BAYCARE BALL PARK BERM WALL REPAIR - 26-0002-PRSECTION V
CONTRACT DOCUMENTS
Table of Contents
PUBLIC CONSTRUCTION BOND 1
CONTRACT 4
CONSENT OF SURETY TO FINAL PAYMENT 8
PROPOSAL/BID 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 17
SCRUTINIZED COMPANIES THAT BOYCOTT ISRAEL LIST CERTIFICATION FORM 18
SECTION V Page i Updated: 7/9/2025
SECTION V — Contract Documents
Bond No.:
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
Creative Contractors, Inc. 3[name]
SURETY OWNER
Principal Name Principal Name
101 Creative Way [Address Line 1]
Clearwater, FL 33759 [Address Line 2]
Principal Business Address Principal Business Address
941-373-5649 , hone number
Principal Phone Number Principal Phone Number
City of Clearwater
Parks and Recreation
PO Box 4748
Clearwater FL 33758-4748
(727) 562-4750
PROJECT NAME: BayCare Ball Park Berm Wall Repair
PROJECT NO.: 26 -002 -
PROJECT DESCRIPTION: The work shall consist of providing new structural stability to the existing
outfield berm wall in the form of soil nail shotcrete walls along the berm. The shotcrete wall will span the
entire height of the berm with a concrete curb 1 ft above the top of soil at the top of wall. The soil nails will
be placed at uniform spacing along the extend of the wall
BY THIS BOND, We, , as Contractor, and
, a corporation, as Surety, are bound to the
City of Clearwater, Florida, herein called Owner, in the sum of $ 1,626,534.60 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 BayCare Ball Park Berm Wall Repair, 26 -0002 -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 may be made in said Plans and Specifications as therein provided for), at
the times and in the manner prescribed in the contract; and
SECTION V Page 1 of 18 Updated: 7/9/2025
SECTION V — Contract Documents
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 18 Updated: 7/9/2025
SECTION V — Contract Documents
Bond No.:
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 day of
, 20
(If sole Ownership or Partnership, two (2) Witnesses are required).
(If Corporation, Secretary only will attest and affix seal).
Creative Contractors, Inc.
By:
Title:
Print Name:
WITNESS: WITNESS:
Corporate Secretary or Witness Print Name:
Print Name:
(affix corporate seal)
(Corporate Surety)
By:
ATTORNEY-IN-FACT
Print Name:
(affix corporate seal)
(Power of Attorney must be attached)
SECTION V Page 3 of 18 Updated: 7/9/2025
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 Creative
Contractors, Inc, of the City of Clearwater 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 , hereinafter 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: BayCare Ball Park Berm Wall Repair
PROJECT NO.: 26 -0002 -PR
in the amount of $1,626,534.60
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 18 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 18 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.
t) 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 18 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 COUN , LORIDA
By:
ifPo',` 'er
City Manager
Countersigned:
By:
Bruce Re
Mayor
Contractor must indicate whether:
X Corporation, Partnership,
ttest:
Rosemarie Call
City Clerk
Approved as to form:
pabSt r Sa)
,Owen Kohler
Lead Assistant City Attorne
Company, or
Creafve ontr
(Contract
Individual
N T
z GO......................
-K
By: . =o ens
`s 1074
'y4y FLORIDP,a•°a
Print Name:
Title:
Alan Holderith
Chief Operating Officer__
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 18 Updated: 7/9/2025
SECTION V — Contract Documents
CONSENT OF SURETY TO FINAL PAYMENT
TO OWNER: City of Clearwater PROJECT NAME: BayCare Ball Park Berm Wall Repair
Parks and Recreation PROJECT NO.: 26 -0002 -PR
100 S Myrtle Ave CONTRACT DATE: [.
Clearwater, FL 33756 BOND NO .: [ 1, recorded in O.R. Book
Paget ], of the Public Records of Pinellas County, Florida.
CONTRACTOR: (�
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 . f Surety]
[address)
tqddres4, SURETY,
on bond of
Creative Contractors, Inc.
