filled out by Vendor ONLY Vendor Number FINANCE 220 Fourth Avenue South - Kent,WA 98032-5895 - Phone: (253) 856-5235 - Fax: (253)856-6200 An incomplete form will create a delay in our payment(s)to you and your payment(s) could be subject to the IRS required back-u withholding. Name, as it will appear on check (NOABBREVIATIONS) Doing Business As(If different than name on check) g i JP' i � Payment Address Business Address City State Zip City State Zip ( ;'� ) 'I �?' ( -- ` -l (7 Phone Number Accounts Receivable Contact .. . check the a ro riate box ❑ Corporation ❑ Government Agency 19 Individual/Sole Proprietor ❑ Non-Profit ❑ Partnership This business is ❑ Minority Owned ❑ Women Owned ❑ Both Minority and Women Owned ❑ Neither Will you provide medical services to the City of Kent? ................................................................Yes No Will you provide legal services to the City of Kent? ....................................................................Yes No Will you provide services other than medical or legal to the City of Kent?....................................Yes No Will you provide parts, supplies or materials to the City of Kent?..................................................Yes No Do you pay sales tax to the State of Washington?........................................................................Yes No if exempt from Form 1099 reporting, and check your qualifying exemption reason below: ❑ 1. Corporation, except there is no exemption for medical and healthcare payments or payments for legal services ❑ 2. Tax Exempt Charity under 501(a), or IRA ❑ 3. The United States or any of its agencies or instrumentalities ❑ 4. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions ❑ 5. A foreign government or any of its political subdivisions Name(Owner of the Tax Payer Identification Number(EIN or SSN) as name appears on IRS or Social Security Administration Records): --- Social Security#: or Federal TIN: _ _— Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me) and, 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends, or(c)the IRS has notified me that I am no longer subject to backup withholding. 9S Signature ► Date ► rics2727 Indd-W04 Form Request for Taxpayer Give Form to the (Rev.October2018) Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. Internal Revenue Service ►Go to www.irs.gov/FormM for instructions and the latest information. 1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank. 2 Business name/disregarded entity name,if different from above m 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions(codes apply only to rn following seven boxes. certain entities,not individuals;see to instructions on page 3): a �y El` Individual/sole proprietor or ❑ C Corporation ❑ S Corporation Partnership ❑ Trustlestate lc single-member LLC Exempt payee code(if any) �v ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)► p 2 Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting c LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is code(if any) another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that a is disregarded from the owner should check the appropriate box for the tax classification of its owner. ❑ Other(see instructions)I,. (Applies to accounts maintained outside the U.S.) N5 Address(number,street,and apt.or suite no.)See instructions. Requester's name and address(optional) L C � S 6 City,state,an ZIP code 7 List account number(s)here(optional) 111111,71 a I Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number backup withholding.For individuals,this is generally your social security number(SSN).However,for a resident alien,sole proprietor,or disregarded entity,see the instructions for Part I,later.For other entities,it is your employer identification number(EIN).If you do not have a number,see How to get a TIN,later. or Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. Certification Under penalties of perjury,I certify that: 1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and 2.1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholding;and 3.1 am a U.S.citizen or other U.S.person(defined below);and 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct. Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid, acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions for Part II,later. Sign �Signature />�AHere Date 0- U.S. �J •Form 1099-DIV(dividends,including those from stocks or mutual General Instructions funds) Section references are to the Internal Revenue Code unless otherwise .Form 1099-MISC(various types of income,prizes,awards,or gross noted. proceeds) Future developments.For the latest information about developments .Form 1099-B(stock or mutual fund sales and certain other related to Form W-9 and its instructions,such as legislation enacted transactions by brokers) after they were published,go to www.irs.gov/FormW9. •Form 1099-S(proceeds from real estate transactions) Purpose of Form •Form 1099-K(merchant card and third party network transactions) An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(student loan interest), information return with the IRS must obtain your correct taxpayer 1098-T(tuition) identification number(TIN)which may be your social security number •Form 1099-C(canceled debt) (SSN),individual taxpayer identification number(ITIN),adoption e Form 1099-A(acquisition or abandonment of secured property) taxpayer identification number(ATIN),or employer identification number (EIN),to report on an information return the amount paid to you,or other Use Form W 9 only if you are a U.S.person(including a resident amount reportable on an information return.Examples of information alien),to provide your correct TIN. returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might •Form 1099-INT(interest earned or paid) be subject to backup withholding.See What is backup withholding, later. Cat.No.10231X Form W-9(Rev.10-2018) Form W-9(Rev.10-2018) Page 2 By signing the filled-out form,you: Example.Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese 1.Certify that the TIN you are giving is correct(or you are waiting fora student temporarily present in the United States.Under U.S.law,this number to be issued), student will become a resident alien for tax purposes if his or her stay in 2.Certify that you are not subject to backup withholding,or the United States exceeds 5 calendar years.However,paragraph 2 of 3.Claim exemption from backup withholding if you are a U.S.exempt the first Protocol to the U.S.