HomeMy WebLinkAboutA6901 - JEANETTE JAIME V CITY OF PALM SPRINGS p�b�al
Memorandum
To: Geoff Kiehl, Director of Finance
James Thompson, City Clerk
From: Douglas Holland, City Attorney
Date: August 18, 2016
Re: Settlement of Jeanette Jaime v. City of Palm Springs
At the City Council's closed session of June 1, 2016, the City Council approved a
settlement in accordance with the terms of the settlement agreement and release
attached to this memorandum. Pursuant to the terms of the settlement agreement, the
City is obligated to pay the sum of$26,750.00. Please prepare a check in the amount of
$26,750.00 payable to "Center for Disability Access" I have also attached a copy of the
applicable W-9 for your files. Please mail the check to Laura Perez, Assistant to
Caroline Byrne at my firm's Costa Mesa mailing address. Thanks.
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SETTLEMENT AGREEMENT AND RELEASE
1. PARTIES: The parties to this Agreement of Settlement and Release ("Agreement") are JEANETTE
JAIME("Plaintiff') on the one hand, and CITY OF PALM SPRINGS ("Defendant") on the other hand
(collectively"the Parties").
2. RECITALS: This Agreement is made with reference to the following facts:
2.1. Defendant owns real property located at 4365 Mesquite Avenue in the City of Palm Springs,County of
Riverside, California. This property,which is the subject of the Disputes between the Parties referenced
in Paragraphs 2.2 and 2.3 below, is hereinafter referred to as"Demuth Park."
2.2. Certain disputes and controversies(the"Disputes")have arisen between the Parties hereto.
2.3. The Disputes are set forth by Plaintiff in a civil action pending in the United States District Court,
Central District of Califomia, entitled JEANETTE JAMIE v. CITY OF PALM SPRINGS, et al., Case
No.5:15-CV-01953-AB-KK(the"Lawsuit").
2.4. In the Lawsuit, Plaintiff claims, inter alia, that the Facility does not comply with the Americans with
Disabilities Act, 42 U.S.C. § 12101 et sec., the Unruh Act, Cal. Civil Code § 51 et seq., and other
statutes. Defendant has denied,and continues to deny,these claims.
2.5. It is the intention of the Parties to settle and dispose of, fully and completely,the Disputes and any and
all claims, potential claims, complaints, demands, and causes of action reflected in the Lawsuit or
relating to Demuth Park.
NOW,THEREFORE,the Parties agree as follows:
3. COMPLIANCE: Defendant will use reasonable and good faith efforts to ensure construction relating to
the improvements to remediate the issues identified in the Lawsuit is started and completed in a
reasonably timely manner.
4. PAYMENT: Within thirty (30) days after execution of this Agreement by the parties, and as a
condition to Plaintiff's duty to dismiss,Defendant shall pay the total sum of Twenty Six Thousand Seven
Hundred and Fifty Dollars($26,750)to Plaintiff and her counsel in the form of a check made payable to
"Center for Disability Access". There shall be no other payment by or to any Party. The details relating
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to the case name and case number shall be included along with the settlement payment and the payment
shall be send to P.O. Box 262490, San Diego, CA 92196-2490. The Tax Identification Number for
Center for Disability Access is 33-0855260,
5. DISMISSAL: After receipt of the payment set forth in Paragraph 4 of this Agreement, Plaintiff shall
dismiss the Lawsuit with prejudice, each Party bearing its own attorneys' fees, experts' fees, and costs.
Each Party hereby irrevocably authorizes and directs its attorneys of record to execute and deliver to the
court the Dismissal with Prejudice, so that the same may be filed with the Court in accordance with this
Agreement.
6. RELEASES AND COVENANTS: In consideration of the mutual releases contained herein, and for
other good and valuable consideration, the receipt of which is acknowledged by each Party, the Parties
promise,agree, and release as follows:
6.1. Except as to such rights or claims as may be created by this Agreement, Plaintiff and Defendant hereby
release, remise, and forever discharge each other Party hereto from any and all claims, potential claims,
demands, and cause or causes of action reflected in the Lawsuit, and any other claims, demands, or
causes of action which may have arisen from the same or similar operative facts as those alleged in the
Lawsuit.
6.2 There is a risk that, after the execution of this Agreement, Plaintiff will manifest new damage, the
scope,location,and character of which is unknown and/or not discovered at the time this Agreement
is signed. There is a risk that the damage of which Plaintiff and his attorney presently is aware may
become more serious or otherwise increase in magnitude (qualitatively and/or quantitatively).