101 Creative Way
Clearwater, FL 33759, 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
Parks and Recreation
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):
(Surety)
(Signature of authorized representative)
(Printed name and title)
SECTION V Page 8 of 18 Updated: 7/9/2025
SECTION V — Contract Documents
PROPOSAL/BID BOND
(Not to be filled out if a certified check is submitted)
KNOWN ALL MEN BY THESE PRESENTS: That we, the undersigned, Creative Contractors, Inc.
as Contractor, and Travelers Casualty and
Surety Company of America as Surety, whose address is
One Tower Square, Hartford, CT 06183 , are held and firmly bound unto the City
of Clearwater, Florida, in the sum of TEN percent of the amount bid Dollars
($ 10% of amount 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 Creative Contractors, Inc.
as Contractor, and Travelers Casualty and Surety Company of America as Surety, for
work specified as: 26 -0002 -PR, BayCare Ball Park Berm Wall Repair
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 Individual
Signed this 25th day of February . 20 26
Creative Contractors, Inc.
Contractor
Creative Contractors, Inc.
Principal
Travelers Casualty(, and Surety Company of America
Surety evin R. Wojtowicz, Attorney -in
The person signing shall, in his own handwriting, sign the Principal's name, his own nan#
where the person is signing for a Corporation, he must, by Affidavit, show his authorityft
Corporation — provide Affidavit. 11-P
SECTION V Page 8 of 16 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
, being duly sworn, deposes and says that he/she is
Secretary of Creative Contractors. Inc.
a corporation organized and existing under and by virtue of the laws of the State of Florida, and having its
principal office at:
101 Creative Way Clearwater FL 33759
(Street & Number)
(City)
Affiant further says that he is familiar with the records,
Creative Contractors, Inc.
(Name of Corporation)
Affiant further says that :----A, is ✓ t'
(Off er's Name) (Title)
of the corporation, is duly authorized to sign the Proposal for Creative Contractors, Inc.
or said corporation by virtue of
(state whether a provision of by laws or a Resolution of
Board of Directors. If by Resolution give date of adoption).
(County)
(State)
minute books and by-laws of
Sworn to before me this 25th day of February
pv������'''
Expires �v%
A0 1/23/2030 ,
Natalie Reyes d
My Commission O
'.y HH 752357 (e.
r.
Afant
,2026
Ntt %1
Notary Public
Net+gty t_ (Zeve,5
Type/print/stamp name of Notary
Title or rank, and Serial No., if any
SECTION V Page 9 of 16 Updated: 7/9/2025
TRAVELERS J
Travelers Casualty and Surety Company of America
Travelers Casualty and Surety Company
St. Paul Fire and Marine Insurance Company
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That Travelers Casualty and Surety Company of America, Travelers Casualty and Surety Company, and
St. Paul Fire and Marine Insurance Company are corporations duly organized under the laws of the State of Connecticut (herein
collectively called the "Companies"), and that the Companies do hereby make, constitute and appoint KEVIN R WOJTOWICZ of
ST PETERSBURG , Florida , their true and lawful Attomey(s)-in-Fact to sign, execute, seal and
acknowledge any and all bonds, recognizances, conditional undertakings and other writings obligatory in the nature thereof on behalf of
the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and executing or
guaranteeing bonds and undertakings required or permitted in any actions or proceedings allowed by law.
IN WITNESS WHEREOF, the Companies have caused this instrument to be signed, and their corporate seals to be hereto affixed, this 21st day of April,
2021.
State of Connecticut
By:
City of Hartford ss.
r
YJ
Robert L. Raney; Senior Vice President
On this the 21st day of April, 2021, before me personally appeared Robert L. Raney, who acknowledged himself to be the Senior
Vice President of each of the Companies, and that he, as such, being authorized so to do, executed the foregoing instrument for the
purposes therein contained by signing on behalf of said Companies by himself as a duly authorized officer.
