NORTHEAST WRF CLARIFIER SPLITTER BOX REHAB - 21-0017-UTSECTION V — Contract Documents
CONTRACT
(1)
This CONTRACT made and entered into this JAY' ��day oL.A.A( , 20WPby and between the City
of Clearwater, Florida, a municipal corporation, hereinafter designated as the "City", and INNOVATIVE
MASONRY RESTORATION LLC, a Minnesota limited liability company authorized to do business in the
State of Minnesota, of the City of Prior Lake, County of Scott, and the State of Florida, 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: NE WRF CLARIFIER SPLITTER BOX REHAB
PROJECT NO.: 21 -0017 -UT
in the amount of $ 656,342.50
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 3 of 16 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 51,000.00 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 51,000.00 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 4 of 16 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(amyclearwater.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 bv 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 bv 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.
f) 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 5 of 16 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.
1) 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 PINELLASJQUNTY, FLORIDA
By:
J'nifet"Poirrier
City Manager
Countersigned:
By:
Bruce RE ctor
Mayor
Contractor must indicate whether:
Corporation, Partnership,
Rosemarie Call
City Clerk
App • -d as to form:
Jerrod i5 •son
Senior ssistant City Attorney
X Company, or
Individual
AO 1i .C_ 4-10A
(Contractor)
By:
Print acne: 12Au UN LA -Pork%
ll rt, CIPa--j 0 c._ r r—
Title:
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 6 of 16 Updated: 7/9/2025
SCRUTINIZED COMPANIES FORMS
SCRUTINIZED COMPANIES AND BUSINESS OPERATIONS WITH
CUBA AND SYRIA CERTIFICATION FORM
IF YOUR BID/PROPOSAL IS $9,000,000 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.
STATE OF
Authorized Signature
David LaPorte
Printed Name
Principal
Title
Innovative Masonry Restoration LLC
MN Name of Entity/Corporation
COUNTY OF
Dakota
The foregoing instrument was acknowledged before me by means of ❑ physical presence or N online
notarization on, this 14 day of October , 20 25 , by David LaPorte
(name of person whose signature is being notarized) as the Principal (title) of
Innovative Masonry Restoration LLC (name of corporation/entity), personally known , or
produced Driver's license (type of identification) as identification, and who did/did not take
an oath.
A '_Tr ALICIA M SCHAUPP
�y\4\ Notary Public - Minnesota
Commission # 997784300032
My Commission Expires
Jan 31, 2028
My Commission Expires: 1/31/28
NOTARY SEAL ABOVE
Notary Public
Alicia Schaupp
Printed Name
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 FORMAS 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, 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.
o1 —1.,-, ALICIAM SCHAUPP
Notary Public - Minnesota.
I�, Commission # 997784300032
off
;' My Commission Expires
Jan 31, 2028
STATE OF
MN
COUNTY OF Dakota
Authorized Signature
David LaPorte
Printed Name
Principal
Title Masonry Restoration LLC
Name of Entity/Corporation
The foregoing instrument was acknowledged before me by means of ❑ physical presence or 1 online
notarization on, this14 day of October , 20 25 , by David LaPorte
(name of person whose signature is being notarized) as the Principal (title) of
Innovative Masonry Restoration LLC (name of corporation/entity), personally known , or
produceddrivcr's liccnsc (type of identification) as identification, and who did/did not take
an oath.
My Commission Expires: 1/31/28
NOTARY SEAL ABOVE
Notary Public
Alicia Schaupp
Printed Name
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: 10/14 , 2025 Signed:
e
Entity:Innovative Masonry Restoration LLC Name: David LaPorte
Title:
Principal
SECTION V - Contract Documents
PROPOSAL/BID BOND
(Not to be filled out if a certified check is submitted)
Bond No. RB0098926
KNOWN ALL MEN BY THESE PRESENTS: That we, the undersigned,. Innovative Masonry
Restoration LLC as Contractor, and Granite Re, Inc.
as Surety, whose address is 14001 Quailbrook Dr.
Oklahoma City, OK 73134 , are held and firmly bound unto the City
of Clearwater, Florida, in the sum of Ten Percent of Bid Amount (10% of bid amount) Dollars
($ xxx ) (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 innovative Masonry
Restoration LLC as Contractor, and Granite Re, Inc. as Surety, for
work specified as: Project No. 21 -0017 -UT , NE WRF Clarifier Splitter Box Rehab
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:
Corporation,
Partnership,
x Company, or
Signed this 13th day of October
Individual
20 25=
Innovative Masonry Restoration LLC
Contractor
Principal
By: Dave LaPorte, Principal
Title
Granite Re, Inc.
Sure s, Attorney -in -Fact
The person signing shall, in his own handwriting, sign the Principal's name, his own name, and hi1-tifie;
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: 6/3/2024
SECTION V — Contract Documents
AFFIDAVIT
(To be filled in and executed if the bidder is a corporation) Whi.
STATE OF FLORIDA
COUNTY OF )
Secretary of
a corporation organized and existing under and by virtue of the laws of the State of Florida, and having its
principal office at:
, being duly sworn, deposes and says that he/she is
(Street & Number) (City) (County) (State)
Affiant further says that he is familiar with the records, minute books and by-laws of
(Name of Corporation)
Affiant further says that is
(Officer's Name)
of the corporation, is duly authorized to sign the Proposal for
or said corporation by virtue of
Sworn to before me this
SECTION V
(Title)
(state whether a provision of by laws or a Resolution of
Board of Directors. If by Resolution give date of adoption).
