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PROOF OF INSURANCE (2015) CLOSED�g �d^� a� Jf7 0 /`a�<iR1:> CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DDIYYYY) 8/26/2015 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 InterWest Insurance Services License #OB01094 P.O. Box 255188 NAME: Joanne Cadarette PHONE g16- 609 -8362 FAX 916 - 979 -7562 �•�4 Ems' /� °' E-MAIL ADDRESS, jadarette @iwins.com INSURER(Sl AFFORDING COVERAGE NAIL # Sacramento CA 95865 -5188 INSURER A: Financial Pacific Ins Company 31453 12/31/2014 INSURED AMER126 INSURERB:Arch Insurance Company 111150 American Asphalt South, Inc 14436 Santa Ana Avenue INSURERC: Fontana CA 92337 INSURER D : DAMAGE TO RENTED PREMISES Ea occurrence ) 5100,000 X INSURER E: $5,000 INSURER F : Contractual Liab COVERAGES CERTIFICATE NLIMRFR- 1569632383 RFVISION NLIMRFR- 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. I�TR TYPE OF INSURANCE INSO WVD I POLICY NUMBER MM /DDYIYYYY MM /DD //YYYY LIMITS A X I COMMERCIAL GENERAL LIABILITY Y Y 60423382 12/31/2014 12/31/2015 EACH OCCURRENCE $2,000,000 CLAIMS -MADE ❑ OCCUR DAMAGE TO RENTED PREMISES Ea occurrence ) 5100,000 X MED EXP (Any one person) $5,000 Contractual Liab X Ded. $5.000 PERSONAL & ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY JJECT LOC PRODUCTS - COMP/OP AGG $4,000,000 ' $ OTHER: A AUTOMOBILE LIABILITY Y Y 60423382 12/31/2014 12/31/2015 COMBINED SINGLE LIMIT $1,000,000 AN Y AUTO BODILY INJURY (Per person) J S AUTOS�ED AUTOSULED 1XX BODILY INJURY (Per accident)! $ HIRED AUTOS X AUTOS �EO (PeraccidentDAMAGE i $ IS A UMBRELLA LIAB X OCCUR 60423382 12/31/2014 12/31/2015 EACH OCCURRENCE $5,000,000 X AGGREGATE $5,000,000 EXCESS LIAB CLAIMS -MADE DED I X I RETENTIONSNone S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR /PARTNER/EXECUTIVE y ZAWC19342800 4/1/2015 4/1/2016 y STATUTE OERH E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? NIA E.L. DISEASE - EA EMPLOYE i S1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 1 51,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached K more space is required) Re: 2014 -2015 Slurry Seal Furnishing /Application - Various Streets. Additional Insured Status Applies To City Of El Segundo, Its Officers, Officials, Emplooyees, Agents, Volunteers (GUAU). Primary Wording, Per Project Aggregate, GUAUMIC Waivers Attached. 30 -Day Notice Of Cancellation Except 10 -Day Notice For Non- Payment Of Premium Applies Per Policy Provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo \ ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo CA 90245 \ AUTHORIZED REPRESENTATIVE / ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS (FORM 13) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: 2014-2015 Slurry Seal Furnishing/Application - Various Streets. Additional Insured Status Applies To City Of El Segundo, Its Officers, Officials, Emplooyees, Agents, Volunteers (GL/AU). Primary Wording, Per Project Aggregate, GL/AU/WC Waivers Attached. 30-Day Notice Of Cancellation Except 10-Day Notice For Non-Payment Of Premium Applies Per Policy Provisions. (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section 11) is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization is held liable for "your work" !or that person or organization by or for you. This endorsement applies to the following work: Description of Job: see Above Location of Job: See Above Al only Effective from: Effective Date:12/31/2014 Expiration Date: 12/31/2015 When this endorsement applies, such insurance as is afforded by the general liability policy is primary and any other insurance shall be excess and shall not contribute to the insurance afforded by this endorsement. CG 20 1011 85 Modified (07-01) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: 6nuz33oz COMMERCIAL GENERAL LIABILITY CG 24 04 10 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ 0[CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person orOrganization: Re: 2014-2015 Slurry Seal Furnishing/Application ' Various Streets. Additional Insured Status Applies To City Of El Segundo, Its Officers, Officials, omPlooyeea, Agents, Volunteers (GL/AU). