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2012-15 CONTRACTOR AGREEMENT THIS AGREEMENT, made and entered into this )s `day of re, bruarc1 2012, A.D., by and between the City of Clermont 685 West Montrose Street, Clermont, Florida (hereinafter referred to as "OWNER "), and A. C. Schultes of Florida, Inc. 11865 US Hwy 41 South, Gibsonton, FL 33543 (hereinafter referred to as "CONTRACTOR "). WITNESSETH: That the parties hereto, for the consideration hereinafter set forth, mutually agree as follows: ARTICLE I - SCOPE OF WORK The CONTRACTOR shall furnish all labor, materials, equipment, machinery, tools, apparatus and transportation and perform all of the work described in the bid documents and specifications entitled: RFB NO. 12 -006 Disston Avenue Potable Water Supply Well and Eastside WRF Reclaimed Water Supply Well as prepared by Owner and its agents shall do everything required by this Contract and the other Contract Documents contained in the specifications, which are a part of these Documents. ARTICLE II - THE CONTRACT SUM The OWNER shall pay to the CONTRACTOR, for the faithful performance of the Contract as set forth in the contract documents and the Unit Price Schedule, attached hereto and incorporated herein as Exhibit "A ", in lawful tender of the United States, the total contract sum not to exceed FIVE HUNDRED THIRTY -THREE THOUSAND THREE HUNDRED AND SEVENTY -FIVE DOLLARS ($533,375.00). ARTICLE III - COMMENCEMENT AND COMPLETION OF WORK 1. The CONTRACTOR shall commence work within 10 calendar days after receipt of (i) Notice to proceed, and (ii) receipt of all permits required to perform the work, and the CONTRACTOR will substantially complete the same within: One hundred fifty (150) calendar days for the Potable Water Supply Well; and Sixty (60) calendar days for the modifications to the Reclaimed Water Supply well unless the period for completion is extended otherwise by the amendment or change order to the Contract. Substantial Completion as provided herein shall be the day the project or designated portion thereof is certified and accepted by the OWNER as sufficiently complete, in accordance with the Contract Documents. 2. The CONTRACTOR shall prosecute the work with faithfulness and diligence. 3. The CONTRACTOR further declares he has examined the sites of the work and that from personal knowledge and experience or that he has made sufficient investigations to fully satisfy himself that such sites are correct and suitable for the work and he assumes full responsibility therefore. The provisions of this Contract shall control any inconsistent provisions contained in the specifications. All Drawings and Specifications have been read and carefully considered by the CONTRACTOR, who understands the same and agrees to their sufficiency for the work to be done. It is expressly agreed that under no circumstances, conditions or situations shall this Contract be more strongly construed against the OWNER than against the CONTRACTOR and any Surety. Any ambiguity or uncertainty in the Plans, Drawings or Specifications shall be interpreted and construed by the OWNER's Project Manager and his decision shall be final and binding upon all parties. It is distinctly understood and agreed that the passing, approval and/or acceptance of any part of the work or material by the OWNER or by any agent or representative as in compliance with the terms of this Contract and/or of the Drawings, Plans and Specifications covering said work shall not operate as a waiver by the OWNER of strict compliance with the terms of this Contract and/or the Drawings and Specifications covering said work; and the OWNER may require the CONTRACTOR and/or his Surety to repair, replace, restore and/or make to comply strictly and in all things with this Contract and the Drawings and Specifications any and all of said work and/or materials which within a period of one year from and after the date of the passing, approval, and or acceptance of any such work or material, are found to be defective or to fail and in any way to comply with this Contract or with the Drawings and Specifications. This provision shall not apply to materials or equipment normally expected to deteriorate or wear out and become subject to normal repair and replacement before their condition is discovered. The CONTRACTOR shall not be required to do normal maintenance work under the guarantee provisions. Failure on the part of the CONTRACTOR and/or his Surety, immediately after Notice to either, to repair or replace any such defective materials and workmanship shall entitle the OWNER, if it sees fit, to replace or repair the same and recover the reasonable cost of such replacement and/or repair from the CONTRACTOR and/or his Surety, who shall in any event be jointly and severally liable to the OWNER for all damages, loss and expense caused to the OWNER by reason of the CONTRACTOR'S breach of this Contract and/or his failure to comply strictly and in all things with this Contract and/or his failure to comply strictly and in all things with this Contract and with the Drawings and Specifications. 4. If required, As -built drawings and warranties acceptable to OWNER must be submitted to the OWNER before final payment will be made to the CONTRACTOR. ARTICLE IV - LIQUIDATED DAMAGES 1. It is mutually agreed that time is of the essence in regard to this Agreement. Therefore, notwithstanding any other provision contained in the Contract Documents, should the CONTRACTOR fail to complete the work within the specified time as set by the Notice to Proceed, or any authorized extension thereof, CONTRACTOR shall pay to OWNER the sum of FIVE HUNDRED DOLLARS ($500.00) per calendar day as fixed, agreed and liquidated damages for each calendar day elapsing beyond the specified time date for either the Potable Water Supply Well or the Reclaimed Water Supply Well; which sum shall represent the damages sustained by the OWNER, and shall be considered not as a penalty, but in liquidation of damages sustained. Contractor shall pay the liquidated damages amount contained herein to Owner within fifteen (15) days of receipt of Owner's written demand for such payment. 2. For the purposes of this Article, the day of final acceptance of the work shall be considered a day of delay, and the scheduled day of completion of the work shall be considered a day schedule for protection. ARTICLE V - PARTIAL AND FINAL PAYMENTS In accordance with the provisions fully set forth in the General Conditions, and subject to additions and deductions as provided, the OWNER shall pay the CONTRACTOR as follows: 1. CONTRACTOR shall submit a progress payment request by the third (3rd) day of each calendar month for work performed during the preceding calendar month. Upon CONTRACTOR's signature accepting the PARTIAL PAYMENT AUTHORIZATION, the OWNER shall make a partial payment to the CONTRACTOR, within thirty (30) calendar days, on the basis of a duly certified and approved payment invoice by the OWNER for work performed during the preceding calendar month under the Agreement. To insure proper performance of the Agreement, the OWNER shall retain ten percent (10 %) of the amount of each invoice until final completion and acceptance of all work covered by the Agreement. 2. Upon submission by the CONTRACTOR of evidence satisfactory to the OWNER that all payrolls, material bills and other costs incurred by the CONTRACTOR in connection with the construction of the work have been paid in full, and also, after all guarantees that may be required in the Specifications have been furnished and are found acceptable by the OWNER, final payment, including any retainage amount, on account of this Agreement shall be made within thirty (30) calendar days after completion of all work by the CONTRACTOR covered by this Agreement and acceptance of such work by the OWNER. ARTICLE VI - ADDITIONAL BONDS It is further mutually agreed between the parties hereto that if, at any time after the execution of this Agreement and the Surety Bonds hereto attached for its faithful performance and payment of labor and materials, the OWNER shall deem the Surety or Sureties upon such bonds to be unsatisfactory, or if, for any reason, such bonds cease to be adequate to cover the performance and payments of the work, the CONTRACTOR shall, at his expense, and within seven (7) days after receipt of Notice from the OWNER to do so, furnish additional bonds, in such form and amounts, and with such Sureties as shall be satisfactory to the OWNER. In such event, no further payment to the CONTRACTOR shall be deemed due under this Agreement until such new or additional security for the faithful performance and for payment of labor and materials of the work shall be furnished in manner and form satisfactory to the OWNER. ARTICLE VII — DISPUTE RESOLUTION - MEDIATION 1. Any claim, dispute or other matter in question arising out of or related to this Agreement shall be subject to mediation as a condition precedent to voluntary arbitration or the institution of legal or equitable proceedings by either party. 2. The OWNER and CONTRACTOR shall endeavor to resolve claims, disputes and other matters in question between them by mediation. 3. The parties shall share the mediator's fee and any filing fees equally. The mediation shall be held in the place where the Project is located, unless another location is mutually agreed upon. Agreements reached in mediation shall be enforceable as settlement agreements in any court having jurisdiction thereof. ARTICLE VIII — INSURANCE AND INDEMNIFICATION RIDER 1. Worker's Compensation Insurance - The CONTRACTOR shall take out and maintain during the life of this Agreement Worker's Compensation Insurance for all his employees connected with the work of this Project and, in case any work is sublet, the CONTRACTOR shall require the subcontractor similarly to provide Worker's Compensation Insurance for all of the latter's employees unless such employees are covered by the protection afforded by the CONTRACTOR. Such insurance shall comply with the Florida Worker's Compensation Law. In case any class of employees engaged in hazardous work under this contract at the site of the Project is not protected under the Worker's Compensation statute, the CONTRACTOR shall provide adequate insurance, satisfactory to the OWNER, for the protection of employees not otherwise protected. 2. Contractor's Public Liability and Property Damage Insurance - The CONTRACTOR shall take out and maintain during the life of this Agreement Comprehensive General Liability and Comprehensive Automobile Liability Insurance as shall protect it from claims for damage for personal injury, including accidental death, as well as claims for property damages which may anse from operating under this Agreement whether such operations are by itself or by anyone directly or indirectly employed by it, and the amount of such insurance shall be minimum limits as follows: (a) Contractor's Comprehensive General, $1,000,000 Each ($2,000,000 aggregate) Liability Coverages, Bodily Injury Occurrence, & Property Damage Combined Single Limit (b) Automobile Liability Coverages, $1,000,000 Each Bodily Injury & Property Damage Occurrence, Combined Single Limit (c) Excess Liability, Umbrella Form $2,000,000 Each Occurrence, Combined Single Limit Insurance clause for both BODILY INJURY AND PROPERTY DAMAGE shall be amended to provide coverage on an occurrence basis. 3. Subcontractor's Public Liability and Property Damage Insurance - The CONTRACTOR shall require each of his subcontractors to procure and maintain during the life of this subcontract, insurance of the type specified above or insure the activities of his subcontractors in his policy, as specified above. 4. Contractor's Protective Liability Insurance - The CONTRACTOR shall procure and furnish a Protective Liability Insurance Policy with the following minimum limits: (a) Bodily Injury Liability & $1,000,000 each ($2,000,000 aggregate) Property Damage Liability Occurrence Combined Single Limit 5. "XCU" (Explosion, Collapse, Underground Damage) - The Contractor's Liability Policy shall provide "XCU" coverage for those classifications in which they are excluded. 6. Broad Form Property Damage Coverage, Products & Completed Operations Coverages - The Contractor's Liability Policy shall include Broad Form Property Damage Coverage, Products and Completed Operations Coverages. 7. Contractual Liability Work Contracts - The Contractor's Liability Policy shall include Contractual Liability Coverage designed to protect the Contractor for contractual liabilities assumed by the Contractor in the performance of this Agreement. 8. Indemnification Rider (a) To cover to the fullest extent permitted by law, the CONTRACTOR shall indemnify and hold harmless the OWNER and its agents and employees from and against all claims, damages, losses and expenses, including but not limited to attorney's fees, arising out of or resulting from the performance of the Work, provided that any such claim, damage, loss or expense (1) is attributable to bodily injury, sickness, disease or death, or to injury to or destruction of tangible property (other than the Work itself) , and (2) is caused in whole or in part by any negligent act or omission of the CONTRACTOR, any subcontractor, anyone directly or indirectly employed by any of them or anyone for whose acts any of them may be liable, regardless of whether or not it is caused in part by a party indemnified hereunder. Such obligation shall not be construed to negate, abridge, or otherwise reduce any other right to obligation of indemnity which would otherwise exist as to any party or person described in this Article. (b) In any and all claims against the OWNER or any of its agents or employees by any employee of the CONTRACTOR, any subcontractor, anyone directly or indirectly employed by any of them or anyone for whose acts any of them may be liable, the indemnification obligations under this Paragraph shall not be limited in any way by any limitation on the amount or type of damages, compensation or benefits payable by or for the CONTRACTOR or any subcontractor under workers' or workmen's compensation acts, disability benefit acts or other employee benefit acts. (c) The CONTRACTOR hereby acknowledges receipt of ten dollars and other good and valuable consideration from the OWNER for the indemnification provided herein. ARTICLE IX - NOTICES All notices shall be in writing and sent by United States mail, certified or registered, with return receipt requested and postage prepaid, or by nationally recognized overnight courier service to the address of the party set forth below. Any such notice shall be deemed given when received by the party to whom it is intended. CONTRACTOR: A.C. Schultes of Florida, Inc. 11865 US Hwy 41, South Gibsonton, FL 33534 Attn.: Gregory Schultes, Vice President OWNER: City of Clermont Attn: Wayne Saunders, City Manager 685 W. Montrose Street Clermont, FL 34711 ARTICLE X — MISCELLANEOUS 1. Attorneys' Fees. In the event a suit or action is instituted to enforce or interpret any provision of this agreement, the prevailing party shall be entitled to recover such sum as the Court may adjudge reasonable as attorneys' fees at trial or on any appeal, in addition to all other sums provided by law. 2. Waiver. The waiver by city of breach of any provision of this agreement shall not be construed or operate as a waiver of any subsequent breach of such provision or of such provision itself and shall in no way affect the enforcement of any other provisions of this agreement. 