-China treaty(dated April 30,1984)allows payee.If applicable,you are also certifying that as a U.S.person,your the provisions of Article 20 to continue to apply even after the Chinese allocable share of any partnership income from a U.S.trade or business student becomes a resident alien of the United States.A Chinese is not subject to the withholding tax on foreign partners'share of student who qualifies for this exception(under paragraph 2 of the first effectively connected income,and protocol)and is relying on this exception to claim an exemption from tax 4.Certify that FATCA code(s)entered on this form(if any)indicating on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to that you are exempt from the FATCA reporting,is correct.See What is support that exemption. FATCA reporting, later,for further information. Note:If you are a U.S.person and a requester gives you a form other If you are a nonresident alien or a foreign entity,give the requester the than Form W-9 to request your TIN,you must use the requester's form if appropriate completed Form W-8 or Form 8233. it is substantially similar to this Form W-9. Backup Withholding Definition of a U.S.person.For federal tax purposes,you are What is backup withholding?Persons making certain payments to you considered a U.S.person if you are: must under certain conditions withhold and pay to the IRS 24%of such •An individual who is a U.S.citizen or U.S.resident alien; payments.This is called"backup withholding." Payments that may be •A partnership,corporation,company,or association created or subject to backup withholding include interest,tax-exempt interest, organized in the United States or under the laws of the United States; dividends,broker and barter exchange transactions,rents,royalties, •An estate(other than a foreign estate);or nonemployee pay,payments made in settlement of payment card and as defined in Regulations section 301.7701 7). third party network transactions,and certain payments from fishing boat •A domestic trust ( 9 operators.Real estate transactions are not subject to backup Special rules for partnerships.Partnerships that conduct a trade or withholding. business in the United States are generally required to pay a withholding You will not be subject to backup withholding on payments you tax under section 1446 on any foreign partners'share of effectively receive if you give the requester your correct TIN,make the proper connected taxable income from such business.Further,in certain cases certifications,and report all your taxable interest and dividends on your where a Form W-9 has not been received,the rules under section 1446 tax return. require a partnership to presume that a partner is a foreign person,and payments you receive will be subject to backup withholding if: pay the section 1446 withholding tax.Therefore,if you are a U.S.person that is a partner in a partnership conducting a trade or business in the 1.You do not furnish your TIN to the requester, United States,provide Form W-9 to the partnership to establish your 2.You do not certify your TIN when required(see the instructions for U.S.status and avoid section 1446 withholding on your share of Part II for details), partnership income. 3.The IRS tells the requester that you furnished an incorrect TIN, In the cases below,the following person must give Form W-9 to the 4.The IRS tells you that you are subject to backup withholding partnership for purposes of establishing its U.S.status and avoiding withholding on its allocable share of net income from the partnership because you did not report all your interest and dividends on your tax return(for reportable interest and dividends only),or conducting a trade or business in the United States. 5.You do •In the case of a disregarded entity with a U.S.owner,the U.S.owner of the disregarded entity and not the entity; backup withholding not certify to the requester that you are not subject to hholding under 4 above(for reportable interest and dividend accounts opened after 1983 only). •In the case of a grantor trust with a U.S.grantor or other U.S.owner, Certain payees and payments are exempt from backup withholding. generally,the U.S.grantor or other U.S.owner of the grantor trust and See Exempt payee code, later,and the separate Instructions for the not the trust;and Requester of Form W-9 for more information. •In the case of a U.S.trust(other than a grantor trust),the U.S.trust (other than a grantor trust)and not the beneficiaries of the trust. Also see Special rules for partnerships,earlier. Foreign person.If you are a foreign person or the U.S.branch of a What is FATCA Reporting? foreign bank that has elected to be treated as a U.S.person,do not use The Foreign Account Tax Compliance Act(FATCA)requires a Form W-9.Instead,use the appropriate Form W-8 or Form 8233(see 9 Pub.'515,Withholding of Tax on Nonresident Aliens and Foreign participating foreign financial institution to report all United States Entities). account holders that are specified United States persons.Certain Nonresident alien who becomes a resident alien.Generally,only a payees are exempt from FATCA reporting.See Exemption from FATCA reporting code, later,and the Instructions for the Requester of Form nonresident alien individual may use the terms of a tax treaty to reduce W_g for more information. or eliminate U.S.tax on certain types of income.However,most tax treaties contain a provision known as a"saving clause."Exceptions Updating Your Information specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise You must provide updated information to any person to whom you become a U.S.resident alien for tax purposes. claimed to be an exempt payee if you are no longer an exempt payee If you are a U.S.resident alien who is relying on an exception and anticipate receiving reportable payments in the future from this contained in the saving clause of a tax treaty to claim an exemption person.For example,you may need to provide updated information if from U.S.tax on certain types of income,you must attach a statement you are a C corporation that elects to be an S corporation,or if you no to Form W-9 that specifies the following five items. longer are tax exempt.In addition,you must furnish a new Form W-9 if 1.The treaty country.Generally,this must be the same treaty under the namdbr TIN changes for the account;for example,if the grantor of a which you claimed exemption from tax as a nonresident alien. grantor trust dies. 2.The treaty article addressing the income. Penalties 3.The article number(or location)in the tax treaty that contains the Failure to furnish TIN.If you fail to furnish your correct TIN to a saving clause and its exceptions. 