Plaintiff shall, and hereby does, assume the above-mentioned risks. This release is expressly
intended to cover and include all future damages, defects and discoveries, including all rights and
causes of action arising against the Defendants therefrom. Plaintiff is aware of the provisions of
California Civil Code section 1542,which provide:
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"A general release does not extend to claims which the creditor does not know or
suspect to exist in his or her favor at the time of executing the release, which if
known by him or her must have materially affected his or her settlement with the
debtor."
Plaintiff hereby expressly waives the provisions of said Section 1542 as to all matters within the
scope of the claims released hereby.Plaintiff hereby warrants and guarantees that they have full and
complete authority to release all such claims on behalf of themselves, their heirs, assigns, and
successors in interest.
6.2. Plaintiffs waivers and releases herein are to claims arising from Demuth Park only. Plaintiff does not
waive or release any claims of any kind arising from other locations.
7. REPRESENTATIONS AND WARRANTIES: Each Party to this Agreement represents,warrants,and
agrees as to itself as follows:
7.1. Each Party has received independent legal advice from its attorneys, with respect to the advisability of
making the settlement provided for herein, with respect to the import of Civil Code § 1542, and with
respect to the advisability of executing this Agreement.
7.2. No Party (nor officer, agent, employee, representative, or attorney of or for any Party) has made any
statement or representation to any other Party regarding any fact relied upon in entering into this
Agreement, neither Party relies upon any statement, representation or promise of any other Party (nor
officer,agent, employee,representative, or attorney for the other Party),in executing this Agreement,or
in making the settlement provided for herein,except as expressly stated in this Agreement.
7.3. Each Party to this Agreement has made such investigation of the facts pertaining to this settlement and
this Agreement and all of the matters pertaining thereto as it deems necessary.
7.4. Each Party or responsible manager or officer thereof has read this Agreement and understands the
contents hereof. Each of the managers or officers executing this Agreement on behalf of their
respective corporations is empowered to do so and thereby binds their respective corporation.
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7.5. Each Parry has not heretofore assigned,transferred,or granted,or purported to assign,transfer, or grant,
any of the claims, potential claims, demands, and cause or causes of action disposed of by this
Agreement.
7.6. The Parties will execute all such further and additional documents as shall be reasonable, convenient,
necessary, or desirable to carry out the provisions of this Agreement.
8. SETTLEMENT: This Agreement affects the settlement of claims which are denied and contested and
nothing contained herein shall be construed as an admission by any Party hereto of any liability of any
kind to any other Party. Each Party denies any liability in connection with any claims and intends
merely to avoid litigation and buy its peace. The Plaintiffs portion of the settlement payment contained
in this Agreement is meant to compensate the Plaintiff for her alleged personal physical injury.
9. SEVERANCE: If any provision of this Agreement is held to be illegal or invalid by a court of
competent jurisdiction, such provision shall be deemed to be severed and deleted; and neither such
provision,nor its severance and deletion,shall affect the validity of the remaining provisions.
10. REPRESENTATION OF COMPREHENSION OF DOCUMENT: In entering into this Settlement
Agreement, the Parties represent that none of them has relied upon the advice of either of their
respective attorneys,if any,and that each respective attorney is the attorney of each client's own choice,
concerning the legal consequences of this Settlement Agreement; that the terms of this Settlement
Agreement have been completely read and explained to each Party by their respective attorney; and the
terms of the Settlement Agreement is fully understood and voluntarily accepted by each Party.
11. WARRANTY OF CAPACITY TO EXECUTE AGREEMENT: The Parties represent and warrant
that no other person or entity has, or has had, any interest in the claims, demands, obligations or causes
of action referred to in this Settlement Agreement, except as otherwise set forth herein; that each Party
has the sole right and exclusive authority to execute this Settlement Agreement and receive or pay the
sums specified in it; and that Plaintiff has not sold, assigned, transferred, conveyed, or otherwise
disposed of any of the claims, demands, obligations or causes of action referred to in this Settlement
Agreement.
1166809.1
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12. INVALIDITY OF ANY CONDITION OR COVENANT: In the event any condition or covenant
herein contained is held to be invalid or void by a court of competent jurisdiction, the same shall be
deemed severable from the remainder of this Settlement Agreement and shall in no way affect any other
covenant or condition herein contained. If such condition or covenant shall be deemed invalid due to
scope or breadth, such condition or covenant shall be deemed valid to the extent of the scope or breadth
permitted by law.
13. AMENDMENT OF AGREEMENT: This Settlement Agreement may be amended only by a written
Agreement executed by Plaintiff and Defendant.
14. NO PREVAILING PARTY:PLAINTIFF TO COVER ALL LIENS: Plaintiff and Defendants agree
to bear their respective attorneys' fees and costs. There is no prevailing party. Plaintiff will satisfy all
liens, including all medical, statutory, and equitable liens, and will hold Defendants harmless for all
liens,including all medical,statutory,and equitable liens.