3. Severability. If any provision of this agreement or the application thereof to any person or circumstance is to any extent invalid or unenforceable, such provision, or part thereof, shall be deleted or modified in such a manner as to make the agreement valid and enforceable under applicable law, the remainder of this agreement and the application of such a provision to other persons or circumstances shall be unaffected, and this agreement shall be valid and enforceable to the fullest extent permitted by applicable law. 4. Amendment. Except for as otherwise provided herein, this agreement may not be modified or amended except by an agreement in writing signed by both parties. 5. Entire Agreement. This agreement including the documents incorporated by reference contains the entire understanding of the parties hereto and supersedes all prior and contemporaneous agreements between the parties with respect to the performance of services by contractor. 6. Assignment. This agreement is personal to the parties hereto and may not be assigned by contractor, in whole or in part, without the prior written consent of city. 7. Venue. The parties agree that the sole and exclusive venue for any cause of action arising out of this agreement shall be Lake County, Florida. 8. Applicable Law. This agreement and any amendments hereto are executed and delivered in the State of Florida and shall be governed, interpreted, construed and enforced in accordance with the laws of the State of Florida. 9. Records. Contractor expressly understands and acknowledges that any and all documents related to the services provided herein, may be considered records that are subject to examination and production in accordance with Florida's Public Records Law. Contractor expressly agrees that it will comply with all requirements related to said law and that it will hold city harmless for any such disclosure related to Florida's Public Records Law. ARTICLE XI - CONTRACT DOCUMENTS The Contract Documents, as listed below are herein made fully a part of this Agreement as if herein repeated. Document Precedence: 1. This Agreement 2. Technical Plan and Specifications 3. All documents contained in RFB No.: 12 -006 Disston Avenue Potable Water Supply Well and Eastside WRF Reclaimed Water Supply Well 4. Instructions to Bidders 5. Drawings 6. Payment and Performance Bonds IN WITNESS WHEREOF, the parties hereto have executed this Agreement on this I`■ day of rebr un r Lk , 2012. City of Clermont 1 1111W _ Ag al11111w R ,, , `� / aro • S. Turville, Jr., Mayor f i r P I ,, 'c:' Atte si' t: r I ` ■x � f � ,, ., Tracy,;Ackroys, City Clerk :f.''..,' A.C. Schultes, of Flonda, Inc . By: A Grego te resi e _ Attest I ' ,,\ � ) ,,,,,r,:,,o , ,,,, J. .rI IL .y,: ' Corp all C �, ,.. t (t 9` �.4 "� (Name Printed or Typed) ay ` ^ 4 ; a A , ,' , ; e, EXHIBIT "A" UNIT PRICE SCHEDULE I ' City of Clermont Bid RFB 12 -006 SECTION — C PRICE SCHEDULE Items below shall include all materials, equipment, labor, permit fees, taxes, tests, miscellaneous cost of all types, overhead, and profit for the item to be complete, In place, and ready for operation in the manner contemplated by the Construction Contract. Respondent submits the following prices to perform all the work as required by the specifications. r <i - ' ' y i; '� •;; : � c - D' escrI tton r .i.; ,. 1 r 4 S RIetEd rCi �t .::.�'; t `� .� P ' EtI Unit,P.rioe'. , : y r ` <. 1- tr∎ Qty / / Unit - . ti . -s. t' r . ALL ,. � r - ) � "�� - 1: - s . _ „; +:..+. ;.= .. ' _ a '-.- i' - ..';�:g- "" -' ;.�. . ':Q , 1 MobillzationlDemobflizatlon (Not to exceed 10- percent of total 1 / LS. base bid) $ sz 6 `dp 2 General Requirements 1 / LS. • 4 3 5 ..i0 3 Indemnification 1 1 LS. $1,000.00 4 Site -work (for two sites) 1 ! LS. ; $ 3000 � t.o Potable SUDDIv Well (Dlsston Avenue) 5 Surface Casing (32 -inch, black steel), Installed 250 ! LF. $ 0,?5`"V $ 6Z,0 6 Final Well casing (24 -Inch, black steel), Installed 350 / LF. $ 22a $ 7 7 wo 7 Cement Grout, Installed 91 /CM. $ IgQ $/ r 2 8 3 8 Limestbnd Gravel, Installed 27 / C.Y. $ [5 $ q f gs 8 Pilo( Hotd Drilling (10 -inch) 950 / LF. $ c 70 $ S 5 moo© - 10 Operi Hole Drilling (23 -inbh) 600 / LF. -$ ! 60 $ 95 000 11 Geophysical Logging 1 1 ! LS. $ 5 12 Video Logging 1 1 / LS. $ / 600 13 Install and Remove Discharge Piping and Appurtenances 1 ! LS. $ 5'0'09 14 Well Development 40 1 HRS $ $ 8000 15 Step Drawdown Test 41 HRS $ �),/a $ L 30Q 16 Geophysical Logging 2 1 / LS. c $ �"'a 0 17 Video Logging 2 1 / LS. . $ / 500 RFB 12 -008 Page 11 of 41 Nov 23, 2011 1Z29:56 AM EST p. 21 1 City of Clermont Bid RFB 12 -006 SECTION — C PRICE SCHEDULE 18 Specific Capacity Test 8 / HRS 19 WeU Disinfection 1 / L.S. $ /COO 20 Plumbness and Alignment Test 1 /'LS. $ 1e00 21 Well Flange Cap 1 / LS. $ /593 Reclaimed Supply Well C/V 22 VIdeo_Loggtng 1 1 / LS. $ /560 23 Geophysical Logging 1 (includes high velocity dynamicllow 1 / LS $ logging) 24 Single Element Packer Testing 2 / E.A. $ It.ZJY)7 $ 1ZCZO 25 Final Well Casing (10 -Inch, black steep, Installed 80 ! LF. $ 3 $ eio (! 26 Cement Grout, Installed 51 C.Y. $ $ l� lam �' 27 Limestone Gravel, Installed 2 / C.Y. $ /� L $ 310 28 Well Development 401 HRS $ S 29 Geophysical Logging 2 1 ! LS.. $ Serb) 30 Video Logging 2 • 1 / LS. 5 / --��CC JJ 31 Step Drawdown Test 4 ! HRS $ $ 32 Install and Remove Discharge Piping and Appurtenances 1 / LS. $ 33 Well Disinfection 1 ! LS. ,$ 007 34 Plumbness & Alignment Test 1 / L.S: $ �j I Co(�J 35 Concrete Pad' and Flange Cap 1 ! LS. $ .,.�:.; ; 110TALBASE BID (SUM OFtI THROUGH ,:.. $5 5 27g Additive Alternate item '36 [Borehole Pondffloning, 15 -inch, 280 ft. to 600 ft. { 1 / LS. $ 2090 y�^ TUT:4L B ASE�'BID�PL'L4S,QLTERNA E }(SUMO - I,TEh75 - 1 =TNROUGFi 36) T ,$ 1 37 . • ' RFB No: 12 -006 Page 12 of 41 Nov 23, 2011 12:20:56 AM EST P n SECTION — C REVISED PRICE SCHEDULE Contractor's Days to Substantial Completion for Potable Water Supply: v'® Working Days. Not to exceed: one- hundred fifty (150) working days from Notice To Proceed. Contractor's days to Final Completion and ready for final payment is within one - hundred eighty (180) working days from Notice To Proceed for Potable Water Supply. Contractor's Days to Substantial Completion for Reclaimed Supply Well: 40 Working Days. Not to exceed: sixty (60) working days from Notice to Proceed. (Notice 'to Proceed fot Reclaimed Supply Well will be issued by the City at a later date to coincide with reduced traffic near Windy Hill Middle School). Contractor's days to Final Completion and ready for final payment is within ninety (90) working days from Notice To Proceed for Reclaimed Supply Well. By signing below, the respondent agrees to all terms, conditions, and specifcations as stated in this solicitation, and Is acting In an arlthorized capacity