7 NO,y�9
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
My Commission expires the 30th day of June, 2026
NOTARY
o�w Y
PUMA
ry Anna P. Nowik, Notary Public
This Power of Attorney is granted under and by the authority of the following resolutions adopted by the Boards of Directors of each of
the Companies, which resolutions are now in full force and effect, reading as follows:
RESOLVED, that the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President, any Vice
President, any Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any Assistant Secretary may appoint
Attomeys-in-Fact and Agents to act for and on behalf of the Company and may give such appointee such authority as his or her certificate of authority
may prescribe to sign with the Company's name and seal with the Company's seal bonds, recognizances, contracts of indemnity, and other writings
obligatory in the nature of a bond, recognizance, or conditional undertaking, and any of said officers or the Board of Directors at any time may
remove any such appointee and revoke the power given him or her; and it is
FURTHER RESOLVED, that the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President or
any Vice President may delegate all or any part of the foregoing authority to one or more officers or employees of this Company, provided
that each such delegation is in writing and a copy thereof is filed in the office of the Secretary; and it is
FURTHER RESOLVED, that any bond, recognizance, contract of indemnity, or writing obligatory• in the nature of a bond, recognizance,
or conditional undertaking shall be valid and binding upon the Company when (a) signed by the President, any Vice Chairman, any Executive
Vice President, any Senior Vice President or any Vice President, any Second Vice President, the Treasurer, any Assistant Treasurer, the
Corporate Secretary or any Assistant Secretary and duly attested and sealed with the Company's seal by a Secretary or Assistant Secretary;
or (b) duly executed (under seal, if required) by one or more Attorneys -in -Fact and Agents pursuant to the power prescribed in his or her
certificate or their certificates of authority or by one or more Company officers pursuant to a written delegation of authority; and it is
FURTHER RESOLVED, that the signature of each of the following officers: President, any Executive Vice President, any Senior Vice President,
any Vice President, any Assistant Vice President, any Secretary, any Assistant Secretary, and the seal of the Company may be affixed by facsimile to
any Power of Attorney or to any certificate relating thereto appointing Resident Vice Presidents, Resident Assistant Secretaries or Attomeys-in-
Fact for purposes only of executing and attesting bonds and undertakings and other writings obligatory in the nature thereof, and any such Power of
Attorney or certificate bearing such facsimile signature or facsimile seal shall be valid and binding upon the Company and any such power so executed
and certified by such facsimile signature and facsimile seal shall be valid and binding on the Company in the future with reypect to any bond or
understanding to which it is attached.,t :.•y `'` ` rr �. •'
1, Kevin E. Hughes, the undersigned, Assistant Secretary of each of the Companies, do hereby certify that the'' awitkfforee fng Is a
• .+ .,., -l4, •
1754;1'''
true and correct copy of the Power of Attorney executed by said Companies, which remains in full force and effect.
Dated this 25th day of February , 2026
Kevin E. Hughes::Assi tantSeyie ary
.
To verify the authenticity of this Power of Attorney, please call us at 1-800-421-3880.
Please refer to the above-named Attorneys) -in -Fact and the details of the bond to which this Power of Attorney is attached.
SECTION V — Contract Documents
NON -COLLUSION AFFIDAVIT
STATE OF FLORIDA )
COUNTY OF Pinellas
Jim Cacini
being, first duly sworn, deposes and says that he is
Vice President of Creative Contractors
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 all statements
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 association
or to any member or agent thereof.
Sworn to and subscribed before me this 25th
Affiant
day of February
,2026
Notary Public d "ate
.atiiinPlk.,
ROBERT J. EGGIMANN
MY COMMISSION # HH 609686
EXPIRES: January 3, 2029
SECTION V Page 10 of 16 Updated: 6/3/2024
SECTION V—Contract Documents
PROPOSAL
(1)
TO THE CITY OF CLEARWATER, FLORIDA, for
BayCare Ball Park Berm Wall Repair (26 -0002 -PR)
and doing such other work incidental thereto, all in accordance with the contract documents, marked
BayCare Ball Park Berm Wall Repair (26 -0002 -PR)
Every bidder must take notice of the fact that even though his proposal be accepted and the documents
signed by the bidder to whom an award is made and by those officials authorized to do so on behalf of the
City of Clearwater, Florida, that no such award or signing shall be considered a binding contract without a
certificate from the Finance Director that funds are available to cover the cost of the work to be done, or
without the approval of the City Attorney as to the form and legality of the contract and all the pertinent
documents relating thereto having been approved by said City Attorney; and such bidder is hereby charged
with this notice.