4.The type and amount of income that qualifies for the exemption requester,you are subject r a penalty of$50 for each such failure from tax. unless your failure is due to reasonable cause and not to willful neglect. 5.Sufficient facts to justify the exemption from tax under the terms of Civil penalty for false information with respect to withholding.If you the treaty article. make a false statement with no reasonable basis that results in no backup withholding,you are subject to a$500 penalty. Form W-9(Rev.10-2018) Page 3 Criminal penalty for falsifying information.Willfully falsifying IF the entity/person on line 1 is THEN check the box for... certifications or affirmations may subject you to criminal penalties a(n)... including fines and/or imprisonment. Misuse of TINs.If the requester discloses or uses TINs in violation of • Corporation Corporation federal law,the requester may be subject to civil and criminal penalties. • Individual Individual/sole proprietor or single- * Sole proprietorship,or member LLC Specific Instructions • Single-member limited liability company(LLC)owned by an Line 1 individual and disregarded for U.S. You must enter one of the following on this line;do not leave this line federal tax purposes. blank.The name should match the name on your tax return. . LLC treated as a partnership for Limited liability company and enter If this Form W-9 is for a joint account(other than an account U.S.federal tax purposes, the appropriate tax classification. maintained by a foreign financial institution(FFI)),list first,and then . LLC that has filed Form 8832 or (P=Partnership;C=C corporation; circle,the name of the person or entity whose number you entered in 2553 to be taxed as a corporation, or S=S corporation) Part I of Form W-9.If you are providing Form W-9 to an FFI to document or a joint account,each holder of the account that is a U.S.person must . LLC that is disregarded as an provide a Form W-9. entity separate from its owner but a. Individual.Generally,enter the name shown on your tax return.If the owner is another LLC that is you have changed your last name without informing the Social Security not disregarded for U.S.federal tax Administration(SSA)of the name change,enter your first name,the last purposes. name as shown on your social security card,and your new last name. • partnership Partnership Note:ITIN applicant:Enter your individual name as it was entered on . Trust/estate Trust/estate your Form W-7 application,line 1 a.This should also be the same as the Trust/estate— name you entered on the Form 1040/1040A/1040EZ you filed with your Line 4, Exemptions application. b. Sole proprietor or single-member LLC.Enter your individual If you are exempt from backup withholding and/orcode(s) that may apply to reporting, name as shown on your 1040/1040A/1040EZ on line 1.You may enter enter in the appropriate space on line 4 any codehat your business,trade,or"doing business as"(DBA)name on line 2. you. C. Partnership,LLC that is not a single-member LLC,C Exempt payee code. corporation,or S corporation.Enter the entity's name as shown on the • Generally,individuals(including sole proprietors)are not exempt from entity's tax return on line 1 and any business,trade,or DBA name on backup withholding. line 2. • Except as provided below,corporations are exempt from backup d. Other entities.Enter your name as shown on required U.S.federal withholding for certain payments,including interest and dividends. tax documents on line 1.This name should match the name shown on the e Corporations are not exempt from backup withholding for payments charter or other legal document creating the entity.You may enter any made in settlement of payment card or third party network transactions. business,trade,or DBA name on line 2. • Corporations are not exempt from backup withholding with respect to e. Disregarded entity.For U.S.federal tax purposes,an entity that is attorneys'fees or gross proceeds paid to attorneys,and corporations disregarded as an entity separate from its owner is treated as a that provide medical or health care services are not exempt with respect "disregarded entity." See Regulations section 301.7701-2(c)(2)(iii).Enter to payments reportable on Form 1099-MISC. the owner's name on line 1.The name of the entity entered on line 1 The following codes identify payees that are exempt from backup should never be a disregarded entity.The name on line 1 should be the withholding.Enter the appropriate code in the space in line 4. name shown on the income tax return on which the income should be reported.For example,if a foreign LLC that is treated as a disregarded 1—An organization exempt from tax under section 501(a),any IRA,or entity for U.S.federal tax purposes has a single owner that is a U.S. a custodial account under section 403(b)(7)if the account satisfies the person,the U.S.owner's name is required to be provided on line 1.If requirements of section 401(f)(2) the direct owner of the entity is also a disregarded entity,enter the first 2—The United States or any of its agencies or instrumentalities owner that is not disregarded for federal tax purposes.Enter the 3—A state,the District of Columbia,a U.S.commonwealth or disregarded entity's name on line 2,"Business name/disregarded entity possession,or any of their political subdivisions or instrumentalities name."If the owner of the disregarded entity is a foreign person,the owner must complete an appropriate Form W-8 instead of a Form W-9. 