to execute this response. The respondent also certifies that It can and Will proWde and make-available, at a minimum, the items set forth in this solicitation. RespDndont,lnformation and''Signature Company Name (print): AC Schultes of Florida Street Address: 11865 US Hwy 41 South Gibsonton,. Florida 33534 Mafing Addrese (If different): Telephone: (813)741 -3010 Fax (813)741 -3178 Emait Greg.aCsf @vertzon.net Payment TOMB: % days, net FEIN: 14 - 187 7186 Professional. License No.: CGC151,6532 Signature: Date: Print Name: •Sch Title: Vice President Does the respondent accept payment using the City's MASTERCARD? ❑ ¥ps 0 No END OF SECTION — C RFB No: 12-006 111 Page 13 of 41 Bond No. SU1115363 PERFORMANCE BOND KNOW ALL MEN BY THESE PRESENTS: That we A C Schultes of Florida, Inc 11865 Highway 41 South Gibsonton, FL 33534 , Principal, and Arch Insurance Company , Surety, are held and firmly bound unto City of Clermont 685 West Montrose Street Clermont, FL , Obligee, in the sum of Five Hundred Thirty Three Thousand Three Hundred Seventy Five Dollars and 00/100 Dollars ($ 533,375 00 ) for the payment of which we bind ourselves, our legal representative, successors and assigns, jointly and severally, firmly by these presents. WHEREAS, Principal has entered into a contract with Obligee, dated February 14, 2012 for RFB No 12 -006, Disston Avenue Potable Water Supply Well and Eastside WRF Reclaimed Water Supply Well copy of which contract Is by reference made a part hereof. NOW, THEREFORE, if Principal shall faithfully perform such contract or shall Indemnify and save harmless the Obligee from all cost and damage by reason of Principal's failure so to do, then this obligation shall be null and void; otherwise it shall remain in full force and effect. Signed, sealed, and dated February 24, 2012 A C Schultes of Florida, Inc (Seal) (Principal) By A � __ 1 (Seal) (Pdndpal) Arch Insurance pany Daniel P Dun - an Attorney - - Fact Bond No. SU1115363 PAYMENT BOND KNOW ALL MEN BY THESE PRESENTS: That A C Schultes of Florida, Inc 11865 Highway 41 South Gibsonton, FL 33534 , Principal, and Arch Insurance Company Surety, are held and firmly bound unto City of Clermont 685 West Montrose Street Clermont, FL , Obligee, in the sum of Five Hundred Thirty Three Thousand Three Hundred Seventy Five Dollars and 00/100 Dollars ($ 533,375 00 ), for the payment of which we bind ourselves, our legal representatives, successors and assigns, jointly and severally, firmly by these presents. WHEREAS, Principal has entered into a contract with Obligee, dated February 14, 2012 for RFB No 12 -006, Disston Avenue Potable Water Supply Well and Eastside WRF Reclaimed Water Supply Well copy of which contract is by reference made a part hereof. NOW, THEREFORE, if Principal shall, in accordance with applicable Statutes, promptly made payment to all persons supplying labor and material in the prosecution of the work provided for in said contract, and any and all duly authorized modifications of said contract that may hereafter be made, notice of which modifications to Surety being waived, then this obligation to be void; otherwise to remain in full force and effect. SIGNED, SEALED AND DATED February 24, 2012 A C Schultes of Flonda, Inc () Arch Insurance Company (Surety) B Daniel P Duni an Attomeyact • • AIC 0000002332 THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS PRINTED ON BLUE BACKGROUND. This Power of Attorney limits the acts of those named herein, and they have no authority to bind the Company except in the manner and to the extent herein stated. Not valid for Mortgage, Note, Loan, Letter of Credit, Bank Deposit, Currency Rate, Interest Rate or Residential Value Guarantees. POWER OF ATTORNEY Know All Persons By These Presents That the Arch Insurance Company, a corporation organized and existing under the laws of the State of Missouri, having its principal administrative office in Jersey City, New Jersey (hereinafter referred to as the "Company ") does hereby appoint Brian C Block, Daniel P Dungan, James L Hahn, James L Hahn, Joseph W. Kolok, Jr., Richard J Decker and William F Simkiss of Paoli, PA (EACH) its true and lawful Attomey(s)in -Fact, to make, execute, seal, and deliver from the date of issuance of this power for and on its behalf as surety, and as its act and deed - - Any and all bonds, undertakings, recognizances and other surety obligations, in the penal sum not exceeding Ninety Million Dollars ($90,000,000 00) This authority does not permit the same obligation to be split into two or more bonds In order to bring each such bond within the dollar limit of authority as set forth herein The execution of such bonds, undertakings, recognizances and other surety obligations in pursuance of these presents shall be as binding upon the said Company as fully and amply to all intents and purposes, as if the same had been duly executed and acknowledged by its regularly elected officers at its principal administrative office in Jersey City, New Jersey This Power of Attorney is executed by authority of resolutions adopted by unanimous consent of the Board of Directors of the Company on September 15, 2011, true and accurate copies of which are hereinafter set forth and are hereby certified to by the undersigned Secretary as being in full force and effect. "VOTED, That the Chairman of the Board, the President, or the Executive Vice President, or any Senior Vice President, of the Surety Business Division, or their appointees designated in writing and filed with the Secretary, or the Secretary shall have the power and authority to appoint agents and attorneys -in -fact, and to authorize them subject to the limitations set forth in their respective powers of attorney, to execute on behalf of the Company, and attach the seal of the Company thereto, bonds, undertakings, recognizances and other surety obligations obligatory in the nature thereof, and any such officers of the Company may appoint agents for acceptance of process " This Power of Attorney is signed, sealed and certified by facsimile under and by authonty of the following resolution adopted by the unanimous consent of the Board of Directors of the Company on September 15, 2011 VOTED, That the signature of the Chairman of the Board, the President, or the Executive Vice President, or any Senior Vice President, of the Surety Business Division, or their appointees designated in writing and filed with the Secretary, and the signature of the - Secretary, the seal of the Company, and certifications by the Secretary, may be affixed by facsimile on any power of attorney or bond executed pursuant to the resolution adopted by the Board of Directors on September 15, 2011, and any such power so executed, sealed and certified with respect to any bond or undertaking to which it is attached, shall continue to be valid and binding upon the Company 00ML0013 00 03 03 Page 1 of 2 Printed in U.S.A. . { AIC 0000002332 In Testimony Whereof, the Company has caused this instrument to be signed and its corporate seal to be affixed by their authorized officers, this 12 day of January, 2012 Attested and Certified Arch Insurance Company f ence AA/ a (wevvilt id Ai .,...4._ 4 1 v , ___________ iirrl '�Yr Martin J Nilson, Secretary David M in <e stein, Executive Vice President STATE OF PENNSYLVANIA SS COUNTY OF PHILADELPHIA SS I, Kathleen Marcinkus, a Notary Public, do hereby certify that Martin J Nilsen and David M Finkelstein personally known to me to