A ffiant
day of , 20
Notary Public
Type/print/stamp name of Notary
Title or rank, and Serial No., if any
Page 9 of 16 Updated: 6/3/2024
ECT1ON V— Contract Documents
NON -COLLUSION AFFIDAVIT
Minnesota
STATE OF.NEOR
COUNTY OF Dakota
Dave LaPorte
being, first duly sworn, deposes and says that he is
Principal of Innovative Masonry Restoration LLC
the party making the foregoing Proposal or Bid; that such Bid is genuine and not col l usi ve 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 pri ce 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 sad proposal or bid are true; and further, that such bidder has not directly or i ndi rectl y
submitted this bid, or the contents thereof, or divulged information or data ret ati ve thereto to any associ ati on
or to any member or agent thereof.
Sworn to and subscribed before me thi s 13th d
TONI L. FERRILL
NOTARY PUBLIC - MINNESOTA
My Commission Expires Jan 31, 2027
X11 ON V
Affi ant
f October
Notary Public
20 25
11` r
Page 10 of 16 Updated: 6/3/2024
SECTION V — Contract Documents
PROPOSAL
(2)
Attached hereto is a bond or certified check on
Bond - Granite RE, Inc as Surety
Bank, for the sum of
Ten Percent of Bid Amount (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:
Jim Dolby
ADDRESSES:
6160 150th St Prior Lake MN 55372
David LaPorte 16264 Lakeside Ave SE Prior Lake MN 55372
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.
Principal: David LaPorte
By: Title: Principal
Company Legal Name: Innovative Masonry Restoration LLC
Doing Business As (if different than above):
Business Address of Bidder:
City and State:
16264 Lakeside Ave SE
Prior Lake MN
Phone: 612-548-5589
Dated at 2:OOpm
SECTION V
Email Address:
, this 14
Zip Code 55372
dave@imrestoration.com
day of October
, A.D., 20 25
Page 12 of 16 Updated: 6/3/2024
SECTION V — Contract Documents
CITY OF CLEARWATER
ADDENDUM SHEET
PROJECT: 21-0017 UT
Acknowledgment is hereby made of the following addenda received since issuance of Plans and
Specifications.
Addendum No. Date: N/A No Addendums Issued
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
Addendum No. Date:
SECTION V
Innovative Masonry Restoration LLC
(Name of Bidder)
(Signature of Officer)
Principal
(Title of Officer)
10/14/25
(Date)
Page 13 of 16 Updated: 6/3/2024
-9
(Rev. March 2024)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Go to wwwins.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 Fan, below.
Print or typo.
See Spoclflc Instructions on page 3.
1 Name of entityAndvdduaL An entry is required. (For a sole proprietor or disregarded entity, enter the owner's mune on line 1, and enter the business/disregarded
entity's name on One 2.)
irtrlovative Masonry Restoration LLC
2 Business nemddfsregaded entity mune. n dinerent frau above.
3a Check the appropriate bar for federal tax classification of the entityAndtvkduai whose name Is entered on line 1. Check
only one of the fotbwing seven boxes.
• Individual/6°4e proprietor • C corporation • S corporation 9 Partnership • Trust/estate
19 LLC. Enter the tax cued, cadbn (C = C corporation, S = S corporation, P = Partnership) . . . . S
4 Exemptions (codes apply only to
certain entitles, not 1ndMduals;
SOB lnstructbu on page 3x
Exempt payee Dade (if any)
Nola Check the 'LLC" box above and. In the entry space, enter the appropriate code (C, S, or P) for tie tax
classification of the LLC, unless It Is a disregarded entity. A disregarded entity should Instead check the appropriate
box for the tax ctasslrx atIon of its owner.
❑ Other (see Instructions)
Exemption from Foreign Account Tax
Compllarxe Act (FATCA) reporting
code Of any)
3b If on tine 3a you checkad -Partnership' or -TtusVesttate, or checked 1LC' and entered P' as its tax classification,
and you are providing this form to a partnership, trust, or estate in which you have en ownership Interest. check
this box if you have any foreign partners, owners, or beneficiaries. See Instructions IIIouCslal)
(� to account maintained
the UnitesStaoat)
5 Address (number, street, and apt. or suite no.). See Instructions.
16264 Lakeside Ave SE
Requester's name and address (optional)
6 City, state, and ZIP code
Prior Lake MN 55372
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 entrly, see the instructions for Part I, later. For other
Soca) security number
—
—
....__......,..._.............................._.... ... r..,........,,...,.,.,..w,. ,
TIN, later.
Not if the account is in more than one narne, see tiro instructions for fine 1. See also What Name and
Number To Give the Requester for guidelines on whose rurub r to enter.
or
Employer Ickattfleatkok number
4
6
4
3
2
0
5
8
5
Part II
Certification
Under penalties of perjury, I certify that
1. The number shown on this Conn is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subiect 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 withthokfirlg; 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 Of 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 [aced to report al interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage Interest paid,
acquisition or abandonment of secured property, cancellation of debt contributions to an Individual retirement arrangement (IRA), and, generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the Instructions for Part II, later.
Sign
Here
Signature or
US. porton
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 lime. 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.
Dole
kJ)Sfa-o�S
New line 3b has been added to this form. A flow-through entity is
required to complete this line to indrrate 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
regardng 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 retum with the IRS is giving you this form because they
Cal. No. 10231X
Form W-9 (Rev. 3-2024)