4—A foreign government or any of its political subdivisions,agencies, This is the case even if the foreign person has a U.S.TIN. or instrumentalities Line 2 5—A corporation If you have a business name,trade name,DBA name,or disregarded 6—A dealer in securities or commodities required to register in the United States,the District of Columbia,or a U.S.commonwealth or entity name,you may enter it on line 2. possession Line 3 7—A futures commission merchant registered with the Commodity Check the appropriate box on line 3 for the U.S.federal tax Futures Trading Commission classification of the person whose name is entered on line 1.Check only 8—A real estate investment trust one box on line 3. 9—An entity registered at all times during the tax year under the Investment Company Act of 1940 10—A common trust fund operated by a bank under section 584(a) 11—A financial institution 12—A middleman known in the investment community as a nominee or custodian 13—A trust exempt from tax under section 664 or described in section 4947 Form W-9(Rev.10-2018) Page 4 The following chart shows types of payments that may be exempt M—A tax exempt trust under a section 403(b)plan or section 457(g) from backup withholding.The chart applies to the exempt payees listed plan above,1 through 13. Note:You may wish to consult with the financial institution requesting IF the payment is for... THEN the payment is exempt this form to determine whether the FATCA code and/or exempt payee for... code should be completed. Interest and dividend payments All exempt payees except Line 5 for 7 Enter your address(number,street,and apartment or suite number). Broker transactions Exempt payees 1 through 4 and 6 This is where the requester of this Form W-9 will mail your information through 11 and all C corporations. returns.If this address differs from the one the requester already has on S corporations must not enter an file,write NEW at the top.If a new address is provided,there is still a exempt payee code because they chance the old address will be used until the payor changes your are exempt only for sales of address in their records. noncovered securities acquired Line 6 prior to 2012. Enter your city,state,and ZIP code. Barter exchange transactions and Exempt payees 1 through 4 patronage dividends Part I. Taxpayer Identification Number (TIN) Payments over$600 required to be Generally,exempt payees Enter your TIN in the appropriate box.If you are a resident alien and reported and direct sales over 1 through 52 you do not have and are not eligible to get an SSN,your TIN is your IRS $5,000, individual taxpayer identification number(ITIN).Enter it in the social security number box.If you do not have an ITIN,see How to get a TIN Payments made in settlement of Exempt payees 1 through 4 below. payment card or third party network If you are a sole proprietor and you have an EIN,you may enter either transactions your SSN or EIN. 1 See Form 1099-MISC,Miscellaneous Income,and its instructions. If you are a single-member LLC that is disregarded as an entity separate from its owner,enter the owner's SSN(or EIN,if the owner has 2 However,the following payments made to a corporation and one).Do not enter the disregarded entity's EIN.If the LLC is classified as reportable on Form 1099-MISC are not exempt from backup a corporation or partnership,enter the entity's EIN. withholding:medical and health care payments,attorneys'fees,gross Note:See What Name and Number To Give the Requester, later,for proceeds paid to an attorney reportable under section 6045(f),and further clarification of name and TIN combinations. payments for services paid by a federal executive agency. How to get a TIN.If you do not have a TIN,apply for one immediately. Exemption from FATCA reporting code.The following codes identify To apply for an SSN,get Form SS-5,Application for a Social Security payees that are exempt from reporting under FATCA.These codes Card,from your local SSA office or get this form online at apply to persons submitting this form for accounts maintained outside www.SSA.gov.You may also get this form by calling 1-800-772-1213. of the United States by certain foreign financial institutions.Therefore,if Use Form W-7,Application for IRS Individual Taxpayer Identification you are only submitting this form for an account you hold in the United Number,to apply for an ITIN,or Form SS-4,Application for Employer States,you may leave this field blank.Consult with the person Identification Number,to apply for an EIN.You can apply for an EIN requesting this form if you are uncertain if the financial institution is online by accessing the IRS website at www.irs.gov/Businesses and subject to these requirements.A requester may indicate that a code is clicking on Employer Identification Number(EIN)under Starting a not required by providing you with a Form W-9 with"Not Applicable"(or Business.Go to www.irs.gov/Forms to view,download,or print Form any similar indication)written or printed on the line for a FATCA W-7 and/or Form SS-4. Or,you can go to www.irs.gov/OrderForms to exemption code. place an order and have Form W-7 and/or SS-4 mailed to you within 10 A—An organization exempt from tax under section 501(a)or any business days. individual retirement plan as defined in section 7701(a)(37) If you are asked to complete Form W-9 but do not have a TIN,apply B—The United States or any of its agencies or instrumentalities for a TIN and write"Applied For"in the space for the TIN,sign and date C—A state,the District of Columbia,a U.S.commonwealth or the form,and give it to the requester.For interest and dividend possession,or any of their political subdivisions or instrumentalities payments,and certain payments made with respect to readily tradable D—A corporation the stock of which is regularly traded on one or 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 more established securities markets,as described in Regulations payments.The 60-day rule does not apply to other types of payments. section 1.1472-1(c)(1)(i) You will be subject to backup withholding on all such payments until E—A corporation that is a member of the same expanded affiliated you provide your TIN to the requester. group as a corporation described in Regulations section 1.1472-1(c)(1)(i) Note:Entering"Applied For"means that you have already applied for a F—A dealer in securities,commodities,or derivative financial TIN or that you intend to apply for one