NORTH GREENWOOD AQUATIC CENTER RENOVATION - 25-0020-PRSECTION V
CONTRACT DOCUMENTS
Table of Contents
PUBLIC CONSTRUCTION BOND 1
CONTRACT 4
CONSENT OF SURETY TO FINAL PAYMENT 8
PROPOSAL/BH) BOND 9
AFFIDAVIT 10
NON -COLLUSION AFFIDAVIT 11
PROPOSAL 12
CITY OF CLEARWATER ADDENDUM SHEET 14
BIDDER'S PROPOSAL 15
SCRUTINIZED COMPANIES AND BUSINESS OPERATIONS WITH CUBA AND SYRIA
CERTIFICATION FORM 19
SCRUTINIZED COMPANIES THAT BOYCOTT ISRAEL LIST CERTIFICATION FORM 20
,
SECTION V
Page i Updated: 7/9/2025
M.E. WILSON
RISK MANAGEMENT • INSURANCE
• BENEFITS • BONDS
October 31, 2025
Mr. Zachary Bandes
Bandes Construction Company, Inc.
1368 Spalding Road, Suite C
Dunedin, FL 34698
Re: Performance and Payment Bond No. 016246040
City of Clearwater, Florida
North Greenwood Aquatic Center Renovation
Bond Amount: $1,979,529.21
Dear Zachary:
Enclosed you will find four (4) original Public Construction Bonds for the above -referenced project, which
we have executed based on the information you provided.
Be sure to affix the bond with the proper signature and'sealprior to presenting the bond to the owner. As
this is a No Date Bond, please do not date.
Florida Statute 255.05(1) requires contractors furnishing Performance and Payment Bonds on public work
to record the bonds with the Clerk of Court in the public records of the county where the project is located
prior to commencement of the work. We have provided an extra, copy of the bond for this purpose.
The statute also requires that the bond you provide to the public Owner be a.certified copy of the
recorded bond reflecting the Official Record Book and Page Numbers, and this must be provided prior
to commencement of construction. You must request this at the recording office when recording the bond:
The Owner is prohibited by statute from making payment to you until you have complied with this
requirement. The law also states that a claimant who requests a copy of the bond is to be provided with a
copy of the recorded bond.
Please review all bond documents and any attachments and notify us if any changes are needed.
Sincerely,
Anthony T. Papa, Jr.
Senior Vice President
ATP/ep
Enclosures
7264 Kyle Court I Sarasota, FL 34240
Voice: 941.999.1900 I Fax: 941.306.2002 I mewilson.com Knowledge is the Best Insurance.
BOND NO.:
CONTRACTOR NAME:
CONTRACTOR ADDRESS:
CONTRACTOR PHONE NO.:
BURL TY COMPANY:
SURETY AGENT':
OWNER NAME:
OWNER ADDRESS:
OWNER PHONE NO.:
OBLIGEE NAME: (If contracting
entity is different from the owner.
the contracting public entity)
OBLIGEE ADDRESS:
OBLIGEE PHONE NO.:
BOND AMOUNT:
CONTRACT NO.: (if applicable)
DESCRIPTION OE WORK:
PROJECT ADDRESS:
LEGAL DESCRIPTION:
PERFORMANCE AND PAYMENT BOND
(Public Work)
In compliance with F.S. Chapter 255.05(1)(a)
016246040
Bandes Construction Company, Inc.
1368 Spalding Road, Suite C
Dunedin, FL 34698
(727) 733-5558
Liberty Mutual Insurance Company
175 Berkeley Street
Boston, MA 02116 (617) 357-9500
M. E. Wilson Company, LLC
7264 Kyle Court
Sarasota, FL 34240
(941) 999-1900
City of Clearwater, Florida - Public Works
PO Box 4748
Clearwater, FL 33758-4748
(727)562-4850
n/a
nLa
S 1,979,529.21
North Greenwood Aquatic Center Renovation
900 North MLK Jr. Ave, Clearwater, FL 33755
North. GreenwosxdAquatic_Cs<nteLRenovation
900 North MLK Jr. Ave, Clearwater, FL 33755
FRONT PAGE
All other Bond page(s) are deemed subsequent to this page regardless of any page number(s) that may be pre-printed thereon.
SECTION V—Contract Documents
Bond No.: 016246040
PUBLIC CONSTRUCTION BOND
(1)
This bond is given to comply with § 255.05, Florida Statutes, and any action instituted by a claimant under
this bond for payment must be in accordance with the notice and time limitation provisions in subsections
(2) and (10).
Pursuant to § 255.05(1)(b), Florida Statutes, "Before commencing the work or before recommencing the
work after a default or abandonment, the contractor shall provide to the public entity a certified copy
of the recorded bond. Notwithstanding the terms of the contract or any other law governing prompt
payment for construction services, the public entity may not make a payment to the contractor until the
contractor has complied with this paragraph."
CONTRACTOR
Bandes Construction Company,
Inc
Principal Name
1368 Spalding Rd Ste. C
Dunedin, FL 34698
Principal Business Address
727-733-5558
Principal Phone Number
SURETY OWNER
[name]
Liberty Mutual Insurance Company
a1 -Name
[Address Line 1], 175 Berkeley Street
[Address Line 4 Boston, MA 02116
Etyria0pal Business Address
[phone number.] (617) 357-9500
ycipal-Phone Number
City of CIearwater
Public Works
PO Box 4748
Clearwater FL 33758-4748
(727) 562-4750
PROJECT NAME: North Greenwood Aquatic Center Renovation
PROJECT NO.: 25 -0020 -PR
PROJECT DESCRIPTION: The City of Clearwater is seeking qualified general contractors to submit
bids for the City's North Greenwood Recreation and Aquatic Center will undergo improvements and
renovations to its aquatic amenities and equipment. The improvements and renovations will include the
resurfacing of all three existing water bodies with a Hydrazzo finish:
a) the Lap Pool (approximately 4,470 sf)
b) the Water Activity Pool (approximately 2,000 sf)
c) the Plunge Pool (approximately 300 sf)
The project will also include removing and replacing the existing concrete deck, replacing the Lap Pool and
Activity Pool Coping, repairing the pool shell crack in the Lap Pool, Rehabilitating the existing Water
Feature in the Water Activity Pool, rehabilitating the existing Slide and Slide Tower in the Plunge Pool,
and modifying the Lap Pool and Activity Pool equipment room. Add alternatives will be under
consideration for this project.
The following plan set (36 pages) digitally signed on 08/05/25 by City Engineer shall be used for bidding
purposes and describe the specific project scope:
1. Lap Pool Resurfacing & Equipment Modification Plans
2. Activity Pool Resurfacing & Equipment Modification Plans
3. Plunge Pool Resurfacing PIans
4. Deck Modification Plans
SECTION V Page 1 of 20 Updated: 7/9/2025
SECTION V — Contract Documents
BY THIS BOND, We, Bandes Construction Company, Inc. , as Contractor, and
Liberty Mutual Insurance Company , a corporation, as Surety, are bound to the
City of Clearwater, Florida, herein called Owner, in the sum of $[ 1,979,529.21 ], for payment of which we
bind ourselves, our heirs, personal representatives, successors, and assigns, jointly and severally.
THE CONDITION OF THIS BOND is that if Contractor:
1. Performs the contract dated , between Contractor and Owner for construction
of North Greenwood Aquatic Center Renovation, 25 -0020 -PR the contract documents being made
a part of this bond by reference (which include the Advertisement for Bids, Proposal, Contract,
Surety Bond, Instructions to Bidders, General Conditions, Plans, Technical Specifications and
Appendix, and such alterations as maybe made in said Plans and Specifications as therein provided
for), at the times and in the manner prescribed in the contract; and
2. Promptly makes payments to all claimants, as defined in Section 255.05(1), Florida Statutes,
supplying Contractor with labor, materials, or supplies, used directly or indirectly by Contractor in
the prosecution of the work provided for in the contract; and
SECTION V Page 2 of 20 Updated: 7/9/2025
SECTION V—Contract Documents
Bond No.: 016246040
PUBLIC CONSTRUCTION BOND
(2)
3. Pays Owner all losses, damages, expenses, costs, and attorney's fees, including appellate
proceedings, that Owner sustains because of a default by Contractor under the contract; and
4. To the limits of § 725.06(2), Florida Statutes, shall indemnify and hold harmless Owner, their
officers and employees, from liabilities, damages, losses and costs, including, but not limited to,
reasonable attorney's fees, to the extent caused by the negligence, recklessness, or intentional
wrongful misconduct of Contractor and persons employed or utilized by Contractor in the
performance of the construction contract; and
5. Performs the guarantee of all work and materials furnished under the contract for the time specified
in the contract, then this bond is void; otherwise, it remains in full force.
6. Any action instituted by a claimant under this bond for payment must be in accordance with the
notice and time limitation provisions in Section 255.05(2), Florida Statutes.
7. Any changes in or under the contract documents and compliance or noncompliance with any
formalities connected with the contract or the changes do not affect Surety's obligation under this
bond, and Surety does hereby waive notice of any such change, extension of time, alteration or
addition to the terms of the contract or to the work or to the specifications.
IN TESTIMONY WHEREOF, witness the hands and seals of the parties hereto this
, 20
(If sole Ownership or Partnership, two (2) Witnesses are required).
(If Corporation, Secretary only will attest and affix seal).
WITNESS:
Corporate Secretary or Witness
Print Name:
(affix corporate seal)
By:
Title:
Print Name:
WIT
Print Name:
day of
Liberty Mutual Insurance Company
(Corporate Surety)
By: �� D T
TTORNEY-Il- ACT
Anthony Papa Jr., Attorney -In -Fact and:
Print Name: Licensed Florida Resident Agent/Al99806
(affix corporate seal)
(Power of Attorney must be attached)
SECTION V Page 3 of 20 Updated: 7/9/2025
Liberty
Mutual
SURETY
POWER OF ATTORNEY
Liberty Mutual Insurance Company
The Ohio Casualty Insurance Company
West American Insurance Company
Certificate No: 8213129-985140
KNOWN ALL PERSONS BY THESE PRESENTS: That The Ohio Casualty Insurance Company is a corporation duly organized under the laws of the State of New Hampshire, that
Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts, and West American Insurance Company is a corporation duly organized
under the laws of the State of Indiana (herein collectively called the "Companies"), pursuant to and by authority herein set forth, does hereby name, constitute and appoint,
Anthony T. Papa, Jr.; Breanne E. Souza; Christine A. Papa; Emily Papa
all of the city of Sarasota state of FL each individually if there be more than one named, its true and lawful attorney-in-fact to make,
execute, seal, acknowledge and deliver, for and on its behalf as surety and as its act and deed, any and all undertakings, bonds, recognizances and other surety obligations, in pursuance
of these presents and shall be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper
persons.
IN WITNESS WHEREOF, this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed
thereto this 13th day of February , 2025 .
State of PENNSYLVANIA
ss
County of MONTGOMERY
On this 13th day of February , 2025 before me personally appeared Nathan J. Zangerle, who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance
Company, The Ohio Casualty Company, and West American Insurance Company, and that he, as such, being authorized so to do, execute the foregoing instrument for the purposes
therein contained by signing on behalf of the corporations by himself as a duly authorized officer.
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my notarial seal at Plymouth Meeting, Pennsylvania, on the day and year first above written.
By:
Liberty Mutual Insurance Company
The Ohio Casualty Insurance Company
West American Insurance Company
Nathan J. Zangerle, Assistant Secretary
-74`�Q�
This Power of Attorney is made and executed pursuant to and by authority of the following By-laws and Authorizations of The Ohio Casualty Insurance Company, Liberty Mutual
Insurance Company, and West American Insurance Company which resolutions are now in full force and effect reading as follows:
ARTICLE IV – OFFICERS: Section 12. Power of Attorney.
Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President, and subject to such limitation as the Chairman or the
President may prescribe, shall appoint such attorneys -in -fact, as may be necessary to act in behalf of the. Corporation to make, execute, seal, acknowledge and deliver as surety
any and all undertakings, bonds, recognizances and other surety obligations. Such attorneys -in -fact, subject to the limitations set forth in their respective powers of attorney, shall
have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation. When so executed, such
instruments shall be as binding as if signed by the President and attested to by the Secretary. Any power or authority granted to any representative or attorney-in-fact under the
provisions of this article may be revoked at any time by the Board, the Chairman, the President or by the officer or officers granting such power or authority.
ARTICLE XIII – Execution of Contracts: Section 5. Surety Bonds and Undertakings.
Any officer of the Company authorized for that purpose in writing by the chairman or the president, and subject to such limitations as the chairman or the president may prescribe,
shall appoint such attorneys -in -fact, as may be necessary to act in behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings,
bonds, recognizances and other surety obligations. Such attorneys -in -fact subject to the limitations set forth in their respective powers of attorney, shall have full power to bind the
Company by their signature and execution of any such instruments and to attach thereto the seal of the Company. When so executed such instruments shall be as binding as if
signed by the president and attested by the secretary.
Certificate of Designation – The President of the Company, acting pursuant to the Bylaws of the Company, authorizes Nathan J. Zangerle, Assistant Secretary to appoint such
attorneys -in -fact as may be necessary to act on behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and
other surety obligations.
Authorization – By unanimous consent of the Company's Board of Directors, the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the
Company, wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds, shall be valid and binding upon the Company with
the same force and effect as though manually affixed.
I, Renee C. Llewellyn, the undersigned, Assistant Secretary, The Ohio Casualty Insurance Company, Liberty Mutual Insurance Company, and West American Insurance Company do
hereby certify that the original power of attorney of which the foregoing is a full, true and correct copy of the Power of Attorney executed by said Companies, is in full force and effect and
has not been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seals of said Companies this day of
Commonwealth of Pennsylvania - Notary Seal
Teresa Pastella, Notary Public
Montgomery County
My commission expires March 28, 2029
Commission number 1126044
Member, Pennsylvania A«iation of Notaries
By:
itato
eresa Pastella, NotaryPublc
eresa Public
LMS -12873 LM IC OCIC WAIC Multi Co 02/24
Renee C. Llewellyn, Assistant Secretary
cti
•N U
"p.„—ca
c-
cE
0
4:1
'Oa
>ce
fa_0
al 'al
O N
<
O
N
X00
0 N
aM
00
aCD
c
-
-f0
0
= U
oCD
LL n
SECTION V — Contract Documents
CONTRACT
(1)
This CONTRACT made and entered into this day of , 20 by and between the City
of Clearwater, Florida, a municipal corporation, hereinafter designated as the "City", and Bandes
Construction Company, Inc, of the City of Dunedin County of Pinellas and State of Florida, hereinafter
designated as the "Contractor".
[Or,if out ;of state:]
This CONTRACT made and entered into this day of , 20 by and between the City
of Clearwater, . Florida, a municipal corporation, ; hereinafter. .designated as the "City",and
a/an (State) Corporation authorized to do
business in the State of Florida, of the City of County of
and State of "' , Thereinafter designated as the "Contractor"
WITNESSETH:
That the parties to this contract each in consideration of the undertakings, promises and agreements on the
part of the other herein contained, do hereby undertake, promise, and agree as follows:
The Contractor, and his or its successors, assigns, executors or administrators, in consideration of the sums
of money as herein after set forth to be paid by the City and to the Contractor, shall and will at their own
cost and expense perform all labor, furnish all materials, tools and equipment for the following:
PROJECT NAME: North Greenwood Aquatic Center Renovation
PROJECT NO.: 25 -0020 -PR
in the amount of $
In accordance with such proposal and technical supplemental specifications and such other special
provisions and drawings, if any, which will be submitted by the City, together with any advertisement,
instructions to bidders, general conditions, technical specifications, proposal and bond, which may be hereto
attached, and any drawings if any, which may be herein referred to, are hereby made a part of this contract,
and all of said work to be performed and completed by the contractor and its successors and assigns shall
be fully completed in a good and workmanlike manner to the satisfaction of the City.
If the Contractor should fail to comply with any of the terms, conditions, provisions or stipulations as
contained herein within the time specified for completion of the work to be performed by the Contractor,
then the City, may at its option, avail itself of any or all remedies provided on its behalf and shall have the
right to proceed to complete such work as Contractor is obligated to perform in accordance with the
provisions as contained herein.
SECTION V Page 4 of 20 Updated: 7/9/2025
SECTION V — Contract Documents
CONTRACT
(2)
THE CONTRACTOR AND HIS OR ITS SUCCESSORS AND ASSIGNS DOES HEREBY AGREE
TO ASSUME THE DEFENSE OF ANY LEGAL ACTION WHICH MAY BE BROUGHT
AGAINST THE CITY AS A RESULT OF THE CONTRACTOR'S ACTIVITIES ARISING OUT
OF THIS CONTRACT AND FURTHERMORE, IN CONSIDERATION OF THE TERMS,
STIPULATIONS AND CONDITIONS AS CONTAINED HEREIN, AGREES TO HOLD THE
CITY FREE AND HARMLESS FROM ANY AND ALL CLAIMS FOR DAMAGES, COSTS OF
SUITS, JUDGMENTS OR DECREES RESULTING FROM ANY CLAIMS MADE UNDER THIS
CONTRACT AGAINST THE CITY OR THE CONTRACTOR OR THE CONTRACTOR'S SUB
CONTRACTORS, AGENTS, SERVANTS OR EMPLOYEES RESULTING FROM ACTIVITIES
BY THE AFOREMENTIONED CONTRACTOR, SUB CONTRACTOR, AGENT SERVANTS OR
EMPLOYEES, TO THE LIMITS OF § 725.06(2).
In addition to the foregoing provisions, the Contractor agrees to conform to the following requirements:
In connection with the performance of work under this contract, the Contractor agrees not to discriminate
against any employee or applicant for employment because of race, sex, religion, color, or national origin.
The aforesaid provision shall include, but not be limited to, the following: employment, upgrading,
demotion, or transfer; recruitment or recruitment advertising; lay off or termination; rates of pay or other
forms of compensation; and selection for training, including apprenticeship. The Contractor agrees to post
hereafter in conspicuous places, available for employees or applicants for employment, notices to be
provided by the contracting officer setting forth the provisions of the non-discrimination clause.
The Contractor further agrees to insert the foregoing provisions in all contracts hereunder, including
contracts or agreements with labor unions and/or worker's representatives, except sub -contractors for
standard commercial supplies or raw materials.
It is mutually agreed between the parties hereto that time is of the essence of this contract, and in the event
that the work to be performed by the Contractor is not completed within the time stipulated herein, it is then
further agreed that the City may deduct from such sums or compensation as may be due to the Contractor
the sum of $1,000.00 per day for each day that the work to be performed by the Contractor remains
incomplete beyond the time limit specified herein, which sum of $1,000.00 per day shall only and solely
represent damages which the City has sustained by reason of the failure of the Contractor to complete the
work within the time stipulated, it being further agreed that this sum is not to be construed as a penalty but
is only to be construed as liquidated damages for failure of the Contractor to complete and perform all work
within the time period as specified in this contract.
It is further mutually agreed between the City and the Contractor that if, any time after the execution of this
contract and the public construction bond which is attached hereto for the faithful performance of the terms
and conditions as contained herein by the Contractor, that the City shall at any time deem the surety or
sureties upon such public construction bond to be unsatisfactory or if, for any reason, the said bond ceases
to be adequate in amount to cover the performance of the work the Contractor shall, at his or its own
expense, within ten (10) days after receipt of written notice from the City to do so, furnish an additional
bond or bonds in such term and amounts and with such surety or sureties as shall be satisfactory to the City.
If such an event occurs, no further payment shall be made to the Contractor under the terms and provisions
of this contract until such new or additional security bond guaranteeing the faithful performance of the work
under the terms hereof shall be completed and furnished to the City in a form satisfactory to it.
SECTION V Page 5 of 20 Updated: 7/9/2025
SECTION V — Contract Documents
CONTRACT
(3)
In addition to all other contract requirements as provided by law, the contractor executing this agreement
agrees to comply with public records law.
IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF
CHAPTER 119, FLORIDA STATUTES, THE CONTRACTORS DUTY TO PROVIDE PUBLIC
RECORDS RELATING TO THIS CONTRACT. CONTACT THE CUSTODIAN OF PUBLIC
RECORDS, Rosemarie Call, City Clerk, at Rosemarie.Call@myclearwater.com, 727-562-4092,
600 Cleveland St., 6th Floor, Clearwater, FL 33756.
The contractor's agreement to comply with public records law applies specifically to:
a) Keep and maintain public records required by the City of Clearwater (hereinafter "public
agency") to perform the service being provided by the contractor hereunder.
b) Upon request from the public agency's custodian of public records, provide the public agency
with a copy of the requested records or allow the records to be inspected or copied within a
reasonable time at a cost that does not exceed the cost provided for in Chapter 119., Florida
Statutes, as may be amended from time to time, or as otherwise provided by law.
c) Ensure that the public records that are exempt or confidential and exempt from public records
disclosure requirements are not disclosed except as authorized by law for the duration of the
contract term and following completion of the contract if the contractor does not transfer the
records to the public agency.
d) Upon completion of the contract, transfer, at no cost, to the public agency all public records in
possession of the contractor or keep and maintain public records required by the public agency
to perform the service. If the contractor transfers all public records to the public agency upon
completion of the contract, the contractor shall destroy any duplicate public records that are
exempt or confidential and exempt from public records disclosure requirements. If the
contractor keeps and maintains public records upon completion of the contract, the contractor
shall meet all applicable requirements for retaining public records. All records stored
electronically must be provided to the public agency, upon request from the public agency's
custodian of public records, in a format that is compatible with the information technology
systems of the public agency.
e) A request to inspect or copy public records relating to a public agency's contract for services
must be made directly to the public agency. If the public agency does not possess the requested
records, the public agency shall immediately notify the contractor of the request and the
contractor must provide the records to the public agency or allow the records to be inspected or
copied within a reasonable time.
1) The contractor hereby acknowledges and agrees that if the contractor does not comply with the
public agency's request for records, the public agency shall enforce the contract provisions in
accordance with the contract.
g) A contractor who fails to provide the public records to the public agency within a reasonable
time may be subject to penalties under Section 119.10, Florida Statutes.
h) If a civil action is filed against a contractor to compel production of public records relating to a
public agency's contract for services, the court shall assess and award against the contractor
the reasonable costs of enforcement, including reasonable attorney fees, if:
1. The court determines that the contractor unlawfully refused to comply with the public
records request within a reasonable time; and
SECTION V
Page 6 of 20 Updated: 7/9/2025
SECTION V— Contract Documents
PROPOSALBID BOND
(Not to be filled out if a certified check is submitted)
KNOWN ALL MEN BY THESE PRESENTS: That we, the undersigned, Bandes Construction Company, Inc.
as Contractor, and Liberty Mutual Insurance Company
as Surety, whose address is 175 Berkeley Street, Boston, MA 02116
, are held and firmly bound unto the City
of Clearwater, Florida, in the sum of 10% of Accompanying Bid Dollars
($ ---10% of Bid--- ) (being a minimum of 10% of Contractor's total bid amount) for the payment of which,
well and truly to be made, we hereby jointly and severally bind ourselves, our heirs, executors,
administrators, successors and assigns.
The condition of the above obligation is such that if the attached Proposal of Bandes Construction Company, Inc.
as Contractor, and Liberty Mutual Insurance Company as Surety, for
work specified as: North Greenwood Aquatic Center Renovation - 900 North MLK Jr. Ave, Clearwater, FL 33755
all as stipulated in said Proposal, by doing all work incidental thereto, in accordance with the plans and
specifications provided herefor, all within Pinellas County, is accepted and the contract awarded to the
above named bidder, and the said bidder shall within ten days after notice of said award enter into a contract,
in writing, and furnish the required Public Construction Bond with surety or sureties to be approved by the
City Manager, this obligation shall be void, otherwise the same shall be in full force and virtue by law and
the full amount of this Proposal/Bid Bond will be paid to the City as stipulated or liquidated damages.