be the same persons whose names are respectively as Secretary and Executive Vice President of the Arch Insurance Company, a Corporation organized and existing under the laws of the State of Missouri, subscribed to the foregoing instrument, appeared before me this day in person and severally acknowledged that they being thereunto duly authorized signed, sealed with the corporate seal and delivered the said instrument as the free and voluntary act of said corporation and as their own free and voluntary acts for the uses and purposes therein set forth Goitartitner q� acIFEN vAisA . N TARCSEAL l tlfo1 n1b1e17Ygt9a eor Kat leen Marcinkus, Not Public My commission expires /14/2014 CERTIFICATION I, Martin J Nilsen, Secretary of the Arch Insurance Company, do hereby certify that the attached Power of Attorney dated January 12, 2012 on behalf of the person(s) as listed above is a true and correct copy and that the same has been in full force and effect since the date thereof and is in full force and effect on the date of this certificate, and I do further certify that the said David M Finkelstein, who executed the Power of Attorney as Executive Vice President, was on the date of execution of the attached Power of Attomey the duly elected Executive Vice President of the Arch Insurance Company IN TESTIMONY WHEREOF, I have hereunto subscnbed my name and affixed the corporate seal of the Arch Insurance Company on this 94th day of F 2042_ , I artin J NiIsJn, Secretary This Power of Attorney limits the acts of those named therein to the bonds and undertakings specifically named therein and they have no authonty to bind the Company except in the manner and to the extent herein stated. PLEASE SEND ALL CLAIM INQUIRIES RELATING TO THIS BOND TO THE FOLLOWING ADDRESS: Arch Insurance — Surety Division 3 Philadelphia, , PA 1500 ....."Zicks Philadelphia, PA 19102 4) 1, 00ML0013 00 03 03 Page 2 of 2 Printed in U.S.A. I ACGREP CERTIFICATE OF LIABILITY INSURANCE 2� ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME. Odell Studner Group, LLC H. OO E 610- 995 -0948 is , Ne) 610 - 995 -0105 Three Radnor Corporate Center EMAIL 100 Matsonford Road, Ste 100 ADDRESS* Radnor PA 19087 INSURER(S) AFFORDING COVERAGE NAIC # INSURERA Mt Hawley Insurance Company 37974 INSURED INSURERB Hartford Fire Insurance Co 19682 A C Schultes of Flonda, Inc INSURERC Starr Indemnity & Liab Co 38318 11865 US Highway 41 South INSURERD .Hanover Insurance Company 22292 Glbsonton FL 33534 INSURER E • INSURER F . COVERAGES CERTIFICATE NUMBER: 2127510399 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDL SUER ' POUCY EFF POUCY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) (MM/DD/YYYY) LIMITS B GENERAL LIABILITY 39UENOH1483 7/1/2011 7/1/2012 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREM SES Ea occurrence) $500,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $10,000 PERSONAL BADV INJURY _ $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $2,000,000 7 POLICY n Fi n LOC $ B AUTOMOBILE LIABILITY 39UENOH1484 7/1/2011 7/1/2012 COMBINED SINGLE LIMIT X (Ea accident) _$1,000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident $ AUTOS AUTOS ( ) X HIRED AUTOS X NON OWNED PROPERTY DAMAGE AUTOS (Perecadent) $ $ C UMBRELLA UAB X OCCUR SISCSEL01536011 7/1/2011 7/1/2012 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE _ 05,000,000 DED 1 RETENTION $ $ B WORKERS COMPENSATION 39WE0H1482 7/1/2011 7/1/2012 X AND EMPLOYERS' LIABILITY Y I N I TORY WC STATU- D LIMITS I ER TH- ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED' N /A E L EACH ACCIDENT 51,000,000 (Mandatory In NH) E L DISEASE - EA EMPLOYEE $1,000,000 If yes, deealbe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $1,000,000 A Bus Personal Property MCP0154827 4/15/2011 4/15/2012 Limit $163,274 RHC7670583 7/1/2011 7/1/2012 Deductible $5,000 Builders Risk/Installation Limit $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, K more apace le required) Commerce and Industry Insurance Company(NAIC#19410) Policy # CPO 19176288 - Pollution Liability - $1,000,000 Each Occurrence /$1,000,000 Aggregate - Deductible $10,000 Policy Term 07/01/2011 to 07/01/2012 Re 12-006 Disston Avenue Potable Water Supply Well Eastside WRF Reclaimed Water Supply Well City of Clearmont is included as Additional Insured where required by wntten contract CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Clearmont ACCORDANCE WITH THE POLICY PROVISIONS. 685 West Montrose St Clermont FL 34711 AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Fomi W -9 Request for Taxpayer Give Form to the (Rev January2011) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service Name (as shown on your income tax retum) A C Schultes of Florida, Inc Business name/disregarded entity name, if different from above ai rn at Check appropnate box for federal tax y classification (required) ❑ Individual/sole propnetor D C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate c� + ❑ Limited liability company Enter the tax classification (C=C corporation, S =S corporation, P =partnership) ► ❑Exempt payee c t , ❑ Other (see instructions) • Address (number, street, and apt or suite no) Requester's name and address (optional) e o, 11865 US HWY 41 CI) City, state, and ZIP code Gibsonton, Florida 33534 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 the "Name" line 1 Social security number to avoid backup withholding. For individuals, this is your social secunty number (SSN). However, for a resident alien, sole propnetor, or disregarded entity, see the Part I instructions on page 3. For other — — entities, it is your employer identification number (EIN) If you do not have a number, see How to get a TIN on page 3 Note. If the account Is in more than one name, see the chart on page 4 for guidelines on whose I Employer identification number number to enter. 1 4 - 1 8 7 1 1 8 6 Part II Certification Under penalties of penury, 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) 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, contnbutions 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 on page 4 Sign Signature of Here U.S. person • Date • General Instructions Note. If 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 Section references are to the Internal Revenue Code unless otherwise to this Form W -9. noted Definition of a U.S. person. For federal tax purposes, you are Purpose of Form considered a U S. person if you are: A person who is required to file an information retum with the IRS must • An individual who is a U.S citizen or U.S resident alien, obtain your correct taxpayer identification number (TIN) to report, for • A partnership, corporation, company, or association created or example, income paid to you, real estate transactions, mortgage interest organized in the United States or under the Taws of the United States, you paid, acquisition or abandonment of secured property, cancellation • An estate (other than a foreign estate), or of debt, or contnbutions you made to an IRA Use Form W -9 onl it you are a U.S • person (including a resident • A domestic trust (as defined in Regulations section 301.7701 -7) y y alien), to provide your correct TIN to the person requesting it (the Special rules for partnerships. Partnerships that conduct a trade or requester) and, when applicable, to business in the United States are generally required to pay a withholding 1. Certify that the TIN you are giving is correct (or you are waiting for a