15. ASSUMPTION OF RISK: The Parties fully understand and declare that if the facts with respect to
which this Agreement is executed are found hereafter to be different from the facts now believed to be
true, the Parties assume the risk of such possible difference in facts and hereby agree this Agreement
shall be in effect and shall remain in effect notwithstanding such difference in facts. The Parties
represent and covenant that each of them is fully informed regarding all facts related to this Agreement
and will not seek to void, rescind, set aside, or alter this Agreement on an assertion of mistake of fact or
law.
16. NO PRIOR ASSIGNMENT OR TRANSFER: Each party to this Agreement represents and warrants
there has been no assignment or other transfer of any claims or causes of action which they are releasing
pursuant to the terms of this Agreement.
17. MISCELLANEOUS:
17.1.This Agreement shall be deemed to have been executed and delivered within the State of California,and
the rights and obligations of the Parties hereunder shall be construed and enforced in accordance with,
and governed by,the laws of the State of California.
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17.2.This Agreement is the entire Agreement between the Parties with respect to the subject matter hereof
and supersedes all prior and contemporaneous oral or written agreements and discussions. This
Agreement may be amended only by an agreement in writing,executed by all Parties hereto,
17.3.This Agreement is binding.upon and shall inure to the benefit of the Parties hereto, their respective
agents, attorneys, employees, representatives, officers, directors, divisions, subsidiaries, affiliates,
tenants,assigns,heirs,spouses,sons,daughters,predecessors,dealers,franchisees,successors in interest
and shareholders,
17A.Each Party has cooperated in the drafting and preparation of this Agreement. Hence,in any construction
to be made of this Agreement,the same shall not be construed against any Party.
17.5.This Agreement may be executed in counterparts and/or by facsimile or other electronic means, and
when each party has sighed and delivered at least one such counterpart,each counterpart shall be deemed
an original, and, when taken together with other signed counterpart, shall constitute one Agreement,
which shall be binding upon and effective as to all Parties.
ocevsw"sr;
6/30/ZDl6 9aAatL
Dated: F........____ssss
fEANETTEIAIME
Dated: G7 3��/ kX51040' vt—�
CITY WALM SPRINGS a public entity
BY
Title:
APPROVED AS TO FORM AND CONTENT:
Dated: POTTER HANDY,LLP
By:
Printed Name
1166909.1
APPROVE AS TO FORM:
Dated: 5 1.911 WOODRUFF,SPRADLIN& SMART,APC
By:
CAROLINE A.BYRNE\
Attorneys for Defendant
i
I
1
1166S09.1
Form W'9 Request for Taxpayer Give Form to the
(Rev.December 2014) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service
t Name(as shown on your income tax return).Name is required on this line;do not leave this line blank.
Potter Handy, LLP
N 2 Business name/disregarded entity name,if different from above
m DBA Center for Disability Access
a 3 Check appropriate box for federal tan classification;check only one of the following seven hazes: 4 Exemptions(codes apply only to
o ❑Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
certain entdies,not individuals;see
m e single-member LLC instructions page f a
a m Exempt payeea code(if any)
�.0 Q Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)► P
p 2 Note.For a single-member LLC that is disregarded,do not check LLC;check the appropriate box in the line above for Exemption from FATCA reporting
4 the tax classification of the single-member owner. code(if any)
C
y U ❑Other(see instructions)► fnaarvesroxcounts,rwinramey artside nre U.S.)
5 Address(number,street,and apt.or suite no.) Requester's name and address(optional)
'u
n 9845 Erma Road, Suite 300
y 6 City,state,and ZIP code
m San Diego, CA 92131
7 List account numbers)here(optional)
JUM Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding.For individuals,this is generally your social security number(SSN).However,fora
resident alien,sole proprietor,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. or
Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identification number
guidelines on whose number to enter.
3 3 - 0 1 8 1 5 1 5 2 6 0
Certification
Under penalties of perjury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3. 1 am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
instructions on page 3.
Sign Signature of
Here us.person► Date► 05/02/2016
General Instructions Form 1096(home mortgage interest),1096-E(student loan interest),1096-T
(tultion)
Section references are to the internal Revenue Code unless otherwise noted. •Form 1099-C(canceled debt)
Future developments.Information about developments affecting Form W-9(such •Form 1099-A facquisition or abandonment of secured property)
as legislation enacted after we release it)is at www.irs.gov/fw9.
Use Form W-9 only if you are a U.S.person(including a resident alien),to
Purpose of Form provide your correct TIN.