The signer of the Proposal, as bidder, also declares that the only person, persons, company or parties
interested in this Proposal, are named in this Proposal, that he has carefully examined the Advertisement,
Instructions to Bidders, Contract Specifications, Plans, Supplemental Specifications, General Conditions,
Special Provisions, and Public Construction Bond, that he or his representative has made such investigation
as is necessary to determine the character and extent of the work and he proposes and agrees that if the
Proposal be accepted, he will contract with the City of Clearwater, Florida, in the form of contract; hereto
annexed, to provide the necessary labor, materials, machinery, equipment, tools or apparatus, do all the
work required to complete the contract within the time mentioned in the General Conditions and according
to the requirements of the City of Clearwater, Florida, as herein and hereinafter set forth, and furnish the
required surety bonds for the following prices to wit:
If the foregoing Proposal shall be accepted by the City of Clearwater, Florida, and the undersigned shall
fail to execute a satisfactory contract as stated in the Advertisement herein attached, then the City may, at
its option determine that the undersigned has abandoned the contract, and thereupon this Proposal shall be
null and void, and the certified check or bond accompanying this Proposal, shall be forfeited to become the
property of the City of Clearwater, Florida, and the full amount of said check shall be retained by the City,
or if the Proposal Bond be given, the full amount of such bond shall be paid to the City as stipulated or
liquidated damages; otherwise, the bond or certified check accompanying this Proposal, or the amount of
said check, shall be returned to the undersigned as specified herein.
SECTION V Page 12 of 18 Updated: 7/9/2025
SECTION V — Contract Documents
PROPOSAL
(2)
Attached hereto is a bond eertifte elle.'_
Bank, for the sum of
10% of bid amount
(being a minimum of 10% of Contractor's total bid amount).
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:
Joshua Bornstein, CEO and President 3201 W Bay Villa Avenue Tampa, FL 33611
H. Alan Holderith, Secretary and Treasurer 410 Althea Road Bellair, FL 33756
Jim Cacini, Vice President 2279 Warwick Drive Oldsmar, FL 34677
Signature of Bidder.
The person signing shall, in his own handwriting, sign the Principal's name, his own name 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.
Princip.. X i r.t eAc.. s s
B
Title: 1%
Company Legal Name: Creative Contractors, Inc.
Doing Business As (if different than above):
Business Address of Bidder: 101 Creative Way
City and State: Clearwater, FL
Phone: 727.461.5522
Dated at 8:40 a.m.
Zip Code 33759
Email Address: jcacini@creativecontractors.com
this 25th day of February , A.D., 20.7 fo
SECTION V Page 12 of 16 Updated: 6/3/2024
SECTION V — Contract Documents
CITY OF CLEARWATER
ADDENDUM SHEET
PROJECT: Baycare Ball Park Berm Wall Repair
Aclrnowledgment is hereby made of the following addenda received since issuance of Plans and
Specifications.
Addendum No. 1 Date: 1/26/26
Addendum No. 2 Date: 1/30/26
Addendum No. 3 Date: 2/4/26
Addendum No. 4 Date: 2/9/26
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Creative Contractors, Inc.
(Name of Bidder)
•
ignature o Officer)
Vice President
(Title of Officer)
2/24/26
(Date)
SECTION V Page 13 of 16 Updated: 6/3/2024
SECTION V — Contract Documents
BIDDER'S PROPOSAL
PROJECT: BayCare Ball Park Berm Wall Repair (26 -0002 -PR)
CONTRACTOR:
BIDDER'S GRAND TOTAL: $ (Numbers)
BIDDER'S GRAND TOTAL:
(Words)
Baycare BallPark
Line Item
1. General
Conditions
Berm Wall Repair
Description
Quantity
Unit of Measure
Creative
Unit Cost
Contractors, Inc.
Total
a. Permits-
total Cost.
N/A
.._
..
b.
Supervision
1
LS
$100,167.00
$100,167.00
c.
Tools, Equip, etc
1
LS
$26,441.00
$26,441.00
d.
Survey Quantities
1
LS
$33,140.00
$33,140.00
e.
The contractor must utilize a
City of Clearwater -Solid
Waste Roll off only (to be
acquired/supplied by the
contractor)
1
LS
$3,244.00
$3,244.00
f.
Dewatering
1
LS
$0.00
$0.00
g.
Testing (Geotech, Soil, etc)
1
LS
$3,244.00
$3,244.00
h.
Mobilization
1
LS
$36,600.00
$36,600.00
i.