Principal must indicate whether:
X Corporation, Partnership, Company, or
Signed this 15th day of October
Bandes Construction Company, Inc.
Individual
, 20 25
Contractor
By: Vice President
Title
Liberty Mutual Insurance Company
Surety
V
Anthony`". Papa -df., Attorney -In -Fact and
Licensed Florida Resident Agent/A199806
The person signing shall, in his own handwriting, sign the Principal's name, his own name, and his title;
where the person is signing for a Corporation, he must, by Affidavit, show his authority to bind the"
Corporation — provide Affidavit.
SECTION V Page 8 of 16 Updated: 7/9/2025
Liberty
Mutual
SURETY
POWER OF ATTORNEY
Liberty Mutual Insurance Company
The Ohio Casualty Insurance Company
West American Insurance Company
Certificate No: 8213129-985140
KNOWN ALL PERSONS BY THESE PRESENTS: That The Ohio Casualty Insurance Company is a corporation duly organized under the laws of the State of New Hampshire, that
Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts, and West American Insurance Company is a corporation duly organized
under the laws of the State of Indiana (herein collectively called the "Companies"), pursuant to and by authority herein set forth, does hereby name, constitute and appoint,
Anthony T. Papa, Jr.; Breanne E. Souza; Christine A. Papa; Emily Papa
all of the city of Sarasota state of FL each individually if there be more than one named, its true and lawful attomey-in-fact to make,
execute, seal, acknowledge and deliver, for and on its behalf as surety and as its act and deed, any and all undertakings, bonds, recognizances and other surety obligations, in pursuance
of these presents and shall be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper
persons.
IN WITNESS WHEREOF, this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed
thereto this 13th day of February , 2025 .
State of PENNSYLVANIA
County of MONTGOMERY ss
On this 13th day of February , 2025 before me personally appeared Nathan J. Zangerle, who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance
Company, The Ohio Casualty Company, and West American Insurance Company, and that he, as such, being authorized so to do, execute the foregoing instrument for the purposes
therein contained by signing on behalf of the corporations by himself as a duly authorized officer.
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my notarial seal at Plymouth Meeting, Pennsylvania, on the day and year first above written.
By:
Liberty Mutual Insurance Company
The Ohio Casualty Insurance Company
West American Insurance Company
diAti
Nathan J. Zangerle, Assistant Secretary
Commonwealth of Pennsylvania - Notary Seal
Teresa Pastella, Notary Public
Montgomery County
My commission expires March 28, 2029
Commission number 1126044
Member, Pennsylvania Association of Notaries
By:
eresa1.1-AIA4,) &fizz)
Pasiela. NotaryPublic
Pastella, Public
•
This Power of Attomey is made and executed pursuant to and by authority of the following By-laws and Authorizations of The Ohio Casualty Insurance Company, Liberty Mutual
Insurance Company, and West American Insurance Company which resolutions are now in full force and effect reading as follows:
ARTICLE IV — OFFICERS: Section 12. Power of Attorney.
Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President, and subject to such limitation as the Chairman or the
President may prescribe, shall appoint such attomeys-in-fact, as may be necessary to act in behalf of the Corporation to make, execute, seal, acknowledge and deliver as surety
any and all undertakings, bonds, recognizances and other surety obligations. Such attomeys-in-fact, subject to the limitations set forth in their respective powers of attomey, shall
have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation. When so executed, such
instruments shall be as binding as if signed by the President and attested to by the Secretary. Any power or authority granted to any representative or attorney-in-fact under the
provisions of this article may be revoked at any time by the Board, the Chairman, the President or by the officer or officers granting such power or authority.
ARTICLE XIII — Execution of Contracts: Section 5. Surety Bonds and Undertakings.
Any officer of the Company authorized for that purpose in writing by the chairman or the president, and subject to such limitations as the chairman or the president may prescribe,
shall appoint such attomeys-in-fact, as may be necessary to act in behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings,
bonds, recognizances and other surety obligations. Such attomeys-in-fact subject to the limitations set forth in their respective powers of attomey, shall have full power to bind the
Company by their signature and execution of any such instruments and to attach thereto the seal of the Company. When so executed such instruments shall be as binding as if
signed by the president and attested by the secretary.
Certificate of Designation — The President of the Company, acting pursuant to the Bylaws of the Company, authorizes Nathan J. Zangerle, Assistant Secretary to appoint such
attomeys-in-fact as may be necessary to act on behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and
other surety obligations.
Authorization — By unanimous consent of the Company's Board of Directors, the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the
Company, wherever appearing upon a certified copy of any power of attomey issued by the Company in connection with surety bonds, shall be valid and binding upon the Company with
the same force and effect as though manually affixed.
I, Renee C. Llewellyn, the undersigned, Assistant Secretary, The Ohio Casualty Insurance Company, Liberty Mutual Insurance Company, and West American Insurance Company do
hereby certify that the original power of attorney of which the foregoing is a full, true and correct copy of the Power of Attomey executed by said Companies, is in full force and effect and
has not been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seals of said Companies this 15th day of October , 2025 .
a) 0
7 Vi
=
cE
co N
>c
U •(9
EE
0
Q O
O
rP
N N
Oeo
CC
a0
00
c0
mas
o m
off
LL 0_
LMS -12873 LMIC OCIC WAIC Multi Co 02/24
By:
Renee C. Llewellyn, Assistant Secretary
SECTION V — Contract Documents
CONTRACT
(4)
2. At least 8 business dans before filing the action, the plaintiff provided written notice of the
public records request, including a statement that the contractor has not complied with the
request, to the public agency and to the contractor.
i) A notice complies with subparagraph (hit. if it is sent to the public agency's custodian of public
records and to the contractor at the contractor's address listed on its contract with the public
agency or to the contractor's registered agent. Such notices must be sent by common carrier
delivery service or by registered, Global Express Guaranteed, or certified mail, with postage or
shipping paid by the sender and with evidence Of delivery, which may be in an electronic
format.
j) A contractor who complies with a public records request within 8 business days after the notice
is sent is not liable for the reasonable costs of enforcement.
IN WITNESS WHEREOF, the parties to the agreement have hereunto set their hands and seals and have
executed this Agreement, the day and year first above written.
CITY OF CLEARWATER
IN PINELLAS COUNTY, FLORIDA
By:
ennifeoirrier
City Manager
Countersigned:
By:
Contractor must indicate whether:
x Corporation, Partnership,
Senior sistant City Attorney
Company, or
Individual
Bandes Construction Company, Inc.
(Contractor)
By
Print Name: ary Bandes
Title: Vice President
(SEAL)
The person signing shall, in his own handwriting, sign the Principal's name, his own name, and his title;
where the person is signing for a Corporation, he must, by Affidavit, show his authority to bind the
Corporation — provide Affidavit.
SECTION V
Page 7 of 20 Updated: 7/9/2025
SECTION V—Contract Documents
CONTRACT
(4)
2. At least 8 business days before filing the action, the plaintiff provided written notice of the
public records request, including a statement that the contractor has not complied with the
request, to the public agency and to the contractor.
i) A notice complies with subparagraph (h)2. if it is sent to the public agency's custodian of public
records and to the contractor at the contractor's address listed on its contract with the public
agency or to the contractor's registered agent. Such notices must be sent by common carrier
delivery service or by registered, Global Express Guaranteed, or certified mail, with postage or
shipping paid by the sender and with evidence of delivery, which may be in an electronic
format.
j) A contractor who complies with a public records request within 8 business days after the notice
is sent is not liable for the reasonable costs of enforcement.
IN WITNESS WHEREOF, the parties to the agreement have hereunto set their hands and seals and have
executed this Agreement, the day and year first above written.
CITY OF CLEARWATER
IN PINELLAS COUNTY, FLORIDA
By:
Jennifer Poirrier
City Manager
Countersigned:
(SEAL)
Attest:
Rosemarie Call
City Clerk
By: Approved as to form:
Bruce Rector
Mayor
Jerrod Simpson
Senior Assistant City Attorney
Contractor must indicate whether:
x Corporation, Partnership, Company, or Individual:;.,.
Bandes Construction Company,:anc. •',:-'.:
(Contractor)
By: ;' t(SEAL)
Print Name: ary Bandes': ',;•
Title: Vice President
The person signing shall, in his own handwriting, sign the Principal's name, his own name,: and'his.title;
where the person is signing for a Corporation, he must, by Affidavit, show his authority to bind the
Corporation — provide Affidavit.
SECTION V Page 7 of 20
Updated: 7/9/2025
SECTION V — Contract Documents
CONSENT OF SURETY TO FINAL PAYMENT
TO OWNER: City of Clearwater PROJECT NAME: North Greenwood Aquatic Center
Renovation
Public Works PROJECT NO.: 25 -0020 -PR
100 S Myrtle Ave CONTRACT DATE: [ ]
Clearwater, FL 33756 BOND NO.: [ 1, recorded in O.R. Book [ l;
Page [ of the Public Records of Pinellas County, Florida.
CONTRACTOR: [ 1
Pursuant to § 255.05(11), Florida Statutes, and in accordance with the provisions of the Contract between
the Owner and the Contractor as indicated above, the:
[insert name of Surety]
[address]
[address], SURETY,
on bond of
[insert name of Contractor]
[address]:
[address], CONTRACTOR,
hereby approves of the final payment to the Contractor, and agrees that final payment to the Contractor
shall not relieve Surety of any of its obligations to
City of Clearwater
Public Works
PO Box 4748
Clearwater, FL 33758-4748, OWNER,
as set forth in said Surety's bond.
IN WITNESS WHEREOF, the Surety has hereunto set its hand this day of
Attest:
(Seal):
SECTION V
(Surety)
(Signature of authorized representative)
(Printed name and title)
Page 8 of 20 Updated: 7/9/2025
SECTION V — Contract Documents
AFFIDAVIT
(To be filled in and executed if the bidder is a corporation)
STATE OF FLORIDA
COUNTY OF Pinellas )
Yolanda Lynch
, being duly sworn, deposes and says that he/she is
Secretary of Bandes Construction Company, Inc.
a corporation organized and existing under and by virtue of the laws of the State of Florida, and having its
principal office at:
1368 Spalding Rd Ste C Dunedin Pinellas FL
(Street & Number) (City) (County) (State)
Affiant further says that he is familiar with the records, minute books and by-laws of
Bandes Construction Company, Inc.
(Name of Corporation)
Affiant further says that Zachary Bandes
(Officer's Name)
is Vice President
(Title)
of the corporation, is duly authorized to sign the Proposal for Bandes Construction Company, Inc.
or said corporation by virtue of
(state whether a provis'on of by laws or a Resolution of
Board of Directors. If . ' '•/• .1 , t. n •4e date of adoption).
/ ,
Sworn to before me this 15th day of October
Sheyla Santiago
Commission N HH 592809
•CommisSian Expires 09-12-2028
Bonded Through • Cynanotaiy
Florida -Notary Public
Yolanda Lync
Affiant
2025 V
Notary Public
Sheyla Santiago
Type/print/stamp name of Notary
HH -592809
Title or rank, and Serial No., if any
SECTION V Page 9 of 16 Updated: 6/3/2024
SECTION V — Contract Documents
NON -COLLUSION AFFIDAVIT
STATE OF FLORIDA )
COUNTY OF T.,1\0\S" )
Zachary Bandes
being, first duly sworn, deposes and says that he is
Vice President of Bandes Construction Company, Inc.
the party making the foregoing Proposal or Bid; that such Bid is genuine and not collusive or sham: that
said bidder is not financially interested in or otherwise affiliated in a business way with any other bidder
on the same contract; that said bidder has not colluded, conspired, connived, or agreed, directly or indirectly,
with any bidders or person, to put in a sham bid or that such other person shall refrain from bidding, and
has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or
conference, with any person, to fix the bid price or affiant or any other bidder, or to fix any overhead, profit
or cost element of said bid price, or that of any other bidder, or to secure any advantage against; the City.of
Clearwater, Florida, or any person or persons interested in the proposed contract; and that atlstatements„
contained in said proposal or bid are true; and further, that such bidder has not directly; or, indirectly
submitted this bid, or the contents thereof, or divulged information or data relative thereto to'any-asssociation
or to any member or agent thereof.