An individu it or entity(Form W-9 requester)who is required to file an information If you do not return Form W-9 to the requester with a TIN,you might be subject
return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What is backup withholding?on page 2.
which may be your social security number fSSN),individual taxpayer identification By signing the filled-out form,you:
number(ITIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are wafting for a number
identification number(EIN),to report on an information return the amount paid to to be issued),
you,or other amount reportable on an information return.Examples of information
returns include,but are not limited to,the following: 2.Certify that you are not subject to backup withholding,or
•Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding if you are a U.S.exempt payee.If
•Form 1099-DIV(dividends,including those from stocks or mutual funs) applicable,you are also certifying that as a U.S.person,your allocable share of
any partnership income from a U.S.trade or business is not subject to the
•Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and
•Farm 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA codes)entered on this form(if any)indicating that you are
brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on
-'Form 1099-S(proceeds from real estate transactions) page 2 for further information.
•Form 1099-K(merchant card and third party network transactions)
Cat.No.10231X Form W-9(Rev.12-2014)
Form W-9(Rev.12-2014) Page 2
Note.If you are a U.S.person and a requester gives you a form other than Form 3.The IRS tells the requester that you furnished an incorrect TIN,
W-9 to request your TIN,you must use the requester's form if it is substantially 4.The IRS tells you that you are subject to backup withholding because you did
similar to this Form W-9. not report all your interest and dividends on your tax return(for reportable interest
Definition of a U.S.person.For federal tax purposes,you are considered a U.S. and dividends only),or
person if you are: 5.You do not certify to the requester that you are not subject to backup
•An individual who is a U.S.citizen or U.S.resident alien; withholding under 4 above(for reportable interest and dividend accounts opened
•A partnership,corporation,company,or association created or organized in the after 1983 only).
United States or under the laws of the United States; Certain payees and payments are exempt from backup withholding.See Exempt
•An estate(other than a foreign estate);or payee code on page 3 and the separate Instructions for the Requester of Form
W-9 for more information.
•A domestic trust(as defined in Regulations section 301.7701-7). Also see Special rules for partnerships above.
Special rules for partnerships.Partnerships that conduct a trade or business in
the United States are generally required to pay a withholding tax under section What is FATCA reporting?
1446 on any foreign partners'share of effectively connected taxable income from
such business.Further,in certain cases where a Form W-9 has not been received, The Foreign Account Tax Compliance Act(FATCA)requires a participating foreign
the rules under section 1446 require a partnership to presume that a partner is a financial institution to report all United States account holders that are specified
foreign person,and pay the section 1446 withholding tax.Therefore,if you are a United States persons.Certain payees are exempt from FATCA reporting.See
U.S.person that is a partner in a partnership conducting a trade or business in the Exemption from FATCA reporting code on page 3 and the Instructions for the
United States,provide Form W-9 to the partnership to establish your U.S.status Requester of Form W-9 for more information.
and avoid section 1446 withholding on your share of partnership income.
In the cases below,the following person must give Form W-9 to the partnership
Updating Your Information
for purposes of establishing its U.S.status and avoiding withholding on its You must provide updated information to any person to whom you claimed to be
allocable share of net income from the partnership conducting a trade or business an exempt payee if you are no longer an exempt payee and anticipate receiving
in the United States: reportable payments in the future from this person.For example,you may need to
•In the case of a disregarded entity with a U.S.owner,the U.S.owner of the provide updated information if you are a C corporation that elects to be an S
disregarded entity and not the entity; corporation,or if you no longer are tax exempt.In addition,you must furnish a new
Form W-9'rf the name or TIN changes for the account;for example,if the grantor
•In the case of a grantor trust with a U.S.grantor or other U.S.owner,generally, of a grantor trust dies.
the U.S.grantor or other U.S.owner of the grantor trust and not the trust;and
•In the case of a U.S.trust(other than a grantor trust),the U.S.trust(other than a Penalties
grantor trust)and not the beneficiaries of the trust. Failure to furnish TIN.If you fail to furnish your correct TIN to a requester,you are
Foreign person.If you are a foreign person or the U.S.branch of a foreign bank subject to a penalty of$50 for each such failure unless your failure is due to
that has elected to be treated as a U.S.person,do not use Form W-9.Instead,use reasonable cause and not to willful neglect.
the appropriate Form W-8 or Form 8233(see Publication 515,Withholding of Tax Civil penalty for false information with respect to withholding.If you make a
on Nonresident Aliens and Foreign Entities). false statement with no reasonable basis that results in no backup withholding,
Nonresident alien who becomes a resident alien.Generally,only a nonresident you are subject to a$500 penalty.
alien individual may use the terms of a tax treaty to reduce or eliminate U.S.tax on Criminal penalty for falsifying information.Willfully falsifying certifications or
certain types of income.However,most tax treaties contain a provision known as affirmations may subject you to criminal penalties including fines and/or
a"saving clause."Exceptions specified in the saving clause may permit an imprisonment.
exemption from tax to continue for certain types of income even after the payee
has otherwise become a U.S.resident alien for tax purposes. Misuse of TINS.If the requester discloses or uses TINS in violation of federal law,
If you are a U.S.resident alien who is relying on an exception contained in the the requester may be subject to civil and criminal penalties.
saving clause of a tax treaty to claim an exemption from U.S.tax on certain types Specific Instructions
of income,you must attach a statement to Form W-9 that specifies the fallowing p
five items:
1.The treaty country.Generally,this must be the same treaty under which you Line 1
claimed exemption from tax as a nonresident alien. You must enter one of the following on this line;do not leave this line blank.The
2.The treaty article addressing the income. name should match the name on your tax return.