tax on any foreign partners' share of income from such business number to be Issued), Further, in certain cases where a Form W -9 has not been received, a partnership is required to presume that a partner is a foreign person, 2. Certify that you are not subject to backup withholding, or and pay the withholding tax Therefore, If you are a U.S person that is a 3. Claim exemption from backup withholding if you are a U.S. exempt partner in a partnership conducting a trade or business in the United payee If applicable, you are also certifying that as a U S person, your States, provide Form W -9 to the partnership to establish your U S allocable share of any partnership income from a U S trade or business status and avoid withholding on your share of partnership income is not subject to the withholding tax on foreign partners' share of - effectively connected income. Cat No 10231X Form W -9 (Rev 1 -2011) i Form W -9 (Rev 1 -2011) Page 2 The person who gives Form W -9 to the partnership for purposes of Certain payees and payments are exempt from backup withholding establishing its U S status and avoiding withholding on its allocable See the instructions below and the separate Instructions for the share of net income from the partnership conducting a trade or business Requester of Form W -9 in the United States is in the following cases. Also see Special rules for partnerships on page 1. • The U.S owner of a disregarded entity and not the entity, Updating Your Information • The U.S grantor or other owner of a grantor trust and not the trust, and You must provide updated information to any person to whom you • The U.S trust (other than a grantor trust) and not the beneficianes of claimed to be an exempt payee if you are no longer an exempt payee the trust and anticipate receiving reportable payments in the future from this person For example, you may need to provide updated information if Foreign person. If you are a foreign person, do not use Form W -9 you are a C corporation that elects to be an S corporation, or if you no Instead, use the appropnate Form W -8 (see Publication 515, longer are tax exempt. In addition, you must furnish a new Form W -9 if Withholding of Tax on Nonresident Aliens and Foreign Entities) the name or TIN changes for the account, for example, if the grantor of a Nonresident alien who becomes a resident alien. Generally, only a grantor trust dies nonresident alien individual may use the terms of a tax treaty to reduce Penalties or eliminate U S. tax on certain types of income However, most tax treaties contain a provision known as a "saving clause " Exceptions Failure to furnish TIN. If you fail to furnish your correct TIN to a specified in the saving clause may permit an exemption from tax to requester, you are subject to a penalty of $50 for each such failure continue for certain types of income even after the payee has otherwise unless your failure is due to reasonable cause and not to willful neglect become a U S resident alien for tax purposes Civil penalty for false information with respect to withholding. If you If you are a U.S. resident alien who is relying on an exception make a false statement with no reasonable basis that results in no contained in the saving clause of a tax treaty to claim an exemption backup withholding, you are subject to a $500 penalty from U S tax on certain types of income, you must attach a statement Criminal penalty for falsifying information. Willfully falsifying to Form W -9 that specifies the following five items certifications or affirmations may subject you to criminal penalties 1 The treaty country. Generally, this must be the same treaty under including fines and/or impnsonment which you claimed exemption from tax as a nonresident alien. Misuse of TINs. If the requester discloses or uses TINs in violation of 2 The treaty article addressing the income federal law, the requester may be subject to civil and cnminal penalties 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions Specific Instructions 4 The type and amount of income that qualifies for the exemption Name from tax. r 5 Sufficient facts to justify the exemption from tax under the terms of If you are an individual, you must generally enter the name shown on the treaty article your income tax return However, if you have changed your last name, for instance, due to mamage without informing the Social Secunty Example. Article 20 of the U.S -China income tax treaty allows an Administration of the name change, enter your first name, the last name exemption from tax for scholarship income received by a Chinese shown on your social secunty card, and your new last name student temporanly present in the United States Under U S law, this student will become a resident alien for tax purposes if his or her stay in If the account is in joint names, list first, and then circle, the name of the United States exceeds 5 calendar years However, paragraph 2 of the person or entity whose number you entered in Part I of the form the first Protocol to the U S -China treaty (dated Apnl 30, 1984) allows Sole proprietor. Enter your individual name as shown on your income the provisions of Article 20 to continue to apply even after the Chinese tax retum on the "Name" line. You may enter your business, trade, or student becomes a resident alien of the United States A Chinese "doing business as (DBA)" name on the "Business name /disregarded i student who qualifies for this exception (under paragraph 2 of the first entity name" line protocol) and is relying on this exception to claim an exemption from tax Partnership, C Corporation, or s Corporation. Enter the entity's name on his or her scholarship or fellowship income would attach to Form on the "Name" line and any business, trade, or "doing business as I W -9 a statement that includes the information descnbed above to (DBA) name" on the "Business name /disregarded entity name" line support that exemption If you are a nonresident alien or a foreign entity not subject to backup Disregarded entity. Enter the owner's name on the "Name" line The name of the entity entered on the "Name" line should never be a withholding, give the requester the appropnate completed Form W -8 disregarded entity. The name on the "Name" line must be the name What is backup withholding? Persons making certain payments to you shown on the income tax retum on which the income will be reported must under certain conditions withhold and pay to the IRS a percentage For example, if a foreign LLC that is treated as a disregarded entity for of such payments This is called "backup withholding " Payments that U.S federal tax purposes has a domestic owner, the domestic owner's may be subject to backup withholding include interest, tax- exempt name is required to be provided on the "Name" line If the direct owner interest, dividends, broker and barter exchange transactions, rents, of the entity is also a disregarded entity, enter the first owner that is not royalties, nonemployee pay, and certain payments from fishing boat disregarded for federal tax purposes Enter the disregarded entity's operators. Real estate transactions are not subject to backup name on the "Business name /disregarded entity name" line If the owner withholding. of the disregarded entity is a foreign person, you must complete an You will not be subject to backup withholding on payments you appropnate Form W -8 receive rf you give the requester your correct TIN, make