Affiant
Sworn to and subscribed before me this 15th day of October
Notary Public
she 1G
20.c�';.
Sheyla Santiago
Commission # NH 592809
Commission Expires 09-12-2028
Bonded Through - Cynanolary
Florida - Notary Public
SECTION V Page 10 of 16 Updated: 6/3/2024
SECTION V — Contract Documents
PROPOSAL
(2)
Attached hereto is a bond or certified check on Libert Mutual Insurance Company,
Bank, for the sum
of 10% of accompanying bid
(being a minimum of 10% of Contractor's total bid amount).
($ 10% of bid
The full names and residences of all persons and parties interested in the foregoing bid are as follows:
(If corporation, give the names and addresses of the President and Secretary. If a firm or partnership, the
names and addresses of the members or partners. The Bidder shall list not only his name but also the name
of any person with whom bidder has any type of agreement whereby such person's improvements,
enrichment, employment or possible benefit, whether sub -contractor, materialman, agent, supplier, or
employer is contingent upon the award of the contract to the bidder).
NAMES: ADDRESSES:
Jillian Bandes, President
Yolanda Lynch, Secretary
828 28th Ave. N., St. Peterseburg, FL 33704
29722 Fog Hollow Drive, Wesley Chapel, FL 33643
;1
Signature of Bidder:
The person signing shall, in his own handwriting, sign the Principal's name, his own nam'e and his "title,
/
Where the person signing for a corporation is other than the President or Vice President,` he must, by
affidavit, show his authority, to bind the corporation.
Principal:
By: Zachary Bandes
Title: Vice
President
Company Legal Name: Bandes Construction Company, Inc.
Doing Business As (if different than above):
Business Address of Bidder: 1368 Spalding Rd Ste C
City and State: Dunedin, FL
Phone: 727-733-5558
Dated at 1368 Spalding Road, Dunedin, FL 34698
Zip Code 34698
Email Address: estimating@bandesconstruction.com
, this 15th day of October
, A.D., 20 5 .
SECTION V Page 12 of 16 Updated: 6/3/2024
October 14, 2025
Mr. Zachary Bandes
Bandes Construction Company, Inc.
1368 Spalding Road, Suite C
Dunedin, FL 34698
M.E. WILSON
RISK MANAGEMENT • INSURANCE
BENEFITS • BONDS
Re: Bid Bond to City of Clearwater, Florida
North Greenwood Aquatic Center Renovation
Estimate: $4,000,000.00
Bid No. 25 -0020 -PR
Bid Date: October 15, 2025
Dear Robert:
Enclosed you will find the bid bond you requested, which we have executed based on the information you provided.
Be sure to affix the bond with the proper signature and seal prior to presenting the bid bond to the owner.
Should your bid amount exceed the original estimate by 10% please contact us for additional surety authorization.
Please provide bid results as soon as they are available.
Please review all bond documents and any attachments and notify us if any changes are needed.
Thank you.
Sincerely,
Anthony T. Papa, Jr.
Senior Vice President
ATP/ep
Enclosure Bid Results:
Please provide names and bid amounts of the three lowest bidders:
1. $
2. $
3. $
Your bid amount, if not among the top three: $
In the interest of time, we are sending this bid bond to you without the surety's authorization. Please be
advised that you may not release this bid bond to the owner until we have advised you that you have the
e
surety's authorization to do so.
7264 Kyle Court I Sarasota, FL 34240
Voice: 941.999.1900 I Fax: 941.306.2002 I mewilson.com Knowledge is the Best Insurance.
SECTION V — Contract Documents
CITY OF CLEARWATER
ADDENDUM SHEET
PROJECT: North Greenwood Aquatic Center Renovation
Acknowledgment is hereby made of the following addenda received since issuance of Plans and
Specifications.
Addendum No. 1 Date: 9/12/25
Addendum No. 2
Addendum No. 3
Addendum No. 4
Addendum No.
Addendum No.
Addendum No.
Addendum No.
Addendum No.
Addendum No.
Addendum No.
Date: 9/17/25
Date: 9/19/25
Date: 9/29/25
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Zachary Bandes
(Name of Bidder)
(Signature of Officer)
Vice President
(Title of Officer)
10/15/25
(Date)
SECTION V Page 13 of 16 Updated: 6/3/2024
SECTION V — Contract Documents
BIDDER'S PROPOSAL
PROJECT: North Greenwood Aquatic Center Renovation (25 -0020 -PR)
CONTRACTOR:
BIDDER'S GRAND TOTAL: $ (Numbers)
BIDDER'S GRAND TOTAL:
(Words)
ITEM No.
DESCRIPTION
UNIT
QTY
UNIT
PRICE
TOTAL
Lap Pool, Activity Pool, Plunge Pool, Equipment,
Hardscape
1:0
Mobilization -and Site, Preparation °
1.1
Maintenance of Traffic
LS
1
$ -
$ -
1.2
Mobilization
LS
1
$ -
$ -
1.3
Demolition
LS
1
$ -
$ -
1.4
Erosion and Sediment Control
LF
600
$ -
$ -
1.5
Sprinklers (Yard Frontage) (Allowance
LS
1
$ -
$ -
1.6
Sod - St. Augustine (if needed) (1,000 s.f.
Allowance)
SF
1,000
$ -
$ -
1.7
Sod - Bahia (if needed) (1,000 s.f. Allowance)
SF
1,000
$ -
$ -
1.8
Project Sign (fixed) (Per City of Clearwater
Template)
LS
1
$ -
$ -
1.9
Fence Removal & Storage
LS
1
$ -
$ -
1.10
Pool Deck Removal & Disposal
SF
13,235
$ -
$ -
1.11
Tree/Palm Removal & Disposal
LS
1
$ -
$ -
1.12
Dumpster Rental & Disposal (Must be obtained from
City of Clearwater Waste Management Dept., No
Outside Vendors)
EA
1
$ -
$ -
2.0
Hardscape
2.1
New Concrete Pool Deck
SF
13,235
$ -
$ -
2.2
Pool Deck Salt Rock Finish- Material Only
SF
13,235
$ -
$ -
2.3
Pool Deck Salt Rock Finish- Labor Only
LS
1
$ -
$ -
2.4
Drain Grates- Material Only
EA
4
$ -
$ -
2.5
Drain Structure- Existing Elevation Change- Labor
EA
1
$ -
$ -
2.6
Drain Structure -New
EA
3
$ -
$ -
2.7
Deck Drain Piping -New
LF
127
$ -
$ -
2.8
Shower Towers -New
EA
2
$ -
$ -
Pool Equipment
3.0
Lap Pool.
SECTION V
Page 15 of 20
Updated: 7/9/2025
SECTION V - Contract Documents
3.1
Poltank 42" Horizontal Sand Filter, Fluidra- Model
#4260-100-E w/ Activated Glass Media
EA
2
$ -
$ -
3.2
BecSys5 Chemical Controller GBIT Ethernet VFD
CP -1 Ready, 1 BecSys Backplate Vertical Mount
EA
1
$ -
$ -
3.3
10" Butterfly Valves
EA
2
$ -
$ -
3.4
Pulsar Precision Chlorinator System- CES Model
#BM 73250
EA
1
$ -
$ -
3.5
Framing/Support System over Existing Concrete
Vault/Tanks to Support New Filters
LS
1
$ -
$ -
3.6
Widen Existing Single Access Door to Equipment
Room into Double Door w/ Louvers (Required to fit
new Filters in Room)
LS
1
$ -
$ -
3.7
SR Smith 'Pal -2' Mobile ADA Lift
EA
1
$ -
$ -
3.8
Aladdin 'Skamp' Mobile Pool Vacuum
EA
1
$ -
$ -
3.9
900 Gallon Vertical Backwash Tank by Chemical
Containers, Inc.
EA
1
$ -
$ -
3.10
Float New Concrete Floor in Collector Tank for
Positive Drainage to Floor Drain
EA
1
$ -
$ -
3.11
Removal/Storage/Reinstall Existing Diving Board
EA
1
$ -
$ -
4.0
Activity Pool
4.1
Poltank 42" Horizontal Sand Filter, Fluidra- Model
#4260-100-E w/ Activated Glass Media
EA
2
$ -
$ -
4.2
BecSys5 Chemical Controller GBIT Ethernet VFD
CP -1 Ready, 1 BecSys Backplate Vertical Mount
EA
1
$ -
$ -
4.3
7.5 HP Yaskawa P7, VFD, 31 amps- Yaskawa Model
#CIMR-P7U27P51, Drive Model #CIMR-
P7U27P51A
EA
2
$ -
$ -
4.4
Pulsar Precision Chlorinator System- CES Model
#BM 73250
EA
1
$ -
$ -
4.5
10" Butterfly Valves
EA
2
$ -
$ -
4.6
SR Smith 'Pal -2' Mobile ADA Lift
EA
1
$ -
$ -
4.7
Aladdin 'Skamp' Mobile Pool Vacuum
EA
1
$ -
$ -
Pool Materials
°5
Lap Pool Materials `
5.1
Lap Pool Drain, Dewatering
LS
1
$ -
$ -
5.2
Water Blasting- Entire Pool Shell
LS
1
$ -
$ -
5.3
Tork-Lock Staple Repair & Expansion Joint Repair
LS
1
$ -
$ -
5.4
Flowable Fill- Under Pool Shell Expansion Joint
Area to Fill Void
LS
1
$ -
$ -
5.5
Hydrazzo Interior Finish w/ Required Prep -Work &
Waterproofing
SF
7,486
$ -
$ -
5.6
Gutter Fittings (2.5" x 6"), Hayward SP-1019/SCP-
Hay -25-1500
EA
36
$ -
$ -
5.7
Floor Return Inlets, Hayward SP-1019/SCP-Hay25-
1501
EA
40
$ -
$ -
5.8
12"x12" Main Drain Frame & Grate (365 GPM
Capacity at 1.5 Ft/S)- Lawson #MLD SG -1212
EA
2
$ -
$ -
5.9
18"x18" Main Drain Frame & Grate (816 GPM
Capacity at 1.5 Ft/S)- Lawson #MLD SG -1818
EA
2
$ -
$ -
5.10
New Waterline Tile
LF
380
$ -
$ -
5.11
New Gutter Cap Tile
LF
376
$ -
$ -
5.12
New Step Cap Tile 'Non Skid'
LF
100
$ -
$ -
5.13
New Lap Lane Tile
LF
355
$ -
$ -
SECTION V
Page 16 of 20
Updated: 7/9/2025
SECTION V - Contract Documents
5.14
New Depth Marker Tile w/ No Diving
EA
19
$ -
$ -
5.15
Remove & Replace Poured Concrete Coping (2'-0"
wide X 3" Thick)
LF
388
$ -
$ -
5.16
Replace Pool Lights w/ Blanco LED
EA
8
$ -
$ -
5.17
Saw Cut & Install New 8" Backwash Line w/
Connection to Storm Drain on Pool Deck
LS
1
$ -
$ -
6 ` .