3.The article number(or location)in the tax treaty that contains the saving If this Form W-9 is for a joint account,list first,and then circle,the name of the
clause and its exceptions. person or entity whose number you entered in Part i of Form W-9.
4.The type and amount of income that qualifies for the exemption from tax. a. Individual.Generally,enter the name shown on your tax return.If you have
changed your last name without informing the Social Security Administration(SSA)
5.Sufficient facts to justify the exemption from tax under the terms of the treaty of the name change,enter your first name,the last name as shown on your social
article. security card,and your new last name.
Example.Article 20 of the U.S.-China income tax treaty allows an exemption Note.ITIN applicant Enter your individual name as it was entered on your Form
from tax for scholarship income received by a Chinese student temporarily present W-7 application,line 1a.This should also be the same as the name you entered on
in the United States.Under U.S.law,this student will become a resident alien for the Form 1040/1040A/1040EZ you filed with your application.
tax purposes if his or her stay in the United States exceeds 5 calendar years. b. Sole proprietor or single-member LLC.Enter your individual name as
However,paragraph 2 of the first Protocol to the U.S.-China even (dated April 30, shown on our 1040/1040A/1040EZ on line 1.You may enter our business,trade,
1984)Chinese
the provisions of Article 20 to continue to apply even after the y y >'
Chinese student becomes a resident alien of the United States,A Chinese student or"doing business as"(DBA)name on line 2.
who qualifies for this exception(under paragraph 2 of the first protocol)and is c. Partnership,LLC that is not a single-member LLC,C Corporation,or S
relying on this exception to claim an exemption from lax on his or her scholarship Corporation.Enter the entity's name as shown on the entity's tax return on line 1
or fellowship income would attach to Form W-9 a statement that includes the and any business,trade,or DBA name on line 2.
information described above to support that exemption. d. other entities.Enter your name as shown on required U.S.federal tax
If you are a nonresident alien or a foreign entity,give the requester the documents on line 1.This name should match the name shown on the charter or
appropriate completed Form W-8 or Form 8233. other legal document creating the entity.You may enter any business,trade,or
DBA name on line 2.
Backup Withholding e. Disregarded entity.For U.S.federal tax purposes,an entity that is
What is backup withholding?Persons making certain payments to you must disregarded as an entity separate from its owner is treated as a"disregarded
under certain conditions withhold and pay to the IRS 2898 of such payments.This entity." See Regulations section 301.7701-2(c)(2)(m).Enter the owner's name on
is called"backup withholding." Payments that may be subject to backup line 1.The name of the entity entered on line 1 should never be a disregarded
withholding include interest,tax-exempt interest,dividends,broker and barter entity.The name on line 1 should be the name shown on the income tax return on
exchange transactions,rents,royalties,nonemployes pay,payments made in which the income should be reported.For example,if a foreign LLC that is treated
settlement of payment card and third parry network transactions,and certain as a disregarded entity for U.S.federal tax purposes has a single owner that is a
payments from fishing boat operators.Real estate transactions are not subject to U.S.person,the U.S.owner's name is required to be provided on line 1.If the
backup withholding. direct owner of the entity is also a disregarded entity,enter the first owner that is
You will not be subject to backup withholding on payments you receive if you not disregarded for federal tax purposes.Enter the disregarded entity's name on
give the requester your coned TIN,make the proper certifications,and report all line 2,"Business name/disregarded entity name."If the owner of the disregarded
your taxable interest and dividends on your tax return. entity is a foreign person,the owner must complete an appropriate Form W-8
instead of a Form W-9. This is the case even if the foreign person has a U.S.TIN.
Payments you receive will be subject to backup withholding if;
1.You do not furnish your TIN to the requester,
2.You do not certify your TIN when required(see the Part II instructions on page
3 for details),
Form W-9(Rev.12-2014) Page 3
Line 2 'However,the following payments made to a corporation and reportable on Form
If you have a business name,trade name,DBA name,or disregarded entity name, 1099-MISC are not exempt from backup withholding:medical and health care
you may enter it on line 2. payments,attomeys'fees,gross proceeds paid to an attorney reportable under
section 6045(f),and payments for services paid by a federal executive agency.