soon. instruments(including notional principal contracts,futures,forwards, Caution:A disregarded U.S.entity that has a foreign owner must use and options)that is registered as such under the laws of the United the appropriate Form W-8. States or any state G—A real estate investment trust Part II. Certification H—A regulated investment company as defined in section 851 or an To establish to the withholding agent that you are a U.S.person,or entity registered at all times during the tax year under the Investment resident alien,sign Form W-9.You may be requested to sign by the Company Act of 1940 withholding agent even if item 1,4,or 5 below indicates otherwise. I—A common trust fund as defined in section 584(a) For a joint account,only the person whose TIN is shown in Part I J—A bank as defined in section 581 should sign(when required).In the case of a disregarded entity,the K—A broker person identified on line 1 must sign.Exempt payees,see Exempt payee code,earlier. L—A trust exempt from tax under section 664 or described in section Signature requirements.Complete the certification as indicated in 4947(a)(1) items 1 through 5 below. Form W-9(Rev.10-2018) Page 5 1.Interest,dividend,and barter exchange accounts opened For this type of account: Give name and EIN of: before 1984 and broker accounts considered active during 1983. 14.Account with the Department of The public entity You must give your correct TIN,but you do not have to sign the Agriculture in the name of a public certification. entity(such as a state or local 2.Interest,dividend,broker,and barter exchange accounts government,school district,or opened after 1983 and broker accounts considered inactive during prison)that receives agricultural 1983.You must sign the certification or backup withholding will apply.If program payments 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 15.Grantor trust filing under the Form The trust certification before signing the form. 1041 Filing Method or the Optional 3.Real estate transactions.You must sign the certification.You may Form 1099 Filing Method 2(see cross out item 2 of the certification. Regulations section 1.6714(b)(2)(i)(B)) 4.Other payments.You must give your correct TIN,but you do not ' List first and circle the name of the person whose number you furnish. have to sign the certification unless you have been notified that you If only one person on a joint account has an SSN,that person's number have previously given an incorrect TIN."Other payments"include must be furnished. payments made in the course of the requester's trade or business for 2 Circle the minor's name and furnish the minor's SSN. rents,royalties,goods(other than bills for merchandise),medical and health care services(including payments to corporations),payments to 3 You must show your individual name and you may also enter your a nonemployee for services,payments made in settlement of payment business or DBA name on the"Business name/disregarded entity" card and third party network transactions,payments to certain fishing name line.You may use either your SSN or EIN(if you have one),but the boat crew members and fishermen,and gross proceeds paid to IRS encourages you to use your SSN. attorneys(including payments to corporations). °List first and circle the name of the trust,estate,or pension trust.(Do 5.Mortgage interest paid by you,acquisition or abandonment of not furnish the TIN of the personal representative or trustee unless the secured property,cancellation of debt,qualified tuition program legal entity itself is not designated in the account title.)Also see Special payments(under section 529),ABLE accounts(under section 529A), rules for partnerships,earlier. IRA,Coverdell ESA,Archer MSA or HSA contributions or *Note:The grantor also must provide a Form W-9 to trustee of trust. distributions,and pension distributions.You must give your correct Note:If no name is circled when more than one name is listed,the TIN,but you do not have to sign the certification. number will be considered to be that of the first name listed. What Name and Number To Give the Requester Secure Your Tax Records From Identity Theft For this type of account: Give name and SSN of: Identity theft occurs when someone uses your personal information 1.Individual The individual such as your name,SSN,or other identifying information,without your 2.Two or more individuals 0oint The actual owner of the account or,if permission,to commit fraud or other crimes.An identity thief may use account)other than an account combined funds,the first individual on your SSN to get a job or may file a tax return using your SSN to receive maintained by an FFI the account' a refund. 3.Two or more U.S.persons Each holder of the account To reduce your risk: (joint account maintained by an FFI) a Protect your SSN, 4.Custodial account of a minor The minor •Ensure your employer is protecting your SSN,and (Uniform Gift to Minors Act) •Be careful when choosing a tax preparer. 5.a.The usual revocable savings trust The grantor-trustee' If your tax records are affected by identity theft and you receive a (grantor is also trustee) notice from the IRS,respond right away to the name and phone number b.So-called trust account that is not The actual owner' printed on the IRS notice or letter. a legal or valid trust under state law If your tax records are not currently affected by identity theft but you 6.Sole proprietorship or disregarded The owner think you are at risk due to a lost or stolen purse or wallet,questionable entity owned by an individual credit card activity or credit report,contact the IRS Identity Theft Hotline 7.Grantor trust filing under Optional The grantor" at 1-800-908-4490 or submit Form 14039. Form 1099 Filing Method 1(see For more information,see Pub.5027,Identity Theft Information for Regulations section 1.671-4(b)(2)(i) Taxpayers. (A)) Victims of identity theft who are experiencing economic harm or a For this type of account: Give name and EIN of: systemic problem,or are seeking help in resolving tax problems that 8.Disregarded entity not owned by an The owner have not been resolved through normal channels,may be eligible for individual Taxpayer Advocate Service(TAS)assistance.You can reach TAS by 9.A valid trust,estate,or pension trust Legal entity° calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059. 