the proper Note. Check the appropriate box for the federal tax classification of the certifications, and report all your taxable interest and dividends on your person whose name is entered on the "Name" line (Individual/sole tax return propnetor, Partnership, C Corporation, S Corporation, Trust/estate) Payments you receive will be subject to backup Limited Liability Company (LLC). If the person identified on the withholding if: "Name" line is an LLC, check the "Limited liability company" box only 1 You do not furnish your TIN to the requester, and enter the appropnate code for the tax classification in the space provided. If you are an LLC that is treated as a partnership for federal 2. You do not certify your TIN when required (see the Part II tax purposes, enter "P" for partnership If you are an LLC that has filed a instructions on page 3 for details), Form 8832 or a Form 2553 to be taxed as a corporation, enter "C" for 3. The IRS tells the requester that you furnished an incorrect TIN, C corporation or "S" for S corporation If you are an LLC that is 4 The IRS tells you that you are subject to backup withholding disregarded as an entity separate from its owner under Regulation because you did not report all your interest and dividends on your tax section the LLC box (except for employment owner t and (required tax), be retum (for reportable interest and dividends only), or not check the LLC bo the w s another f a the LLC t is not d to ge identified on the "Name" line) is another LLC that is not disregarded for 5. You do not certify to the requester that you are not subject to federal tax purposes If the LLC is disregarded as an entity separate backup withholding under 4 above (for reportable interest and dividend from its owner, enter the appropnate tax classification of the owner accounts opened after 1983 only). identified on the "Name" line. Form W -9 (Rev 1 -2011) Page 3 Other entities. Enter your business name as shown on required federal Part I. Taxpayer Identification Number (TIN) tax documents on the "Name" line This name should match the name shown on the charter or other legal document creating the entity You Enter your TIN in the appropriate box. If you are a resident alien and may enter any business, trade, or DBA name on the "Business name/ you do not have and are not eligible to get an SSN, your TIN is your IRS disregarded entity name" line individual taxpayer identification number (ITIN) Enter it in the social secunty number box If you do not have an ITIN, see How to get a TIN Exempt Payee below If you are exempt from backup withholding, enter your name as If you are a sole proprietor and you have an EIN, you may enter either descnbed above and check the appropriate box for your status, then your SSN or EIN However, the IRS prefers that you use your SSN check the "Exempt payee" box in the line following the "Business name/ If you are a single- member LLC that is disregarded as an entity disregarded entity name," sign and date the form separate from its owner (see Limited Liability Company (LLC) on page 2), Generally, individuals (including sole propnetors) are not exempt from enter the owner's SSN (or EIN, if the owner has one) Do not enter the backup withholding Corporations are exempt from backup withholding disregarded entity's EIN If the LLC is classified as a corporation or for certain payments, such as interest and dividends partnership, enter the entity's EIN Note. If you are exempt from backup withholding, you should still Note. See the chart on page 4 for further clanfication of name and TIN complete this form to avoid possible erroneous backup withholding combinations The following payees are exempt from backup withholding 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 Secunty 1 An organization exempt from tax under section 501(a), any IRA, or a Card, from your local Social Security Administration office or get this custodial account under section 403(b)(7) if the account satisfies the form online at www.ssa gov You may also get this form by calling requirements of section 401(f)(2), 1- 800 - 772 -1213 Use Form W -7, Application for IRS Individual Taxpayer 2 The Unrted States or any of its agencies or instrumentalities, Identification Number, to apply for an ITIN, or Form SS -4, Application for 3 A state, the Distnct of Columbia, a possession of the United States, Employer Identification Number, to apply for an EIN You can apply for or any of their political subdivisions or instrumentalities, an EIN online by accessing the IRS website at www.irs.gov/businesses 4 and clicking on Employer Identification Number (EIN) under Starting a A foreign government or any of its political subdivisions, agencies, Business You can get Forms W -7 and SS -4 from the IRS by visiting or instrumentalities, or IRS gov or by calling 1- 800 -TAX -FORM (1- 800 - 829 - 3676). 5. An international organization or any of its agencies or If you are asked to complete Form W -9 but do not have a TIN, write instrumentalities "Applied For" in the space for the TIN, sign and date the form, and give Other payees that may be exempt from backup withholding include it to the requester. For interest and dividend payments, and certain 6 A corporation, payments made with respect to readily tradable instruments, generally 7. A foreign central bank of issue, you will 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 8 A dealer in securities or commodities required to register in the not apply to other types of payments You will be subject to backup United States, the District of Columbia, or a possession of the United withholding on all such payments until you provide your TIN to the States, requester. 9 A futures commission merchant registered with the Commodity Note. Entenng "Applied For" means that you have already applied for a Futures Trading Commission, TIN or that you intend to apply for one soon 10 A real estate investment trust, Caution: A disregarded domestic entity that has a foreign owner must 11 An entity registered at all times dunng the tax year under the use the appropriate Form W -8. Investment Company Act of 1940, Part II. Certification 12. A common trust fund operated by a bank under section 584(a), To establish to the withholding agent that you are a U.S 13 A financial institution, 9 9 Y person, or resident alien, sign Form W -9 You may be requested to sign by the 14 A middleman known in the investment community as a nominee or withholding agent even if item 1, below, and items 4 and 5 on page 4 custodian, or indicate otherwise 15 A trust exempt from tax under section 664 or descnbed in section For a joint account, only the person whose TIN is shown in Part I 4947 should sign (when required) In the case of a disregarded entity, the person identified on the "Name" line must sign. Exempt payees, see The following chart shows types of payments that may be exempt from backup withholding The chart applies to the exempt payees listed Exempt Payee on page 3. above, 1 through 15. Signature requirements. Complete the certification as indicated in items 1 through 3, below, and items 4 and 5 on page 4 IF the payment is for ... THEN the payment is exempt 1. Interest, dividend, and barter exchange accounts opened for ... before 1984 and broker accounts considered active during 1983. Interest and dividend payments All exempt payees except You must give your correct TIN, but you do not have to sign the certification for 9 Broker transactions Exempt