Linea Exemption from FATCA reporting code.The following codes identify payees
Check the appropriate box in line 3 for the U.S.federal tax classification of the that are exempt from reporting under FATCA.These codes apply to persons
person whose name is entered on line 1.Check only one box in line 3. submitting this form for accounts maintained outside of the United States by
Limited Liability Company(LLC).If the name on line 1 is an LLC treated as a certain foreign financial institutions.Therefore,if you are only submitting this form
"Limited Liability Company
for an account you hold in the United Stales,you may leave this field blank.
partnership for U.S.federal tax purposes,check the"Lim
'
box In the space provided.If the LLC has filed Form 8832 any Consult with the person requesting this form if you are uncertain if the financial
and enter"U
be taxed as corporation,check the"Limited Liability Company"box and 2 to institution is subject to these requirements.A requester may indicate that a code is
the
not required by providing you with a Form W-9 with"Not Applicable"(or any
space provided enter"C"for C corporation or"S"for corporation.If it is a
similar indication)written or printed on the line far a FATCA exemption code.
single-member LLC that is a disregarded entity,do not check the"Limited Liability
Company"box;instead check the first box in line 3"IndividuaVsole proprietor or A—An organization exempt from tax under section 501(a)or any individual
single-member LLC." retirement plan as defined in section 7701(a)(37)
Line 4,Exemptions B—The United States or any of its agencies or instrumentalities
If you are exempt from backup withholding and/or FATCA reporting,enter in the C—A state,the District of Columbia,a U.S.commonwealth or possession,or
appropriate space in line 4 any cotle(s)that may apply to you.
any of their political subdivisions or instrumentalities
D—A corporation the stock of which is regularly traded on one or more
Exempt payee code. established securities markets,as described in Regulations section
• Generally,individuals(including sole proprietors)are not exempt from backup 1.1472-1(c)(1)(i)
withholding. E—A corporation that is a member of the same expanded affiliated group as a
• Except as provided below,corporations are exempt from backup withholding corporation described in Regulations section 1.1472-1(c)(1)O
for certain payments,including interest and dividends, F—A dealer in securities,commodities,or derivative financial instruments
• Corporations are not exempt from backup withholding for payments made in (including notional principal contracts,futures,forwards,and options)that is
settlement of payment card or third party network transactions. registered as such under the laws of the United Stales or any state
• Corporations are not exempt from backup withholding with respect to attorneys' G—A real estate investment trust
fees or gross proceeds paid to attorneys,and corporations that provide medical or H—A regulated investment company as defined in section 851 or an entity
health care services are not exempt with respect to payments reportable on Form registered at all fimes during the tax year under the Investment Company Act of
1099-MISC. 1940
The following codes identify payees that are exempt from backup withholding.
Enter the appropriate code in the space in line 4. 1—A common trust fund as defined in section 584(a)
1—An organization exempt from tax under section 501(a),any IRA,or a J—A bank as defined in section 581
custodial account under section 403(b)(7)if the account satisfies the requirements K—A broker
of section 401(f)(2) L—A trust exempt from tax under section 664 or described in section 4947(a)(1)
2—The United States or any of its agencies or instrumentalities M—A tax exempt trust under a section 403(b)plan or section 457(g)plan
3—A state,the District of Columbia,a U.S.commonwealth or possession,or Note.You may wish to consult with the financial institution requesting this forth to
any of their political subdivisions or instrumentalities determine whether the FATCA code and/or exempt payee code should be
4—A foreign government or any of its political subdivisions,agencies,or completed.
instrumentalities
Line 6
5—A corporation
6—A dealer in securities or commodities required to register in the United Enter your address(number,street,and apartment or suite number).This is where
States,the District of Columbia,or a U.S.commonwealth or possession the requester of this Form W-9 will mail your information returns.
7—A futures commission merchant registered with the Commodity Futures Line 6
Trading Commission Enter your city,state,and ZIP code.
8—A real estate investment trust
9—An entity registered at all times during the tax year under the Investment Part I.Taxpayer Identification Number(TIN)
Company Act of 1940 Enter your TIN in the appropriate box.If you are a resident alien and you do not
10—A common trust fund operated by a bank under section 584(a) have and are not eligible to get an SSN,your TIN is your IRS individual taxpayer
identification number(ITIN).Enter it in the social security number box.If you do not
11—A Financial institution have an ITIN,see How to get a TIN below.
12—A middleman known in the investment community as a nominee or If you are a sole proprietor and you have an FIN,you may enter either your SSN
custodian or EIN.However,the IRS prefers that you use your SSN.