10.Corporation or LLC electing The corporation Protect yourself from suspicious emails or phishing schemes. corporate status on Form 8832 or Phishing is the creation and use of email and websites designed to Form 2553 mimic legitimate business emails and websites.The most common act 11.Association,club,religious, The organization is sending an email to a user falsely claiming to be an established charitable,educational,or other tax- legitimate enterprise in an attempt to scam the user into surrendering exempt organization private information that will be used for identity theft. 12.Partnership or multi-member LLC The partnership 13.A broker or registered nominee The broker or nominee Form W-9(Rev.10-2018) Page 6 The IRS does not initiate contacts with taxpayers via emails.Also,the privacy Act Notice IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers,passwords,or similar secret access Section IN t of the Internal Revenue Code requires you r provide your information for their credit card,bank,or other financial accounts. correct TIN i o persons(including federal agencies)who are required to If you receive an unsolicited email claiming to be from the IRS, file information returns with the IRS or report interest,dividends,or Y g certain other income paid to you;mortgage interest you paid;the forward this message to phishing@irs.gov.You may also report misuse acquisition or abandonment of secured property;the cancellation of of the IRS name,logo,or other IRS property to the Treasury Inspector debt;or contributions you made to an IRA,Archer MSA,or HSA.The General for Tax Administration(TIGTA)at 1-800-366-4484.You can person collecting this form uses the information on the form to file forward suspicious emails to the Federal Trade Commission at information returns with the IRS,reporting the above information. spam@uce.gov or report them at www.ftc.gov/complaint.You can Routine uses of this information include giving it to the Department of contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT(877-438-4338). Justice for civil and criminal litigation and to cities,states,the District of If you have been the victim of identity theft,see www.ldentityTheft.gov Columbia,and U.S.commonwealths and possessions for use in and Pub.5027. administering their laws.The information also may be disclosed to other Visit www.irs.govIldentityTheft to learn more about identity theft and countries under a treaty,to federal and state agencies to enforce civil how to reduce your risk. and 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.Under section 3406,payers must generally withhold a percentage of taxable interest,dividend,and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. wit t CD Vim- 9 cn N { r OD s > -7 + � ITl > CD (D u ' ; • t r• rI � T N. 6 6/5/23,4:15 PM Landmark Web Official Records Search Instrument Number:20230411000918 Document:EAS Rec:$208.50 Page-1 of 6 Record Date:4/11/2023 4:56 PM Electronically Recorded King County,WA EXCISE TAX NOT REQUIRED BY ROBERT DUTTON,DEPUTY WHEN RECORDED RETURN TO: City Clerk City of Kent 220 Fourth Avenue South Kent, Washington 98032 Grantor: Dana Lee Adams and Deanna Mary Adams Grantee: City of Kent — Abbreviated Legal Description: Ptn Lot 2 Less Co Rd.,KC SP No. 1284005, Rec. No. 86121512117 Additional Legal Description can: Exhibit"A" ---- Assessor's Tax parcel ID No.: 072205-9223 STR: 07-22-05 Project Name: KEN-50 S 218t" St 98t" Ave S from 94t" PI S to S 216t" 5t. SUBTERRANEAN EASEMENT The Grantors, Dana Lee Adams, as a separate estate, and Deanna Mary Adams, presumptively subject to the community interest of her spouse or registered domestic partner, if married or a registered domestic partner, as their interests may appear of record (collectively "Grantor"), for and in consideration of Ten Dollars and No/100 ($10.00) and/or other valuable consideration, receipt of which is hereby acknowledged, grants to City of Kent, a Washington municipal corporation ("Grantee"), a permanent subterranean easement ("Easement") over, under, through, across and upon the portion of the property situated in King County, Washington, specifically described in Exhibit "A" and graphically depicted in Exhibit "B", both of which are attached and incorporated herein (the"Easement Area"). The f Grantor agrees that this easement touches and concerns the lanbl described in Exhibit A, and that this easement shall run with the land. Grantee intends to construct a permanent retaining wall ("Wall") utilizing an earth shoring system. This would require soil reinforcement within the Easement Area by drilling and inserting tiebacks (`Tiebacks"); or by excavation and installation of soil reinforcing grids. The subterranean easement includes a "no dig" area through Page 1 of 4 i i https://recordsearch.kingcounty.gov/Landmarkweb/search/index?theme=.blue&section=searchCriteriaName&quickSearchSelection=# 1/6 6/5/23,4:15 PM Landmark Web Official Records Search Instrument Number:20230411000918 Document:EAS Rec: $208.50 Page-2 of 6 Record Date:4/11/2023 4:56 PM King County,WA and under the portion of the Property needed to support the Wall to prevent any digging in the Easement Area and preserve the integrity of the Wall's shoring system. Grant. Grantor hereby grants, conveys and warrants to Grantee, subject to matters of record, a nonexclusive subterranean easement over, under, through, across, and upon the Easement Area. This Easement touches and concerns the land described in Exhibit A and runs with the land for the purposes of (1) drilling, excavating, installing, constructing, and maintaining the shoring system in connection with the construction of a retaining wall, and (2) preventing the erection of any structures on, digging or excavation in the Easement Area. Construction_. Grantee shall ensure that the drilling, excavation, installation, construction, and maintenance of the shoring system shall not damage the property or any improvements, outside of the Easement Area. Grantee shall restore, as practicable, the Easement Area to as or, better than the condition of the Easement Area prior to entering the Easement Area. Prior to any drilling, excavation, construction, and installation of the shoring system, Grantee shall immediately