Cleanup and Demobilize
1
LS
$10,814.00
$10,814.00
j.
P&P Bond
1
LS
$12,027.00
$12,027.00
SECTION V
Page 15 of 18
Updated: 7/9/2025
SECTION V — Contract Documents
2.
Demolition
a.
Partial Berm Demolition
1
LS
$16,589.00
$16,589.00
3. Soil Nail
Wall
a.
Steel reinforcing (1/S2.0)
25500
LF
$2.16
$55,080.00
b.
Shotcrete (1/S2.0)
237
CY
$2,725.86
$646,028.82
c.
Concrete Soil Nails (1/S2.0,
2/S2.0)
225
EA
$2,379.08
$535,293.00
Total. '
$1478,667.82'
Contigency
Line Item
Description
10% contingency from total
in above table
Quantity
1
Unit of Measure
LS
Unit Cost
$147,866.78
Creative Contractors,
Inc.
Total
$147,866.78
1
Total -
g
„ µ , '4"`
$147,866.78:;
Grand Total
1,626,534.6
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 16 of 18 Updated: 7/9/2025
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 Companies
with Activities in the Iran Petroleum Sector List, or engaged in business operations in Cuba and Syria.
r r
horized Signature
Jim Cacini
Printed Name
Vice President
Title
Creative Contractors, Inc.
Name of Entity/Corporation
STATE OF Florida
COUNTY OF Pinellas
The foregoing instrument was acknowledged before me by means of 0 physical presence or 0 online
notarization on, this 25th day of February , 2026 , by Jim Cacini
(name of person whose signature is being notarized) as the Vice President (title) of
Creative Contractors, Inc. (name of corporation/entity), personally known x , or
produced (type of identification) as identification, and who did/did not take
an oath.
My Commission Expires:
NOTARY SEAL ABOVE
T .
Notary Public
Printed Name
1
ROBERTJ.EGGIMANN
MY COMMISSION # HH 609686
EXPIRES: January 3, 2029
1
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 mariner. 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, 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 that Boycott Israel List, or engaged
in a boycott of Israel.
STATE OF Florida
COUNTY OF Pinellas
The foregoing instrument
notarization on, this 25th
(name of person whose
Creative Contractors, Inc.
(type of iden ' ation) as identification, and who did/did not take
);36171--.'/:
Notary Public
horized Signature
Jim Cacini
Printed Name
Vice President
Title
Creative Contractors, Inc.
Name of Entity/Corporation
was acknowledged before me by means of ❑ physical presence or 0 online
day of February , 20_, by Jim Cacini
signature is being notarized) as the Vice President (title) of
(name of corporation/entity), personally known X , or
produced
an oath.
My Commission Expires:
NOTARY SEAL ABOVE
Printed Name
4
ISA
i►T,,
ROBERT J. EGGIMANN
MY COMMISSION # HH 808686
EXPIRES: January 3, 2029
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: February 25 a 2026 Signed:
Entity: Creative Creative Contractors, Inc.
Name: Jim
acini
Title: Vice President
City of Clearwater
Public Works
Marcus Williamson, Department Director
100 South Myrtle Avenue, Clearwater, FL 33756
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
ITB No. 26 -0002 -PR
Baycare Ball Park Berm Wall Repair
RESPONSE DEADLINE: February 25, 2026 at 2:00 pm
Report Generated: Wednesday, February 25, 2026
Creative Contractors, Inc. Response
CONTACT INFORMATION
Company:
Creative Contractors, Inc.
Email:
msavigny@creativecontractors.com
Contact:
Mark Savigny
Address:
101 Creative Way
Clearwater, FL 33759
Phone:
(941) 373-5649
Website:
creativecontractors.com
Submission Date:
Feb 25, 2026 1:25 PM (Eastern Time)
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
ITB No. 26 -0002 -PR
Baycare Ball Park Berm Wall Repair
Addendum #1
Confirmed Feb 23, 2026 12:03 PM by Mark Savigny
Addendum #2
Confirmed Feb 23, 2026 12:03 PM by Mark Savigny
Addendum #3
Confirmed Feb 23, 2026 12:03 PM by Mark Savigny
Addendum #4
Confirmed Feb 23, 2026 12:03 PM by Mark Savigny
ADDENDA CONFIRMATION
QUESTIONNAIRE
1. Certified Business*
Are you a Certified Small Business or a Certified Minority, Woman or Disadvantaged Business Enterprise?