13—A trust exempt from tax under section 664 or described in section 4947 If you are a single-member LLC that is disregarded as an entity separate from Its
The following chart shows types of payments that may be exempt from backup owner(see Limited Liability Company(LLC)on this page),enter the owner's SSN
withholding.The chart applies to the exempt payees listed above,1 through 13. (or FIN,if the owner has one).Do not enter the disregarded entity's FIN.If the LLC
is classified as a corporation or partnership,enter the entity's EIN.
IF the payment Is for... THEN the payment is exempt for... Note.See the chart on page 4 for further clarification of name and TIN
_ combinations.
Interest and dividend payments All exempt payees except How to get a TIN.If you do not have a TIN,apply for one immediately.To apply
for 7 for an SSN,get Form SS-5,Application for a Social Security Card,from your local
SSA office or get this form online at www.ssa.gov.You may also get this form by
Broker transactions Exempt payees 1 through 4 and 6 calling 1-800-772-1213.Use Form W-7,Application for IRS Individual Taxpayer
through 11 and all C corporations.S Identification Number,to apply for an ITIN,or Form SS-4,Application for Employer
corporations must not enter an exempt Identiffdation Number,to apply for an EIN.You can apply for an EIN online by
payee code because they are exempt accessing the IRS website at www.in;.gowbusinesses and clicking on Employer
only for sales of noncovered securities Identification Number(EIN)under Starting a Business.You can get Forms W-7 and
acquired prior to 2012. SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM
(1-800-829-3676).
Barter exchange transactions and Exempt payees 1 through 4 If you are asked to complete Form W-9 but do not have a TIN,apply for a TIN
patronage dividends and write"Applied For"in the space for the TIN,sign and date the form,and give it
Payments over$600 required to be Generally,exempt payees to the requester.For interest and dividend payments,and certain payments made
reported and direct sales over$5,000' 1 through 5' with respect to readily tradable instruments,generally you will have 60 days to get
9 a TIN and give it to the requester before you are subject to backup withholding on
payments.The 60-day rule does not apply to other types of payments.You will be
Payments made in settlement of Exempt payees 1 through 4 subject to backup withholding on all such payments until you provide your TIN to
payment card or third party network the requester.
transactions Note.Entering"Applied For"means that you have already applied for a TIN or that
'See Form 1099-MISC,Miscellaneous Income,and its instructions. you intend to apply for one soon.
Caution:A disregarded U.S.entity that has a foreign owner must use the
appropriate Farm W-8.
Form W-9(Rev.12-2014) Page 4
Part 11.Certification You must show your individual name and you may also enter your business or DBA name on
To establish to the withholding agent that you are a U.S.person,or resident alien, the"Business name/disregarded entity"name line.You may use either your SSN or EIN(f you
have one),but the IRS encourages you to use your SSN.
sign Form W-9.You may be requested to sign by the withholding agent even if list first and circle the name of the cast,estate,or pension trust.(Do not furnish the TIN of the
items 1,4,or 5 below indicate otherwise. personal representative or trustee unless the legal entity itself is not designated Inthe account
For a joint account,only the person whose TIN is shown in Part I should sign tine)ase see Special rules forpartnershipson page 2.
(when required).In the case of a disregarded entity,the person identified on line 1 'Note.Grantor also must provide a Farm W-9 to trustee of trust,
must sign.Exempt payees,see Exempt payee code earlier. Note.If no name is circled when more than one name is listed,the number will be
signature requirements.Complete the certification as indicated in items 1 considered to be that of the first name listed.
throughInterest,
5 below. Secure Your Tax Records from Identity Theft
1.Interest,tllvltlentl,and barter exchange accounts opened before 1984
and broker accounts considered active during 1983.You must give your Identity theft occurs when someone uses your personal information such as your
correct TIN,but you do not have to sign the certification. name,SSN,or other identifying information,without your permission,to commit
2.Interest,dividend,broker,and barter exchange accounts opened after fraud or other crimes.An identity thief may use your SSN to get a job or may file a
1983 and broker accounts considered inactive during 1983.You must sign the tax return using your SSN to receive a refund.
certification or backup withholding will apply.If you are subject to backup To reduce your risk:
withholding and you are merely providing your correct TIN to the requester,you •Protect your SSN,
must cross out Rem 2 in the certification before signing the form.
3.Real estate transactions.You must sign the certification.You may cross out •Ensure your employer is protecting your SSN,and
item 2 of the certification. •Be careful when choosing a tax preparer.