provide to Grantor any information obtained by Grantee regarding any underground storage tanks, unstable fill material, gravel substratum, utility facilities and other underground improvements within the property. Grantee's Dbliqations. Grantee agrees to retain, at its sole cost, the services of a licensed engineer to determine the exact specified locations of the underground shoring system. These locations shall be identified on drawings provided to Grantor before construction. Grantee shall provide to Grantor, upon completion of the shoring system and retaining wall, detailed as-built drawings showing the locations (including elevations) and dimensions of all Tiebacks or reinforcing grids, and other underground improvements that have been installed by Grantee within the Easement Area. Reservation of Rights. Grantor reserves for itself and its successors and assigns the right to use the Easement Area and the remainder of subject property for any lawful use not inconsistent with the Easement. Grantor shall retain the right to use the surface of this Easement Area, including the immediately adjacent incidental areas, so long as that use is not inconsistent with the purposes of the Easement and does not interfere with the Grantee's uses as described in this document. Under no circumstances shall Grantor and its successors conduct any digging or excavation in the Easement Area without prior express written approval of Grantee. Indemnity.. Grantee accepts the Easement Area in its present physical condition, AS IS. Grantee does hereby release, indemnify and promise to defend and save harmless Grantor from and against any and all liability, loss, damage, expense, actions and claims, including costs and reasonable attorney's fees incurred by Grantor in connection therewith, arising directly on account of or out of the negligent exercise by Grantee, its servants, agents, employees and contractors of the rights granted in this Easement. i I Page 2 of 4 t I { i https://recordsearch.kingcounty.gov/Landmarkweb/search/index?theme=.blue&section=searchCriteriaName&quickSearchSelection=# 2/6 6/5/23,4:15 PM Landmark Web Official Records Search Instrument Number:20230411000918 Document:EAS Rec: $208.50 Page-3 of 6 Record Date:4/11/2023 4:56 PM King County,WA Binding Effect. This Easement and its terms and conditions set forth herein shall be a covenant running with the land, and shall bind Grantor's successors, heirs and assigns, and all future owners of the real property affected by this Easement. TOR: kP Name: Dana Lee Adams Name: Deanna Maryr Adams _ Date: -_:4-_d_ eej 0'Z ,3 Date: ,�L'�'i STATE OF WASHINGTON ) ss. COUNTY OF KING ) I certify that I know or have satisfactory evidence that Dana Lea Adams is the person who appeared before me, and said person acknowledged that she signed this instrument and acknowledged it to be her free and voluntary act for the uses and purposes mentioned in the instrument. Dated -Notary Seal Must Appear Within This Box- IN WITNESS WHEREOF, I have hereunto set my hand and official seal the day and yeq��ft� 6ove written. L ilk. 4k It/ UPIL 11, ,L`e, (Signature) NOTARY PUBLIC, in and for the State �. °.® A40800 F z of Washington, residing at aV, 11 My appointment expires Additional notary acknowledgment on following page Page 3 of 4 https://recordsearch.kingcounty.gov/LandmarkWeb/search/index?theme=.blue&section=searchCriteriaName&quickSearchSelection=# 3/6 6/5/23,4:15 PM Landmark Web Official Records Search Instrument Number:20230411000918 Document:EAS Rec: $208.50 Page-4 of 6 Record Date:4/11/2023 4:56 PM King County,WA STATE OF WASHINGTON ) ss. COUNTY OF KING ) I certify that I know or have satisfactory evidence that Deanna fury Adams is the person who appeared before me, and said person acknowledged that she signed this instrument and acknowledged it to be her free and voluntary act for the uses and purposes mentioned in the instrument. Dated: -Notary Seal Must Appear Within This Box- IN WITNESS WHEREOF, I have hereunto set my hand and official seal the day and year fl,C " p written. /y� y a��,a®`ourv,a { 0 +�cy� ��i� (Signature) � �> NOTARY PUBLIC, in and for the State 0w of Washington, residing at 'P g Z 5 My appointment expires ACCEPTED: CITY OF KENT By: Dana Ralph Title: Mayor _.__ Date: 04/07/2023 i I� I i Page 4 of 4 i i i I https://recordsearch.kingcounty.gov/LandmarkWeb/search/index?theme=.blue&section=searchCriteriaName&quickSearchSelection=# 4/6 6/5/23,4:15 PM Landmark Web Official Records Search Instrument Number:20230411000918 Document:EAS Rec: $208.50 Page-5 of 6 Record Date:4/11/2023 4:56 PM King County,WA EXHIBIT—A TAX LOT 0722059223 EASEMENT THE SOUTH 4.00 FEET OF LOT 2, KING COUNTY SHORT PLAT NUMBER 1284005, RECORDED UNDER RECORDING NUMBER 8612151217, RECORDS OF KING COUNTY, WASHINGTON, IN THE NORTHEAST QUARTER OF THE SOUTHEAST QUARTERILIANOCITY OF�C:NT�IN�KINGICOUNTYRTH, RANGE 5 WASHINGTONAS-f", WILLAMETTE MER , CONTAINING 598 SQUARE FEET, MORE OR LESS. Qgpgp@1M@ppY@YNe@Yq@ •���*+ YYYY�r�lY s 4 YY9 @/Y@t@@p@@pR@pYppp@��fp� dl/lJ3l 2".t�2..2^ I I 1 i i l i i I i i j i 1 https://recordsearch.kingcounty.gov/Landmarkweb/search/index?theme=.blue&section=searchCriteriaName&quickSearchSelection=# 5/6 6/5/23,4:15 PM Landmark Web Official Records Search Instrument Number:20230411000918 Document:EAS Rec: $208.50 Page-6 of 6 Record Date:4/11/2023 4:56 PM King County,WA i I I i �nw_4m00CMr mom-1C)sz� mo �am�allod m�n�m� > ' mwo�mmDc zu)c:-� O rn oz A�cnn z a m en �® n in Mx fn nm co m'°G m'4+'� O cr 0 �0 mzIT1z —@ �Tma �m z� r n spa4a1 (AMix e z 0 w O rn � _ a p z m m z in r4 https://recordsearch.kingcounty.gov/LandmarkWeb/search/index?theme=.blue&section=searchCriteriaName&quickSearchSelection=# 6/6 6/5/23,4:14 PM Landmark Web Official Records Search Instrument Number:20230411000910 Document:EAS Rec:$207.50 Page-1 of 5 Record Datc:4/11/2023 4:53 PM Electronically Recorded King County,WA EXCISE TAX NOT REQUIRED BY HOLLY FERGUSON,DEPUTY After recording return document to: City Clerk City of Kent 220 4th Avenue South Kent,WA 98032 Document Title: Temporary Easement Reference Number of Related Document: N/A Grantor(s): Dana Lee Adams and Deanna Mary Adams Grantee(s): City of Kent Legal Description: Ptn. Lot 2, Less Co Rd,KC SP No. 1284005,Ree No.86121512117 