Activity Pool Materials
6.1
Activity Pool Drain & Dewatering
LS
1
$ -
$ -
6.2
Water Blasting- Entire Pool Shell
LS
1
$ -
$ -
6.3
Hydrazzo Interior Finish w/ Required Prep -Work &
Waterproofing
SF
2,346
$ -
$ -
6.4
Remove Existing Zero Entry Concrete where
cracking exisits & Re -Pour w/ Brushed finish to
Meet ADA Requirements
SF
310
$ -
$ -
6.5
Gutter Fittings (2.5" x 6"), Hayward SP-1019/SCP-
Hay -25-1500
EA
21
$ -
$ -
6.6
Floor Return Inlets, Hayward SP-1019/SCP-Hay25-
1501
EA
41
$ -
$ -
6.7
12"x12" Main Drain Frame & Grate (365 GPM
Capacity at 1.5 Ft/S)- Lawson #MLD SG -1212
EA
2
$ -
$ -
6.8
18"x18" Main Drain Frame & Grate (816 GPM
Capacity at 1.5 Ft/S)- Lawson #MLD SG -1818
EA
2
$ -
$ -
6.9
New Waterline Tile
LF
178
$ -
$ -
6.10
New Gutter Cap Tile
LF
160
$ -
$ -
6.11
New Step Cap Tile 'Non Skid'
LF
154
$ -
$ -
6.12
New Depth Marker Tile w/ No Diving
EA
11
$ -
$ -
6.13
Remove & Replace Poured Concrete Coping (2'-0"
wide X 3" Thick)
LF
310
$ -
$ -
6.14
Replace Pool Lights w/ Blanco LED
EA
4
$ -
$ -
6.15
Play Feature Restoration Gel Coat (Safe Slide or City
approved equal)
LS
1
$ -
$ -
6.16
Run New 1 1/2" Spray Jets Line back to New Valve
Box & New Line back to equipment Pack
LS
1
$ -
$ -
7
Plunge. Pool: Materials
7.1
Plunge Pool Drain & Dewatering
LS
1
$ -
$ -
7.2
Water Blasting- Entire Pool Shell
LS
1
$ -
$ -
7.3
Hydrazzo Interior Finish w/ Required Prep -Work &
Waterproofing
SF
594
$ -
$ -
7.4
New Fittings & Main Drain Covers
LS
1
$ -
$ -
7.5
New Waterline Tile
LF
79
$ -
$ -
7.6
New Step Cap Tile 'Non Skid'
LF
30
$ -
$ -
7.7
New Depth Marker Tile w/ No Diving
EA
4
$ -
$ -
7.8
Remove & Replace Poured Concrete Coping (2'-0"
wide X 3" Thick)
LF
94
$ -
$ -
7.9
Replace Pool Lights w/ Blanco LED
EA
2
$ -
$ -
7.10
Slide Tower Sand Blast & Painting
LS
1
$ -
$ -
7.11
Slide Restoration Gel Coat (Safe Slide or City
approved equal)
LS
1
$ -
$ -
8
Add Alternates
8.1
Remove Existing Concrete Planter, Soil, and Debris
LS
1
$ -
$ -
8.2
New Concrete Pool Decking (In Removed Planter
Area) to Match Adjacent Pool Decking
SF
946
$ -
$ -
8.3
Pool Deck Rock Salt Finish- Material Only
SF
946
$ -
$ -
SECTION V
Page 17 of 20
Updated: 7/9/2025
SECTION V — Contract Documents
8.4
Pool Deck Rock Salt Finish- Labor Only
LS
1
$ -
$ -
8.5
Re -install Fencing on New Pool Decking
LS
1
$ -
$ -
8.6
Activity Pool Water Feature (Complete Removal and
Replacement w/ New Feature)
LS
1
$ -
$ -
8.7
Lap Pool (Complete Removal and Replacement of
Diving Board w/ New Diving Board)
LS
1
$ -
$ -
8.8
Lap Pool (Metal restoration of Existing Diving Board
Frame & Platform)
LS
1
$ -
$ -
8.9
Install New 6' High Black Aluminum Fencing to
replace white PVC vinyl Fencing in Planter
LS
1
$ -
$ -
8.10
Install New Pool Safety/Pool Rules Signage for Lap
Pool, Activity Pool & Plunge Pool
LS
1
$ -
$ -
SUBTOTAL
$ -
TOTAL CONTINGENCY 10%
LS
1
$ -
TOTAL CONTRACT
$ -
Bid Grand Total
$ -
THE BIDDER'S GRAND TOTAL ABOVE IS HIS TOTAL BID BASED ON HIS UNIT PRICES
AND LUMP SUM PRICES AND THE ESTIMATED QUANTITIES REQUIRED FOR EACH
SECTION. THIS FIGURE IS FOR INFORMATION ONLY AT THE TIME OF OPENING BIDS.
THE CITY WILL MAKE THE TABULATION FROM THE UNIT PRICES AND LUMP SUM
PRICE BID. IF THERE IS AN ERROR IN THE TOTAL BY THE BIDDER, IT SHALL BE
CHANGED AS ONLY THE UNIT PRICES AND LUMP SUM PRICE SHALL GOVERN.
THE CONTRACTOR SHALL PROVIDE COPIES OF A CURRENT CONTRACTOR
LICENSE/REGISTRATION WITH THE STATE OF FLORIDA AND PINELLAS COUNTY IN
THE BID RESPONSE.
SECTION V Page 18 of 20 Updated: 7/9/2025
PRICE TABLES
North Greenwood Recreation and Aquatic Center Renovations and Improvements
Line Item Description Quantity Unit of Measure Unit Cost Total
Lap PooActivity Pool, Plunge Pool, EquipmentHardscape
1.0 Mobilization and Site Preparation
1.1
Maintenance of Traffic 1 LS
$20,00080 $20,000.00
1.2 Mobilization 1 LS $452,000l0 $452,000.00
1.3 Demolition 1 LS $08,000l0 $88000.00
1.4 Erosion and Sediment 600 LF $5.00 $3,000.00
Control
1.5 Sprinklers (Yard Frontage) 1 LS $5,000.00 $5,000.00
1.6 Sod - St. Augustine (if 1000 SF $2.00 $2,000.0O
needed)(1,000 SF
ALLOWANCE)
1.7 Sod ' Bahia (if needed) 1000 SF $1l0 $1,000.00
(1,000 SF ALLOWANCE)
1.8 Project Sign (fixed) (Per 1 LS $2,000.00 $2,000.00
City of Clearwater
Template)
1.9 Fence Removal & Storage 1 LS $2,000.00 $2,000.00
1.10 Pool Deck Removal & 13.235 SF $3.00 $39706
Disposal
1.11 Tree/Palm Removal {1 1 LS $3,000.00 $3'000.00
Disposal
1.12 Dumpster Rent |&
Disposal (Must be
obtained from City of
Clearwater Waste
Managemerit Dept., No
Outside Vendors)
2.0 Hardscape
1 EA
$5,000.00 $5,000.00
2.1 New ConcretPool Deck 1]2]5 SF $10.00 $132350.00
--'---- - - ' — --------- - - —'- ---'---- '
2.2 Pool Deck Light Broom 13235 SF $1.00 $1323580
Finish- Material OnIy
2.3 Pool Deck Light Broom 1 LS $13,000.00 $13,000.00
Finish- Labor OnIy
Z4 Drain Grates- Material 4 EA $5,000.00 $20,000D0
Only
2.5 Dram Structure- Existing 1 EA $4,000.00 $4,000.00
Elevation Change- Labor
2.6 Drain Structure -New 3 EA
2.7 Deck Drain Piping -New 127 LF
2.8 Shower Towers -New 2 EA
3.0 Lap Pool
3.1 Poltank 42" Horizontal
Sand Filter, Fluidra- Model
#4260-100-E w/ Activated
Glass Media
3.2 BecSyss Chemical
Controller GBIT Ethernet
VFD CP -1 Ready, 1 BecSys
Backplate Vertical Mount
3.3 10" Butterfly Valves
3.4 Pulsar Precision
Chlorinator System- CES
Model #BM 73250
3.5 Framing/Support System
over Existing Concrete
Vault/Tanks to Support
New Filters
3.6 Widen Existing Single
Access door to Equipment
Room into Double Door
w/ Louvers (Required to fit
new Filters in Room)
3.7
SR Smith 'Pal -2' Mobile
ADA Lift
3.8 Aladdin 'Skamp' Mobile
Pool Vacuum
3.9 900 Gallon Vertical
Backwash Tank by
Chemical Containers, Inc.
3.10 Float New Concrete Floor
in Collector Tank for
Positive Drainage to Floor
Drain
2 EA
1 EA
2 EA
1 EA
1 LS
1 LS
$5,000.00
$100.00
$15,000.00
$12,700.00
$9,262.50 $18,525.00
$46,962.50 $93,925.00
$10,400.00 $10,400.00
$2,600.00 $5,200.00
$8,255.00 $8,255.00
$28,600.00 $28,600.00
$10,000.00 $10,000.00
1 EA $13,000.00 $13,000.00
1 EA $4,550.00 $4,550.00
1 EA $3,250.00 $3,250.00
1 EA ..... __ _ $1,950.00 $1,950.00
3.11 Removal/Storage/Reinstall 1 EA
Existing Diving Board
4.0 Activity Pool
4.1 Poltank 42" Horizontal
Sand Filter, Fluidra- Model
#4260-100-E w/ Activated
Glass Media
4.2 BecSys5 Chemical
Controller GBIT Ethernet
VFD CP -1 Ready, 1 BecSys
Backplate Vertical Mount
2 EA
1 EA
$1,950.00
$46,962.50
$1,950.00
$93,925.00
$10,400.00 $10,400.00
4.3 7.5 HP Yaskawa P7, VFD,
31 amps- Yaskawa Model
#CIMR-P7U27P51, Drive
Model #CIMR-P7U27P51A
4.4 Pulsar Precision
Chlorinator System- CES
Model #BM 73250
4.5 10" Butterfly Valves
4.6 SR Smith 'Pal -2' Mobile
ADA Lift
4.7 Aladdin 'Skamp' Mobile
Pool Vacuum
Pool Materials
5.0 Lap Pool Materials
5.1 Lap Pool Drain,
Dewatering
5.2 Water Blasting- Entire
Pool Shell
5.3 Tork-Lock Staple Repair &
Expansion Joint Repair
5.4 Flowable Fill- Under Pool
Shell Expansion Joint Area
to Fill Void
2 EA
1 EA
2 EA
1 EA
1 EA
1 LS
1 LS
1 LS
1 LS
5.5 Hydrazzo Interior Finish 7486 SF
w/ Required Prep -Work &
Waterproofing
36 EA
5.6 Gutter Fittings (2.5" x 6"),
Hayward SP-1019/SCP-
Hay-25-1500
5.7 Floor Return Inlets,
Hayward SP-1019/SCP-
Hay25-1501
40 EA
5.8 12"x12" Main Drain Frame 2 EA
& Grate (365 GPM
Capacity at 1.5 Ft/S)-
Lawson #MLD SG -1212
5.9 18"x18" Main Drain Frame
& Grate (816 GPM
Capacity at 1.5 Ft/S)-
Lawson #MLD SG -1818
2 EA
$9,880.00 $19,760.00
$8,255.00
$8,255.00
$2,600.00 $5,200.00
$13,000.00
$4,550.00
$13,000.00
$4,550.00
$104,000.00
$23,249.20
$3,250.00
$7,150.00
$7.80
$32.50
$32.50
$325.00
$104,000.00
$23,249.20
$3,250.00
$7,150.00
$58,390.80
$1,170.00
$1,300.00
$650.00
$ 585.00 $1,170.00
5.10 New Waterline Tile 380 LF $26.00 $9,880.00
5.11 New Gutter Cap Tile 376 LF $26.00 $9,776.00
5.12 New Step Cap
Tile 'Non 100 LF $26.00 $2,600.00
Skid'
5.13 New Lap Lane Tile 355 LF $26.00 $9,230.00
5.14 New Depth Marker Tile w/ 19 EA $390.00 $7,410.00
No Diving
5.15 Remove & Replace Poured
Concrete Coping (2'-0"
wide X 3" Thick)
5.16 Replace Pool Lights w/
Blanco LED
5.17 Saw Cut & Install New 8"
Backwash Line w/
Connection to Storm
Drain on Pool Deck
6.0 Activity Pool Materials
6.1 Activity Pool Drain &
Dewatering
6.2 Water Blasting- Entire
Pool Shell
6.3 Hydrazzo Interior Finish
w/ Required Prep -Work &
Waterproofing
6.4 Remove Existing Zero
Entry Concrete where
cracking exisits & Re -Pour
w/ Brushed finish to Meet
ADA Requirements
6.5 Gutter Fittings (2.5" x 6"),
Hayward SP-1019/SCP-
Hay-25-1500
6.6 Floor Return Inlets,
Hayward SP-1019/SCP-
Hay25-1501
6.7 12"x12" Main Drain Frame
& Grate (365 GPM
Capacity at 1.5 Ft/S)-
Lawson #MLD SG -1212
6.8 18"x18" Main Drain Frame
& Grate (816 GPM
Capacity at 1.5 Ft/S)-
Lawson #MLD SG -1818
6.9
6.10
6.11
6.12
6.13
6.14
New Waterline Tile
New Gutter Cap Tile
New Step Cap Tile 'Non
Skid'
New Depth Marker Tile w/
No Diving
Remove & Replace Poured
Concrete Coping (2'-0"
wide X 3" Thick)
Replace Pool Lights w/
Blanco LED
6.15 Play Feature Restoration
Gel Coat (Safe Slide or
City approved equal)
388 LF
8 EA
1 LS
1 LS
1 LS
2346 SF
310 SF
21 EA
41 EA
2 EA
2 EA
178 LF
160 LF
154 LF
11 EA
310 LF
4 EA
1 LS
$ 50.00
$1,300.00
$3,900.00
$19,400.00
$10,400.00
$3,900.00
$650.00 $650.00
$13,000.00
$7.80
$20.00
$32.50
$32.50
$325.00
$13,000.00
$18,298.80
$6,200.00
$682.50
$1,332.50
$650.00
$585.00 $1,170.00
$26.00 $4,628.00
$26.00 $4,160.00
$26.00 $4,004.00
$390.00 $4,290.00
$ 50.00 $15,500.00
$1,300.00 $5,200.00
$35,614.80 $35,614.80
6.16 Run New 1 1/2" Spray Jets 1 LS $8,450.00 $8,450.00
Line back to New Valve
Box & New Line back to
equipment Pack
7.0 Plunge Pool Materials
7.1 Plunge Pool Drain & 1 LS $325.00 $325.00
Dewatering
7.2 Water Blasting- Entire
Pool Shell
1 LS
$9,750.00 $9,750.00
7.3 Hydrazzo Interior Finish 594 SF $19.50 $11,583.00