4.Other payments.You must give your correct TIN,but you do not have to sign If your tax records are affected by identity theft and you receive a notice from
the certification unless you have been notified that you have previously given an the IRS,respond right away to the name and phone number printed on the IRS
incorrect TIN."Other payments'include payments made in the course of the notice or letter.
requester's trade or business for rents,royalties,goods(other than bills for If your tax records are not currently affected by identity theft but you think you
merchandise),medical and health care services(including payments to are at nsk due to a lost or stolen purse or wallet,questionable credit card activity
corporations),payments to a nonemployee for services,payments made in or credit report,contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit
settlement of payment card and third parry network transactions,payments to Form 14039.
certain fishing boat crew members and fishermen,and gross proceeds paid to attorneys(including payments to corporations). For more information,see Publication 4535,Identity Theft Prevention and Victim
Assistance.
5.Mortgage interest paid by you,acquisition or abandonment of secured
property,cancellation of debt,qualified tuition program payments(under Victims of identity theft who are experiencing economic harm or a system
section 529),IRA,Coverciell ESA,Archer MSA or HSA contributions or problem,or are seeking help in resolving tax problems that have not been resolved
distributions,and pension distributions.You most give your correct TIN,but you through normal channels,may be eligible for Taxpayer Advocate Service(TAB)
do not have to sign the certification. assistance.You can reach TAS by calling the TAS toll-free case intake line at
1-877-777-4778 or TTY/TDD 1-800-829-4059.
What Name and Number To Give the Requester Protect yourself from suspicious smalls or phishing schemes. Phishing is the
creation and use of email and websites designed to mimic legitimate business
For this type of account: Give name and SSN oF. emails and websims.The most common act is sending an email to a user falsely
1.Individual The individual claiming to be an established legitimate enterprise in an attempt to scam the user
into surrendering private information that will be used for identity theft.
2.Two or more individuals(joint The actual owner of the account or, The IRS does not initiate contacts with taxpayers via emails.Also,the IRS does
account) if combined funds,the first not request personal detailed information through email or ask taxpayers for the
individual on the account PIN numbers,passwords,or similar secret access information for their credit card,
3.Custodian account of a minor The minor' bank,or other financial accounts.
(Uniform Gift to Minors Act) If you receive an unsolicited email claiming to be from the IRS,forward this
4.a.The usual revocable savings The grantor-trustee message to phishingrgirs.gov.You may also report misuse of the IRS name,logo,
trust(grantor is also trustee) or other IRS property to the Treasury Inspector General for Tax Administration
b.So-called trust account that is The actual owner (TIGTA)at 1-800-366-4484.You own forward suspicious emails to the Federal
not a legal or valid trust under Trade Commission at:spam@uce.gov or contact them at wwwJtc.gov/idtheff or
state law 1-877-IDTHEFT(1-877-438-4338).
5.Sole proprietorship or disregarded The owner' Visit IRS.gov to learn more about identity theft and how to reduce your risk.
entity owned by an Individual
6.Grantor trust filing under Optional The grantor' Privacy Act Notice
Form 1099 Filing Method 1(see
Regulations section 1.671-4(b)(2)O Section 6109 of the Internal Revenue Code requires you to provide your correct
(A)) TIN to persons(including federal agencies)who are required to file information
For this type of account: Give name and EIN o/: returns with the IRS to report interest,dividends,or certain other income paid to
you;mortgage interest you paid;the acquisition or abandonment of secured
7.Disregarded entity not owned by an The owner property;the cancellation of debt;or contributions you made to an IRA,Archer
individual MSA,or HSA.The person collecting this form uses the information on the form to
8.A valid trust,estate,or pension trust Legal entity' file information returns with the IRS,reporting the above information.Routine uses
of this information include giving it to the Department of Justice for civil and
9.Corporation or LLC electing The corporation criminal litigation and to dies,states,the District of Columbia,and U.S.
corporate status on Form 8832 or commonwealths and possessions for use in administering their laws.The
Form 2553 information also may be disclosed to other countries under a tresty,to federal and
10.Association,club,religious, The organization state agencies to enforce civil and criminal laws,or to federal law enforcement and
charitable,educational,or other tax- intelligence agencies to combat terrorism.You must provide your TIN whether or
exempt organization not you are required to file atax return.Under section 3406,payers most generally
11.Partnership or mufti-member LLC The partnership withhold a percentage of taxable interest,dividend,and certain other payments to
12.A broker or registered nominee The broker or nominee a payee who does not give a TIN to the payer-Certain penalties may also apply for
re9 providing false or fraudulent information.
13.Account with the Department of The public entity
Agriculture in the name of a public
entity(such as a state or local
government,school district,or
prison)that receives agricultural
program payments
14.Grantor trust filing under the Form The trust
1041 Fling Method or the Optional
Form 1099 Filing Method 2(see
Regulations section 1.6714(b)(2Ki)
(B))
list first and arcle the name of the person whose number you furnish.If only one persan on a
joint account has an SSN,that persons number must bB furnished,
Circus the minor's name and furnish the minors SSN.