Additional Legal Description is on Exhibit A of Document. Assessor's Tax Parcel Number- 072205-9223 TEMPORARY EASEMENT KEN-50 South 218'h Street/98th Avenue South from 941h Place South to South 216t', Street Project The Grantor(s), Dana Lee Adams, as a separate estate, and Deanna Mary Adams, presumptively subject to the community interest of her spouse or registered domestic partner, if married or a registered domestic partner, as their interests may appear of record,,for and in consideration of TEN AND NO/100 ($10.00) DOLLARS, and other valuable consideration, conveys and grants unto the City of Kent, and its assigns, Grantee, under the imminent threat of the Grantee's exercise of its right of Eminent Domain,the right,privilege and easement over, upon, through and across the hereinafter described lands for the purpose of widening South 218th Street and 98th Avenue South(from 94th PL S to 99th Ave S)to three lanes and including paving, concrete curbs & gutters, sidewalks, paved shoulders, street lighting, storm drainage, sanitary sewer, water mains replacement, landscaping, and channelization. This project will also include undergrounding all the overhead utilities to a Joint Utility Trench. Said lands being situated in King County,State of Washington,and described in Exhibit A and depicted in Exhibit 13,attached hereto and made a part hereof. FA No. LPA-325 Page I of(3)Pages Parcel Number:122204-9085 Rev.5/2021 https://recordsearch.kingeounty.gov/LandmarkWeb/search/index?theme=.blue&section=searchCriteriaName&quickSearchSelection=# 1/5 6/5/23,4:14 PM Landmark Web Official Records Search Instrument Number:20230411000910 Document:EAS Rec: $207.50 Page-2 of 5 Record Date:4/11/2023 4:53 PM King County,WA TEMPORARY EASEMENT The term of this Temporary Easement shall commence on the date of acceptance of this Temporary Easement by Grantee and shall terminate on October 31, 2024, hereinafter the "Term". Provided.however,that Grantee's use and occupancy of the easement area is limited to between August 1,2023 and October 31,2024. It is further agreed that this Temporary Easement may be extended by up to six months at the Grantee's option.The rate associated with this extension shall be at the same rate as the original Temporary Easement, or at the newly established rate determined by an updated administrative offer; whichever is higher. Grantee shall notify Grantor in writing prior to exercising this option. Grantee shall provide Grantor written notice no less than three days in advance of Grantee's intent to exercise its rights under this Temporary Easement. It is understood and agreed that delivery of this temporary easement is hereby tendered and that the terms and obligations hereof shall not become binding upon the City of Kent unless and until accepted and approved hereon in writing for the City of Kent,by its authorized agent. Dated: C`r Z-6 2-73 Grantor: (1)41'ereA'damsLa Deanna Mary Adams Accepted and Approved City of Kent Dana Ralph Mayor Date: 04/07/2023 Notary acknowledgments on following page LPA-325 Page 2 of(3)Pages Rev.5/2021 https://recordsearch.kingeounty.gov/LandmarkWeb/search/index?theme=.blue&section=searchCriteriaName&quickSearchSelection=# 2/5 6/5/23,4:14 PM Landmark Web Official Records Search Instrument Number:20230411000910 Document:EAS Rec: $207.50 Page-3 of 5 Record Date:4/11/2023 4:53 PM King County,WA TEMPORARY EASEMENT STATE OF WASHINGTON ) ss. COUNTY OF KING ) I certify that I know or have satisfactory evidence that Dana Lee Adams is the person who appeared before me,and said person acknowledged that he/she signed this instrument and acknowledged it to be his/her free and voluntary act for the uses and purposes mentioned in the instrument. Dated: 9, -Notary Seal Must Appear Within This Box- IN W1TNES�NN \FtREOF,I have hereunto set my hand and official seal the day and year first above written. .,a'`N\t�CJlt, r'Pt> rat� ' t°°s , n O'A.V Aair S (Printed Name) C.hr—>!L NOTARY PUBLIC,in and for the State p7g of Washington,residing at „`AO My appointment expires— oil W STATE OF WAS ) ss. COUNTY OF KING ) I certify that I know or have satisfactory evidence that Deanna Mary Adams is the person who appeared before me,and said person acknowledged that he/she signed this instrument and acknowledged it to be his/her free and voluntary act for the uses and purposes mentioned in the instrument. Dated: -Notary Seal Must Appear Within This Box- IN WITNESS WHER\ \�OF,I have hereunto set my hand and official seal the day and year first above written. .,^ 1 � 0 (Printed Name) Cher34 fLUICtk� ft7L1�� ,NOTARY PUBLIC,in and for the State 1976 a' -,of Washington,residing at a B%,N -My appointment expires /I WA err.. rdrtMtl\\1���®'� i LPA-325 Page 3 of(3)Pages Rev.5/2021 https://recordsearch.kingeounty.gov/LandmarkWeb/search/index?theme=.blue&section=searchCriteriaName&quickSearchSelection=# 3/5 6/5/23,4:14 PM Landmark Web Official Records Search Instrument Number:20230411000910 Document:EAS Rec: $207.50 Page-4 of 5 Record Date:4/11/2023 4:53 PM King County,WA EXHIBIT_.,.A TAX LOT 0722059223 TEMPORARY CONSTRUCTION EASEMENT THE SOUTH 10.00 FEET OF LOT 2, KING COUNTY SHORT PLAT NUMBER 1284005, RECORDED UNDER RECORDING NUMBER 8612.151217, RECORDS OF KING COUNTY, WASHINGTON, IN THE NORTHEAST QUARTER OF THE SOUTHEAST QUARTER OF SECTION 7, TOWNSHIP 22 NORTH, RANGE. 5 EAST, WILLAMETTE MERIDIAN, CITY OF KENT, IN KING COUNTY, WASHINGTON. CONTAINING 1,495 SQUARE FEET, MORE OR LESS. tttttgtt##ttt#8##Y9#4 ##t Na*! +tea L � r t Y 6t ,i i I l S 4� 1 https://recordsearch.kingcounty.gov/Landmarkweb/search/index?theme=.blue&section=searchCriteriaName&quickSearchSelection=# 4/5 6/5/23,4:14 PM Landmark Web Official Records Search Instrument Number:20230411000910 Document:EAS Rec: $207.50 Page-5 of 5 Record Date:4/11/2023 4:53 PM King County,WA 1 EXHIBIT B Dc�cn-f, n ODcmmnOZ rnazmDz mam�Z SOZma -�1 m-+3 y ;U -imm 'mmCp-j > 0(>,rz�o< zw *azarm ^fvoQ — - -- f lO S Z I �D rnin cn a 0 m i 'n cn m RM m zz © 0 m O O rn- U) En Z A I es'S �} z 0 d�j x a C®e �.. ITI 0 o to CAI c, z ® CA 0 ® .✓ ; .'' mrn ... _...... _ - - ni d � > O IF 1 N 8 C 0 I J-B �\ N :� —4 ®1 W M z r. Mo U) M tz c I w z https://recordsearch.kingeounty.gov/LandmarkWeb/search/index?theme=.blue&section=searchCriteriaName&quickSearchSelection=# 5/5