w/ Required Prep -Work &
Waterproofing
7.4 New Fittings & Main Drain 1 LS $975.00 $975.00
Covers
7.5 New Waterline Tile 79 LF $26.00 $2,054.00
7.6 New Step Cap Tile 'Non 30 LF $26.00 $780.00
Skid'
7.7 New Depth Marker Tile w/
No Diving
7.8 Remove & Replace Poured
Concrete Coping (2.-0"
wide X 3" Thick)
7.9 Replace Pool Lights w/
Blanco LED
4 EA $390.00
94 LF
2 EA
$1,560.00
$50.00 $4,700.00
$1,300.00 $2,600.00
7.10 Slide Tower Sand Blast & 1 LS $76,270.00 $76,270.00
Painting
7.11 Slide Restoration Gel Coat 1 LS $77,688.00 $77,688.00
(Safe Slide or City
approved equal)
8.0 Add Alternates
8.1 Remove Existing Concrete 1 LS $4,000.00 $4,000.00
Planter, Soil, and Debris
8.2 New Concrete Pool
Decking to Match
Adjacent Pool Decking
8.3 Pool Deck Stain- Material
Only
8.4 Pool Deck Stain- Labor
Only
8.5 Re -install Fencing on New
Pool Decking
8.6 Activity Pool Water
Feature (Complete
Removal and Replacement
w/ New Feature)
8.7 Lap Pool (Complete
Removal and Replacement
of Diving Board w/ New
Diving Board)
946 SF
946 SF
$10.00 $9,460.00
$5.00 $4,730.00
1 LS $5,000.00
1 LS
1 LS
$5,000.00
$3,000.00 $3,000.00
$238,283.50 $238,283.50
1 LS $36,400.00 $36,400.00
8.8
Contigency
Lap Pool (Metal 1 LS $6,500.0O $6,500.0O
restoration of Existing
Diving Board Frame &
Platform)
-- -- ` - ` - '- - - -- - -- ---- - - --- ----------- Install New Ne*R High Black 1 LS $21,0008O $21,000.00
Aluminum Fencing to
replace white PVC vinyl
Fencing in Planter
Install New Poo
Safety/Pool Rules Signage
for Lap Pool, Activity Pool
& Plunge Pool
Total
1 LS
�000.0O �000.00
$2,05,434.805
Line Item Description
Quantity Unit of Measure Unit CosTotal
1.0 10% OF TOTAL ABOVE
1 LS $206543.48 $206543.48
$206,543.48
SCRUTINIZED COMPANIES FORMS
SCRUTINIZED COMPANIES AND BUSINESS OPERATIONS WITH
CUBA AND SYRIA CERTIFICATION FORM
IF YOUR BID/PROPOSAL IS $1,000,000 OR MORE, THIS FORM MUST BE COMPLETED AND
SUBMITTED WITH THE BID/PROPOSAL. FAILURE TO SUBMIT THIS FORM AS REQUIRED MAY
DEEM YOUR SUBMITTAL NONRESPONSIVE.
The affiant, by virtue of the signature below, certifies that:
1. The vendor, company, individual, principal, subsidiary, affiliate, or owner is aware of the requirements
of section 287.135, Florida Statutes, regarding companies on the Scrutinized Companies with Activities in Sudan
List, the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or engaging in business
operations in Cuba and Syria; and
2. The vendor, company, individual, principal, subsidiary, affiliate, or owner is eligible to participate in this
solicitation and is not listed on either the Scrutinized Companies with Activities in Sudan List, the Scrutinized
Companies with Activities in the Iran Petroleum Sector List, or engaged in business operations in Cuba and
Syria; and
3. Business Operations means, for purposes specifically related to Cuba or Syria, engaging in commerce
in any form in Cuba or Syria, including, but not limited to, acquiring, developing, maintaining, owning, selling,
possessing, leasing or operating equipment, facilities, personnel, products, services, personal property, real
property, military equipment, or any other apparatus of business or commerce; and >` /.
4. If awarded the Contract (or Agreement), the vendor, company, individual, principal, subsidiary, affiliate,
or owner will immediately notify the City of Clearwater in writing, no later than five (5) calendar days,after any of
its principals are placed on the Scrutinized Companies with Activities in Sudan List, the Scrutinized Corripanies
with Activities in the Iran Petroleum Sector List, or engaged in business operations in Cuba and Syria.
STATE OF `cLO rfr i1
COUNTY OF � t v\Q,l caS'
Authorized Signature
Zachary Bandes
Printed Name
Vice President
Title
Bandes Construction Company, Inc.
Name of Entity/Corporation
The foregoing instrument was acknowledged before me by means of 14hy ical presence or 0 online
notarization on, this 15th day of October , 20 25 , by ztlt P)Q r.Cle 3 -
me
( me of perso whose si natur is being notarized) as the V; Le Ernes{dka-4- (tit1) of
Jaikole3 L-)NS}�or Cf)LIL)c i (name of corporation/entity), personally known ✓ or
produced 1 (typ� of identification) as identification, and who did/did not take
an oath.
My Commission Expires:
NOTARY SEAL ABOVE
Z -202-8
i 4', J.,:tka..-,y
Nota p_ul, �Gti���'
J O
Printed Name
Sheyla Santiago
Commission # HH 592809
Commission Expires 09-12.2028
Bonded Through - Cynanotary
Florida - Notary Public
SCRUTINIZED COMPANIES FORMS
SCRUTINIZED COMPANIES THAT BOYCOTT ISRAEL LIST CERTIFICATION FORM
THIS FORM MUST BE COMPLETED AND SUBMITTED WITH THE BID/PROPOSAL.
FAILURE TO SUBMIT THIS FORM AS REQUIRED MAY DEEM YOUR SUBMITTAL
NONRESPONSIVE.
The affiant, by virtue of the signature below, certifies that:
1. The vendor, company, individual, principal, subsidiary, affiliate, or owner is aware of the requirements
of section 287.135, Florida Statutes, regarding companies on the Scrutinized Companies that Boycott
Israel List, or engaged in a boycott of Israel; and
2. The vendor, company, individual, principal, subsidiary, affiliate, or owner is eligible to participate in this
solicitation and is not listed on the Scrutinized Companies that Boycott Israel List, or engaged in a
boycott of Israel; and
3. "Boycott Israel" or "boycott of Israel" means refusing to deal, terminating business activities, or taking
other actions to limit commercial relations with Israel, or persons or entities doing business in Israel or
in Israeli -controlled territories, in a discriminatory manner. A statement by a company that it is
participating in a boycott of Israel, or that it has initiated a boycott in response to a request for a boycott
of Israel or in compliance with, or in furtherance of, calls for a boycott of Israel, may be considered as
evidence that a company is participating in a boycott of Israel; and . ,>
4. If awarded the Contract (or Agreement), the vendor, company, individual, principal, subsidiaryaffiliate �%2
or owner will immediately notify the City of Clearwater in writing, no later than five (5) c dar'days7.'. 2,
after any of its principals are placed on the Scrutinized Companies that Boycott Israel L' isteor engaged.:
in a boycott of Israel.
STATE OF-0bricla.
COUNTY OF 51.t vie
Authorized Signature
Zachary Bandes
Printed Name
Vice President
Title
Bandes Construction Company, Inc.
Name of Entity/Corporation
The foregoing instrument was acknowledged before me by means of Ehysical presence or ❑ online
notarization on, this 15th day of October 20 25 by 7 a r k i ry A noleS
name of person whose sis-�nature -is being notarized) as the V i (' e. (rc.Jti df'?ar (title) o
:.! • ��
. l (hn
CSkr &c -k cup �no►P�� (name of corporation/entity), personally known r
produced (typ� of identification) as identification, and who did/did not take
an oath.
My Commission Expires: — l2 -- 2.02.13.
NOTARY SEAL ABOVE
LPOt
Nota ublic 0 (� I1U
•2 t3\ Q cJ (� 'h Q
Printed Name
Sheyla Santiago
C809
Commission Expires 9mission # 9 2 2028
Bonded Through - Cynanotary
Florida - Notary Public
Compliance with Anti -Human Trafficking Laws
Pursuant to Section 787.06 (13), Florida Statutes, this form must be completed by an officer or
representative of a non-governmental entity when a contract is executed, renewed, or extended
between the non-governmental entity and the City of Clearwater.
The undersigned, on behalf of the entity listed below ("Entity"), hereby attests under penalty of
perjury that:
Entity does not use coercion for labor or services as defined in Section 787.06, Florida"Statutes.';=;'.
The undersigned is authorized to execute this form on behalf of Entity.
Date: October 15th , 20 25 Signed:
Entity: Bandes Construction Company, Inc. Name: Zachary Bandes
Title: Vice President
Form VJ
-9
(Rev. March 2024)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Go to www.irs.gov/FormW9 for instructions and the latest information.
Give form to the
requester. Do not
send to the IRS.
Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.
Print or type.
See Specific Instructions on page 3.
1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner's name on line 1, and enter the business/disregarded
entity's name on line 2.)
Bandes Construction Company, Inc.
2 Business name/disregarded entity name, if different from above.
3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check
only one of the following seven boxes.
4 Exemptions (codes apply only to
certain entities, not individuals;
see instructions on page 3):
Exempt payee code (if any)
1 Individual/sole proprietor 1 C corporation [X S corporation 1 Partnership
1 Trust/estate
. .
1 LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) . .
Note: Check the "LLC" box above and, in the entry space, enter the appropriate code (C, S, or P)
classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check
box for the tax classification of its owner.
for the tax
the appropriate
Exemption from Foreign Account Tax
Compliance Act (FATCA) reporting
code (if any)
1 Other (see instructions)
3b If on line 3a you checked "Partnership" or "Trust/estate," or checked "LLC" and entered "P" as its tax
and you are providing this form to a partnership, trust, or estate in which you have an ownership interest,
this box if you have any foreign partners, owners, or beneficiaries. See instructions
classification,
check
(Applies lies to accounts maintained
outside the United States)
1
5 Address (number, street, and apt. or suite no.). See instructions.
1368 Spalding Road, Suite C
Requester's name and address (optional)
6 City, state, and ZIP code
Dunedin, Florida 34698
7 List account number(s) here (optional)
Part 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
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.