payees 1 through 5 and 7 2. Interest, dividend, broker, and barter exchange accounts through pa s 1 t ro opened after 1983 and broker accounts considered inactive during g corporations 1983. You must sign the certification or backup withholding will apply. If Barter exchange transactions and Exempt payees 1 through 5 you are subject to backup withholding and you are merely providing patronage dividends your correct TIN to the requester, you must cross out item 2 in the certification before signing the form Payments over $600 required to be Generally, exempt payees 3. Real estate transactions. You must sign the certification You may reported and direct sales over 1 through 7 $5,000' cross out item 2 of the certification ' See Form 1099 -MISC, Miscellaneous Income, and its instructions '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, and payments for services paid by a federal executive agency Form W -9 (Rev 1 -2011) Page 4 4. Other payments. You must give your correct TIN, but you do not Note. If no name is circled when more than one name is listed, the have to sign the certification unless you have been notified that you number will be considered to be that of the first name listed have previously given an Incorrect TIN "Other payments" include payments made in the course of the requester's trade or business for Secure Your Tax Records from Identity Theft rents, royalties, goods (other than bills for merchandise), medical and Identity theft occurs when someone uses your personal information health care services (including payments to corporations), payments to such as your name, social secunty number (SSN), or other identifying a nonemployee for services, payments to certain fishing boat crew information, without your permission, to commit fraud or other cnmes members and fishermen, and gross proceeds paid to attorneys An identity thief may use your SSN to get a job or may file a tax retum (including payments to corporations) using your SSN to receive a refund 5. Mortgage interest paid by you, acquisition or abandonment of To reduce your risk• secured property, cancellation of debt, qualified tuition program . protect your SSN, payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You • Ensure your employer is protecting your SSN, and must give your correct TIN, but you do not have to sign the certification • Be careful when choosing a tax preparer. If your tax records are affected by identity theft and you receive a What Name and Number To Give the Requester notice from the IRS, respond nght away to the name and phone number For this type of account Give name and SSN of punted on the IRS notice or letter If your tax records are not currently affected by identity theft but you 1 Individual The individual think you are at nsk due to a lost or stolen purse or wallet, questionable 2 Two or more Individuals Cant The actual owner of the account or, credit card activity or credit report, contact the IRS Identity Theft Hotline account) if combined funds, the first at 1 - 908 - 4490 or submit Form 14039. individual on the account' 3 Custodian account of a minor The minor: For more information, see Publication 4535, Identity Theft Prevention (Uniform Grft to Minors Act) and Victim Assistance 4 a The usual revocable savings The grantor - trustee' Victims of identity theft who are expenencing economic harm or a trust (grantor is also trustee) system problem, or are seeking help in resolving tax problems that have b So called trust account that Is The actual owner not been resolved through normal channels, may be eligible for not a legal or valid trust under Taxpayer Advocate Service (TAS) assistance. You can reach TAS by state law calling the TAS toll -free case intake line at 1- 877 - 777 -4778 or TTY/TDD 5 Sole propnetorship or disregarded The owner ° 1 - 800 - 829 - 4059. entity owned by an individual 6 Grantor trust filing under Optional The grantor' Protect yourself from suspicious emails or phishing schemes. Form 1099 Filing Method 1 (see Phishing is the creation and use of email and websites designed to Regulation section 1 671 4(b)(2)(i)(/)) mimic legitimate business emails and websites The most common act For this type of account Give name and EIN of is sending an email to a user falsely claiming to be an established legitimate enterpnse in an attempt to scam the user into surrendering 7 Disregarded entity not owned by an The owner pnvate information that will be used for identity theft individual 8 A valid trust, estate, or pension trust Legal entity The IRS does not initiate contacts with taxpayers via emails. Also, the 9 Corporation or LLC electing The corporation IRS does not request personal detailed information through email or ask corporate status on Form 8832 or taxpayers for the PIN numbers, passwords, or similar secret access Form 2553 information for their credit card, bank, or other financial accounts 10 Association, club, religious, The organization If you receive an unsolicited email claiming to be from the IRS, chantable, educational, or other forward this message to phfshfng @irs gov. You may also report misuse tax exempt organization of the IRS name, logo, or other IRS property to the Treasury Inspector 11 Partnership or multi member LLC The partnership General for Tax Administration at 1- 800 - 366 -4484. You can forward 12 A broker or registered nominee The broker or nominee suspicious emails to the Federal Trade Commission at spam @uce.gov 13 Account with the Department of The public entity or contact them at www.ftc govlidtheft or 1 - 877 - IDTHEFT Agnculture in the name of a public (1 - 877 - 438 - 4338) entity (such as a state or local Visit IRS gov to learn more about identity theft and how to reduce govemment, school distnct, or - your nsk pnson) that receives agncultural program payments 14 Grantor trust filing under the Form The trust 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulation section 1 671- 4(b)(2)O(B)) ' List first and circle the name of the person whose number you furnish If only one person on a Joint account has an SSN, that person's number must be furnished 2 Circle the minor's name and furnish the minor's SSN 'You must show your indmdual name and you may also enter your business or 'DIM" name on the "Business name/disregarded entity" name line You may use either your SSN or EIN (ff you have one), but the IRS encourages you to use your SSN ° List 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 ) Also see Special rules for partnerships on page 1 *Note. Grantor also must provide a Form W -9 to trustee of trust 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 retums 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 contnbutions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file Information retums with the IRS, reporting the above information Routine uses of this information include giving it to the Department of Justice for cml and criminal litigation and to cities, states, the District of Columbia, and U S possessions for use in administenng their laws The information also may be disclosed to other countnes under a treaty, to federal and state agencies to enforce civil and cnrninal laws, or to federal law enforcement and intelligence agencies to combat terronsm You must provide your TIN whether or not you are required to file a tax retum Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer Certain penalties may also apply for providing false or fraudulent Information