No
2. Vendor Certification*
By submitting this response, the Vendor hereby certifies that:
A. It is under no legal prohibition on contracting with the City of Clearwater.
B. It has read, understands, and is in compliance with the specifications, terms and conditions stated herein, as well as its
attachments, and any referenced documents.
C. It has no known, undisclosed conflicts of interest.
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
Invitation To Bid - Baycare Ball Park Berm Wall Repair
Page 2
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
ITB No. 26 -0002 -PR
Baycare Ball Park Berm Wall Repair
D. The prices offered were independently developed without consultation or collusion with any of the other vendors or potential
vendors or any other anti-competitive practices.
E. No offer of gifts, payments or other consideration were made to any City employee, officer, elected official, or consultant who
has or may have had a role in the procurement process for the commodities or services covered by this contract. The Vendor
has not influenced or attempted to influence any City employee, officer, elected official, or consultant in connection with the
award of this contract.
F. It understands the City may copy all parts of this response, including without limitation any documents or materials copyrighted
by the Vendor, for internal use in evaluating respondent's offer, or in response to a public records request under Florida's public
records law (F.S. Chapter 119) or other applicable law, subpoena, or other judicial process; provided that the City agrees not to
change or delete any copyright or proprietary notices.
G. It hereby warrants to the City that the Vendor and its subcontractors will comply with, and are contractually obligated to comply
with, all federal, state, and local laws, rules, regulations, and executive orders.
H. It certifies that Vendor is not presently debarred, suspended, proposed for debarment, declared ineligible, voluntarily excluded,
or disqualified from participation in this matter from any federal, state, or local agency.
I. It will provide the commodities or services specified in compliance with all federal, state, and local laws, rules, regulations, and
executive orders if awarded by the City.
J. It is current in all obligations due to the City.
K. It will accept all terms and conditions as set forth in this solicitation if awarded by the City.
L. The signatory is an officer or duly authorized representative of the Vendor with full power and authority to submit binding offers
and enter into contracts for the commodities or services as specified herein.
Confirmed
3. E -Verify System Certificattion*
PER FLORIDA STATUTE 448.095, CONTRACTORS AND SUBCONTRACTORS MUST REGISTER WITH AND USE THE E -VERIFY SYSTEM TO
VERIFY THE WORK AUTHORIZATION STATUS OF ALL NEWLY HIRED EMPLOYEES.
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
Invitation To Bid - Baycare Ball Park Berm Wall Repair
Page 3
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
ITB No. 26 -0002 -PR
Baycare Ball Park Berm Wall Repair
The affiant, by virtue of confirming below, certifies that:
A. The Contractor and its Subcontractors are aware of the requirements of Florida Statute 448.095.
B. The Contractor and its Subcontractors are registered with and using the E -Verify system to verify the work authorization status
of newly hired employees.
C. The Contractor will not enter into a contract with any Subcontractor unless each party to the contract registers with and uses
the E -Verify system.
D. The Subcontractor will provide the Contractor with an affidavit stating that the Subcontractor does not employ, contract with,
or subcontract with unauthorized alien.
E. The Contractor must maintain a copy of such affidavit.
F. The City may terminate this Contract on the good faith belief that the Contractor or its Subcontractors knowingly violated Florida
Statutes 448.09(1) or 448.095(2)(c).
G. If this Contract is terminated pursuant to Florida Statute 448.095(2)(c), the Contractor may not be awarded a public contract for
at least 1 year after the date on which this Contract was terminated.
H. The Contractor is liable for any additional cost incurred by the City as a result of the termination of this Contract.
Confirmed
4. Scrutinized Company Certification*
Please download the below documents, complete, notarize, and upload.
• SCRUTINIZED COMPANIES AND B...
SCRUTINIZED_COMPAN IES_AND_BUSINESS_OPERATIONS_CERTIFICATION.pdf
5. Compliance with Anti -Human Trafficking Laws*
Please download the below documents, complete, and upload.
• Compliance with 787.06 form...