Note: If the account is in more than one name, see the instructions for line 1. See also What Name and
Number To Give the Requester for guidelines on whose number to enter.
Social security number
or
Employer identification number
5
9
2
8
1
7
6
8
4
Part II
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. I 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. I 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; y. ware- equired to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign Signature of
Here U.S. person
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
What's New
Line 3a has been modified to clarify how a disregarded entity completes
this line. An LLC that is a disregarded entity should check the
appropriate box for the tax classification of its owner. Otherwise, it
should check the "LLC" box and enter its appropriate tax classification.
Date
01/06/2025
New line 3b has been added to this form. A flow-through entity is
required to complete this line to indicate that it has direct or indirect
foreign partners, owners, or beneficiaries when it provides the Form W-9
to another flow-through entity in which it has an ownership interest. This
change is intended to provide a flow-through entity with information
regarding the status of its indirect foreign partners, owners, or
beneficiaries, so that it can satisfy any applicable reporting
requirements. For example, a partnership that has any indirect foreign
partners may be required to complete Schedules K-2 and K-3. See the
Partnership Instructions for Schedules K-2 and K-3 (Form 1065).
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS is giving you this form because they
Cat. No. 10231X
Form W-9 (Rev. 3-2024)
Form W-9 (Rev. 3-2024) Page 2
must obtain your correct taxpayer identification number (TIN), which
may be your social security number (SSN), individual taxpayer
identification number (ITIN), adoption taxpayer identification number
(ATIN), or employer identification number (EIN), to report on an
information retum the amount paid to you, or other amount reportable
on an information retum. Examples of information returns include, but
are not limited to, the following.
• Form 1099 -INT (interest earned or paid).
• Form 1099 -DIV (dividends, including those from stocks or mutual
funds).
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds).
• Form 1099 -NEC (nonemployee compensation).
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers).
• Form 1099-S (proceeds from real estate transactions).
• Form 1099-K (merchant card and third -party network transactions).
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
and 1098-T (tuition).
• Form 1099-C (canceled debt).
• Form 1099-A (acquisition or abandonment of secured property).
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
Caution: If you don't return Form W-9 to the requester with a TIN, you
might be subject to backup withholding. See What is backup
withholding, later.
By signing the filled -out form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued);
2. Certify that you are not subject to backup withholding; or
3. Claim exemption from backup withholding if you are a U.S. exempt
payee; and
4. Certify to your non -foreign status for purposes of withholding under
chapter 3 or 4 of the Code (if applicable); and
5. Certify that FATCA code(s) entered on this form (if any) indicating
that you are exempt from the FATCA reporting is correct. See What Is
FATCA Reporting, later, for further information.
Note: If you are a U.S. person and a requester gives you a form other
than Form W-9 to request your TIN, you must use the requester's form if
it is substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien;
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States;
• An estate (other than a foreign estate); or
• A domestic trust (as defined in Regulations section 301.7701-7).
Establishing U.S. status for purposes of chapter 3 and chapter 4
withholding. Payments made to foreign persons, including certain
distributions, allocations of income, or transfers of sales proceeds, may
be subject to withholding under chapter 3 or chapter 4 of the Code
(sections 1441-1474). Under those rules, if a Form W-9 or other
certification of non -foreign status has not been received, a withholding
agent, transferee, or partnership (payor) generally applies presumption
rules that may require the payor to withhold applicable tax from the
recipient, owner, transferor, or partner (payee). See Pub. 515,
Withholding of Tax on Nonresident Aliens and Foreign Entities.
The following persons must provide Form W-9 to the payor for
purposes of establishing its non -foreign status.
• In the case of a disregarded entity with a U.S. owner, the U.S. owner
of the disregarded entity and not the disregarded entity.
• In the case of a grantor trust with a U.S. grantor or other U.S. owner,
generally, the U.S. grantor or other U.S. owner of the grantor trust and
not the grantor trust.
• In the case of a U.S. trust (other than a grantor trust), the U.S. trust
and not the beneficiaries of the trust.
See Pub. 515 for more information on providing a Form W-9 or a
certification of non -foreign status to avoid withholding.
Foreign person. If you are a foreign person or the U.S. branch of a
foreign bank that has elected to be treated as a U.S. person (under
Regulations section 1.1441-1(b)(2)(iv) or other applicable section for
chapter 3 or 4 purposes), do not use Form W-9. Instead, use the
appropriate Form W-8 or Form 8233 (see Pub. 515). If you are a
qualified foreign pension fund under Regulations section 1.897(I) -1(d), or
a partnership that is wholly owned by qualified foreign pension funds,
that is treated as a non -foreign person for purposes of section 1445
withholding, do not use Form W-9. Instead, use Form W-8EXP (or other
certification of non -foreign status).
Nonresident alien who becomes a resident alien. Generally, only a
nonresident alien individual may use the terms of a tax treaty to reduce
or eliminate U.S. tax on certain types of income. However, most tax
treaties contain a provision known as a saving clause. Exceptions
specified in the saving clause may permit an exemption from tax to
continue for certain types of income even after the payee has otherwise
become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an exemption
from U.S. tax on certain types of income, you must attach a statement
to Form W-9 that specifies the following five items.
1. The treaty country. Generally, this must be the same treaty under
which you claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the
saving clause and its exceptions.
4. The type and amount of income that qualifies for the exemption
from tax.
5. Sufficient facts to justify the exemption from tax under the terms of
the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an
exemption from tax for scholarship income received by a Chinese
student temporarily present in the United States. Under U.S. law, this
student will become a resident alien for tax purposes if their stay in the
United States exceeds 5 calendar years. However, paragraph 2 of the
first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the
provisions of Article 20 to continue to apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of the first
Protocol) and is relying on this exception to claim an exemption from tax
on their scholarship or fellowship income would attach to Form W-9 a
statement that includes the information described above to support that
exemption.
If you are a nonresident alien or a foreign entity, give the requester the
appropriate completed Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons making certain payments to you
must under certain conditions withhold and pay to the IRS 24% of such
payments. This is called "backup withholding." Payments that may be
subject to backup withholding include, but are not limited to, interest,
tax-exempt interest, dividends, broker and barter exchange
transactions, rents, royalties, nonemployee pay, payments made in
settlement of payment card and third -party network transactions, and
certain payments from fishing boat operators. Real estate transactions
are not subject to backup withholding.
You will not be subject to backup withholding on payments you receive
if you give the requester your correct TIN, make the proper certifications,
and report all your taxable interest and dividends on your tax return.
Payments you receive will be subject to backup withholding if:
1. You do not furnish your TIN to the requester;
2. You do not certify your TIN when required (see the instructions for
Part II for details);
3. The IRS tells the requester that you fumished an incorrect TIN;
4. The IRS tells you that you are subject to backup withholding
because you did not report all your interest and dividends on your tax
return (for reportable interest and dividends only); or
5. You do not certify to the requester that you are not subject to
backup withholding, as described in item 4 under "By signing the filled -
out form" above (for reportable interest and dividend accounts opened
after 1983 only).
Form W-9 (Rev. 3-2024) Page 3
Certain payees and payments are exempt from backup withholding.
See Exempt payee code, later, and the separate Instructions for the
Requester of Form W-9 for more information.
See also Establishing U.S. status for purposes of chapter 3 and
chapter 4 withholding, earlier.
What Is FATCA Reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a
participating foreign financial institution to report all U.S. account
holders that are specified U.S. persons. Certain payees are exempt from
FATCA reporting. See Exemption from FATCA reporting code, later, and
the Instructions for the Requester of Form W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you
claimed to be an exempt payee if you are no longer an exempt payee
and anticipate receiving reportable payments in the future from this
person. For example, you may need to provide updated information if
you are a C corporation that elects to be an S corporation, or if you are
no longer tax exempt. In addition, you must fumish a new Form W-9 if
the name or TIN changes for the account, for example, if the grantor of a
grantor trust dies.
Penalties
Failure to fumish TIN. If you fail to fumish your correct TIN to a
requester, you are subject to a penalty of $50 for each such failure
unless your failure is due to reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you
make a false statement with no reasonable basis that results in no
backup withholding, you are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal penalties
including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of
federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Line 1
You must enter one of the following on this line; do not leave this line
blank. The name should match the name on your tax return.
If this Form W-9 is for a joint account (other than an account
maintained by a foreign financial institution (FFI)), list first, and then
circle, the name of the person or entity whose number you entered in
Part I of Form W-9. If you are providing Form W-9 to an FFI to document
a joint account, each holder of the account that is a U.S. person must
provide a Form W-9.
• Individual. Generally, enter the name shown on your tax return. If you
have changed your last name without informing the Social Security
Administration (SSA) of the name change, enter your first name, the last
name as shown on your social security card, and your new last name.
Note for ITIN applicant: Enter your individual name as it was entered
on your Form W-7 application, line la. This should also be the same as
the name you entered on the Form 1040 you filed with your application.
• Sole proprietor. Enter your individual name as shown on your Form
1040 on line 1. Enter your business, trade, or "doing business as" (DBA)
name on line 2.
• Partnership, C corporation, S corporation, or LLC, other than a
disregarded entity. Enter the entity's name as shown on the entity's tax
return on line 1 and any business, trade, or DBA name on line 2.
• Other entities. Enter your name as shown on required U.S. federal tax
documents on line 1. This name should match the name shown on the
charter or other legal document creating the entity. Enter any business,
trade, or DBA name on line 2.
• Disregarded entity. In general, a business entity that has a single
owner, including an LLC, and is not a corporation, is disregarded as an
entity separate from its owner (a disregarded entity). See Regulations
section 301.7701-2(c)(2). A disregarded entity should check the
appropriate box for the tax classification of its owner. Enter the owner's
name on line 1. The name of the owner entered on line 1 should never
be a disregarded entity. The name on line 1 should be the 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 entity for U.S.
federal tax purposes has a single owner that is a U.S. person, the U.S.
owner's name is required to be provided on line 1. If the direct owner of
the entity is also a disregarded entity, enter the first owner that is not
disregarded for federal tax purposes. Enter the disregarded entity's
name on line 2. 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. This is the case even if the foreign person has a U.S. TIN.
Line 2
If you have a business name, trade name, DBA name, or disregarded
entity name, enter it on line 2.
Line 3a
Check the appropriate box on line 3a for the U.S. federal tax
classification of the person whose name is entered on line 1. Check only
one box on line 3a.
IF the entity/individual on line 1
is a(n) ...
THEN check the box for ...
• Corporation
Corporation.
• Individual or
• Sole proprietorship
Individual/sole proprietor.
• LLC classified as a partnership
for U.S. federal tax purposes or
• LLC that has filed Form 8832 or
2553 electing to be taxed as a
corporation
Limited liability company and
enter the appropriate tax
classification:
P = Partnership,
C = C corporation, or
S = S corporation.
• Partnership
Partnership.
• Trust/estate
Trust/estate.
Line 3b
Check this box if you are a partnership (including an LLC classified as a
partnership for U.S. federal tax purposes), trust, or estate that has any
foreign partners, owners, or beneficiaries, and you are providing this
form to a partnership, trust, or estate, in which you have an ownership
interest. You must check the box on line 3b if you receive a Form W-8
(or documentary evidence) from any partner, owner, or beneficiary
establishing foreign status or if you receive a Form W-9 from any
partner, owner, or beneficiary that has checked the box on line 3b.
Note: A partnership that provides a Form W-9 and checks box 3b may
be required to complete Schedules K-2 and K-3 (Form 1065). For more
information, see the Partnership Instructions for Schedules K-2 and K-3
(Form 1065).
If you are required to complete line 3b but fail to do so, you may not
receive the information necessary to file a correct information return with
the IRS or furnish a correct payee statement to your partners or
beneficiaries. See, for example, sections 6698, 6722, and 6724 for
penalties that may apply.
Line 4 Exemptions
If you are exempt from backup withholding and/or FATCA reporting,
enter in the appropriate space on line 4 any code(s) that may apply to
you.