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
Invitation To Bid - Baycare Ball Park Berm Wall Repair
Page 4
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
ITB No. 26 -0002 -PR
Baycare Ball Park Berm Wall Repair
Compliance_with_787.06_form.pdf
6. Section V - Contract Documents*
Please download the below documents, complete, and upload.
• Section V - Contract Docume...
Contract_Docu mentsCreative. pdf
7. W-9*
Upload your current W-9 form. (available at https://www.irs.gov/pub/irs-pdf/fw9.pdf)
Creative_W-9.pdf
PRICE TABLES
BAYCARE BALLPARK BERM WALL REPAIR
Line Item
1. General Conditions
Description Quantity Unit of Unit Cost Total
Measure
a. Permits -total Cost N/A
b.
Supervision
1
LS
$100,167.00
$100,167.00
c.
Tools, Equip, etc
1
LS
$26,441.00
$26,441.00
d.
Survey Quantities
1
LS
$33,140.00
$33,140.00
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
Invitation To Bid - Baycare Ball Park Berm Wall Repair
Page 5
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
ITB No. 26 -0002 -PR
Baycare Ball Park Berm Wall Repair
Line Item
e.
Description
The contractor must utilize a City of Clearwater -Solid Waste Roll off only (to be
acquired/supplied by the contractor)
Quantity
1
Unit of
Measure
LS
Unit Cost
$3,244.00
Total
$3,244.00
f.
Dewatering
1
LS
$0.00
$0.00
g.
Testing (Geotech, Soil, etc)
1
LS
$3,244.00
$3,244.00
h.
Mobilization
1
LS
$36,600.00
$36,600.00
i.
Cleanup and Demobilize
1
LS
$10,814.00
$10,814.00
j.
P&P Bond
1
LS
$12,027.00
$12,027.00
2. Demolition
a.
Partial Berm Demolition
1
LS
$16,589.00
$16,589.00
3. Soil Nail Wall
a.
Steel reinforcing (1/S2.0)
25,500
LF
$2.16
$55,080.00
b.
Shotcrete (1/S2.0)
237
CY
$2,725.86
$646,028.82
c.
Concrete Soil Nails (1/S2.0, 2/S2.0)
225
EA
$2,379.08
$535,293.00
TOTAL
$1,478,667.82
CONTIGENCY
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
Invitation To Bid - Baycare Ball Park Berm Wall Repair
Page 6
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
ITB No. 26 -0002 -PR
Baycare Ball Park Berm Wall Repair
Line Item
1.
Description
10% contingency from total in above table
Quantity Unit of Unit Cost Total
Measure
1
LS
$147,866.78
TOTAL
$147,866.78
$147,866.78
[CREATIVE CONTRACTORS, INC.] RESPONSE DOCUMENT REPORT
Invitation To Bid - Baycare Ball Park Berm Wall Repair
Page 7
Form ■■-9
(Rev. October 2018)
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.
1 Name (as shown on your Income tax retum). Name Is required on this Ilne; do not leave this line blank.
CREATIVE CONTRACTORS. INC.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
0 Individual/sole proprietor or 0 C Corporation ❑✓ S Corporation 0 Partnership 0 Trust/estate
single -member LLC
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnershlp) ►
Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check
LLC if the LLC Is classified as a single -member LLC that Is disregarded from the owner unless the owner of the LLC is
another LLC that Is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
❑ Other (see instructions) ►
4 Exemptions (codes apply only to
certain entitles, not Individuals; see
instructions on page 3):
Exempt payee code (Nam)
Exemption from FATCA reporting
code (If any)
Nppurs to accounts maintained outside the u.s.)
5 Address (number, street, and apt. or suite no.) See instructions.
101 CREATIVE WAY
8 City, state, and ZIP code
CLEARWATER, FL 33759
Requester's name and address (optional)
7 List account number(s) here (optional)
Part 1
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. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Social security number
or
Employer Identification number
5
9
1
5
6
1
1
3
2
Part 11
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2.1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. 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 retum. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part I1, later.
Sign ("7
Here AarSeC4.4JMa ePA Date► /// 7 20 24%
il� r:
• 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-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),
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.
If you do not retum Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Signature of
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.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information retum with the IRS 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 return 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 eamed or paid)
Cat. No. 10231X Form W-9 (Rev. 10-2018)