Exempt payee code.
• Generally, individuals (including sole proprietors) are not exempt from
backup withholding.
• Except as provided below, corporations are exempt from backup
withholding for certain payments, including interest and dividends.
• Corporations are not exempt from backup withholding for payments
made in settlement of payment card or third -party network transactions.
• Corporations are not exempt from backup withholding with respect to
attorneys' fees or gross proceeds paid to attorneys, and corporations
that provide medical or health care services are not exempt with respect
to payments reportable on Form 1099-MISC.
The following codes identify payees that are exempt from backup
withholding. Enter the appropriate code in the space on line 4.
1—An organization exempt from tax under section 501(a), any IRA, or
a custodial account under section 403(b)(7) if the account satisfies the
requirements of section 401(f)(2).
Form W-9 (Rev. 3-2024)
Page 4
2—The United States or any of its agencies or instrumentalities.
3—A state, the District of Columbia, a U.S. commonwealth or territory,
or any of their political subdivisions or instrumentalities.
4—A foreign government or any of its political subdivisions, agencies,
or instrumentalities.
5—A corporation.
6—A dealer in securities or commodities required to register in the
United States, the District of Columbia, or a U.S. commonwealth or
territory.
7—A futures commission merchant registered with the Commodity
Futures Trading Commission.
8—A real estate investment trust.
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 as defined under section 581.
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.
The following chart shows types of payments that may be exempt
from backup withholding. The chart applies to the exempt payees listed
above, 1 through 13.
IF the payment is for ...
THEN the payment is exempt
for...
• Interest and dividend payments
All exempt payees except
for 7.
• Broker transactions
Exempt payees 1 through 4 and 6
through 11 and all C corporations.
S corporations must not enter an
exempt payee code because they
are exempt only for sales of
noncovered securities acquired
prior to 2012.
• Barter exchange transactions
and patronage dividends
Exempt payees 1 through 4.
• Payments over $600 required to
be reported and direct sales over
$5,0001
Generally, exempt payees
1 through 52
• Payments made in settlement of
payment card or third -party
network transactions
Exempt payees 1 through 4.
t See Form 1099-MISC, Miscellaneous Information, and its instructions.
2 However, the following payments made to a corporation and
reportable on Form 1099-MISC are not exempt from backup
withholding: medical and health care payments, attorneys' fees, gross
proceeds paid to an attorney reportable under section 6045(f), and
payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify
payees that are exempt from reporting under FATCA. These codes
apply to persons submitting this form for accounts maintained outside
of the United States by certain foreign financial institutions. Therefore, if
you are only submitting this form for an account you hold in the United
States, you may leave this field blank. Consult with the person
requesting this form if you are uncertain if the financial institution is
subject to these requirements. A requester may indicate that a code is
not required by providing you with a Form W-9 with "Not Applicable" (or
any similar indication) entered on the line for a FATCA exemption code.
A—An organization exempt from tax under section 501(a) or any
individual retirement plan as defined in section 7701(a)(37).
B—The United States or any of its agencies or instrumentalities.
C—A state, the District of Columbia, a U.S. commonwealth or
territory, or any of their political subdivisions or instrumentalities.
D—A corporation the stock of which is regularly traded on one or
more established securities markets, as described in Regulations
section 1.1472-1(c)(1)(i).
E—A corporation that is a member of the same expanded affiliated
group as a corporation described in Regulations section 1.1472-1(c)(1)(i).
F—A dealer in securities, commodities, or derivative financial
instruments (including notional principal contracts, futures, forwards,
and options) that is registered as such under the laws of the United
States or any state.
G—A real estate investment trust.
H—A regulated investment company as defined in section 851 or an
entity registered at all times during the tax year under the Investment
Company Act of 1940.
I—A common trust fund as defined in section 584(a).
J—A bank as defined in section 581.
K—A broker.
L—A trust exempt from tax under section 664 or described in section
4947(a)(1).
M—A tax-exempt trust under a section 403(b) plan or section 457(g)
plan.
Note: You may wish to consult with the financial institution requesting
this form to determine whether the FATCA code and/or exempt payee
code should be completed.
Line 5
Enter your address (number, street, and apartment or suite number).
This is where the requester of this Form W-9 will mail your information
returns. If this address differs from the one the requester already has on
file, enter "NEW" at the top. If a new address is provided, there is still a
chance the old address will be used until the payor changes your
address in their records.
Line 6
Enter your city, state, and ZIP code.
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. If you are a resident alien and
you do not have, and are not eligible to get, an SSN, your TIN is your
IRS ITIN. Enter it in the entry space for the Social security number. If you
do not have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may enter either
your SSN or EIN.
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
one). If the LLC is classified as a corporation or partnership, enter the
entity's EIN.
Note: See What Name and Number To Give the Requester, later, for
further clarification of name and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately.
To apply for an SSN, get Form SS -5, Application for a Social Security
Card, from your local SSA office or get this form online at
www.SSA.gov. You may also get this form by calling 800-772-1213. Use
Form W-7, Application for IRS Individual Taxpayer Identification
Number, to apply for an ITIN, or Form SS -4, Application for Employer
Identification Number, to apply for an EIN. You can apply for an EIN
online by accessing the IRS website at www.irs.gov/EIN. Go to
www.irs.gov/Forms to view, download, or print Form W-7 and/or Form
SS -4. Or, you can go to www.irs.gov/OrderForms to place an order and
have Form W-7 and/or Form SS -4 mailed to you within 15 business
days.
If you are asked to complete Form W-9 but do not have a TIN, apply
for a TIN and enter "Applied For" in the space for the TIN, sign and date
the form, and give it to the requester. For interest and dividend
payments, and certain payments made with respect to readily tradable
instruments, you will generally have 60 days to get a TIN and give it to
the requester before you are subject to backup withholding on
payments. The 60 -day rule does not apply to other types of payments.
You will be subject to backup withholding on all such payments until
you provide your TIN to the requester.
Note: Entering "Applied For" means that you have already applied for a
TIN or that you intend to apply for one soon. See also Establishing U.S.
status for purposes of chapter 3 and chapter 4 withholding, earlier, for
when you may instead be subject to withholding under chapter 3 or 4 of
the Code.
Caution: A disregarded U.S. entity that has a foreign owner must use
the appropriate Form W-8.
Form W-9 (Rev. 3-2024) Page 5
Part 11. Certification
To establish to the withholding agent that you are a U.S. person, or
resident alien, sign Form W-9. You may be requested to sign by the
withholding agent even if item 1, 4, or 5 below indicates otherwise.
For a joint account, only the person whose TIN is shown in Part I
should sign (when required). In the case of a disregarded entity, the
person identified on line 1 must sign. Exempt payees, see Exempt payee
code, earlier.
Signature requirements. Complete the certification as indicated in
items 1 through 5 below.
1. Interest, dividend, and barter exchange accounts opened
before 1984 and broker accounts considered active during 1983.
You must give your correct TIN, but you do not have to sign the
certification.
2. Interest, dividend, broker, and barter exchange accounts
opened after 1983 and broker accounts considered inactive during
1983. You must sign the certification or backup withholding will apply. If
you are subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2 in the
certification before signing the form.
3. Real estate transactions. You must sign the certification. You may
cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but you do not
have to sign the certification unless you have been notified that you
have previously given an incorrect TIN. "Other payments" include
payments made in the course of the requester's trade or business for
rents, royalties, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to
a nonemployee for services, payments made in settlement of payment
card and third -party network transactions, payments to certain fishing
boat crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified tuition program
payments (under section 529), ABLE accounts (under section 529A),
IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct
TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account: Give name and SSN of:
1. Individual
2. Two or more individuals (joint account)
other than an account maintained by
an FFI
3. Two or more U.S. persons
(joint account maintained by an FFI)
4. Custodial account of a minor
(Uniform Gift to Minors Act)
5. a. The usual revocable savings trust
(grantor is also trustee)
b. So-called trust account that is not
a legal or valid trust under state law
6. Sole proprietorship or disregarded
entity owned by an individual
7. Grantor trust filing under Optional
Filing Method 1 (see Regulations
section 1.671-4(b)(2)(i)(A))"
The individual
The actual owner of the account or,
if combined funds, the first individual
on the account,
Each holder of the account
The minor2
The grantor -trustee,
The actual owner'
The owner3
The grantor`
For this type of account:
8. Disregarded entity not owned by an
individual
9. A valid trust, estate, or pension trust
10. Corporation or LLC electing corporate
status on Form 8832 or Form 2553
11. Association, club, religious, charitable,
educational, or other tax-exempt
organization
12. Partnership or multi -member LLC
13. A broker or registered nominee
14. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or prison)
that receives agricultural program
payments
15. Grantor trust filing Form 1041 or
under the Optional Filing Method 2,
requiring Form 1099 (see Regulations
section 1.671-4(b)(2)(1)(B))**
Give name and EIN of:
The owner
Legal entity4
The corporation
The organization
The partnership
The broker or nominee
The public entity
The trust
'List first and circle the name of the person whose number you fumish.
If only one person on a joint account has an SSN, that person's number
must be fumished.
'Circle the minor's name and furnish the minor's SSN.
3You must show your individual name on line 1, and enter your business
or DBA name, if any, on line 2. You may use either your SSN or EIN (if
you have one), but the IRS encourages you to use your SSN.
4List first and circle the name of the trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the
legal entity itself is not designated in the account title.)
* Note: The grantor must also provide a Form W-9 to the trustee of the
trust.
"For more information on optional filing methods for grantor trusts, see
the Instructions for Form 1041.
Note: If no name is circled when more than one name is listed, the
number will be considered to be that of the first name listed.
Secure Your Tax Records From Identity Theft
Identity theft occurs when someone uses your personal information,
such as your name, SSN, or other identifying information, without your
permission to commit fraud or other crimes. An identity thief may use
your SSN to get a job or may file a tax return using your SSN to receive
a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax return preparer.
If your tax records are affected by identity theft and you receive a
notice from the IRS, respond right away to the name and phone number
printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you
think you are at risk due to a lost or stolen purse or wallet, questionable
credit card activity, or a questionable credit report, contact the IRS
Identity Theft Hotline at 800-908-4490 or submit Form 14039.
For more information, see Pub. 5027, Identity Theft Information for
Taxpayers.
Form W-9 (Rev. 3-2024) Page 6
Victims of identity theft who are experiencing economic harm or a
systemic problem, or are seeking help in resolving tax problems that
have not been resolved through normal channels, may be eligible for
Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
calling the TAS toll-free case intake Zine at 877-777-4778 or TTY/TDD
800-829-4059.
Protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of email and websites designed to
mimic legitimate business emails and websites. The most common act
is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
private information that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails. Also, the
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers, passwords, or similar secret access
information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishing@irs.gov. You may also report misuse
of the IRS name, logo, or other IRS property to the Treasury Inspector
General for Tax Administration (TIGTA) at 800-366-4484. You can
forward suspicious emails to the Federal Trade Commission at
spam@uce.gov or report them at www.ftc.gov/complaint. You can
contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338).
If you have been the victim of identity theft, see www.IdentityTheft.gov
and Pub. 5027.
Go to www.irs.gov/ldentityTheft to learn more about identity theft and
how to reduce your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your
correct TIN to persons (including federal agencies) who are required to
file information returns with the IRS to report interest, dividends, or
certain other income paid to you; mortgage interest you paid; the
acquisition or abandonment of secured property; the cancellation of
debt; or contributions you made to an IRA, Archer MSA, or HSA. The
person collecting this form uses the information on the form to file
information returns with the IRS, reporting the above information.
Routine uses of this information include giving it to the Department of
Justice for civil and criminal litigation and to cities, states, the District of
Columbia, and U.S. commonwealths and territories for use in
administering their laws. The information may also be disclosed to other
countries under a treaty, to federal and state agencies to enforce civil
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, payors must
generally withhold a percentage of taxable interest, dividends, and
certain other payments to a payee who does not give a TIN to the payor.
Certain penalties may also apply for providing false or fraudulent
information.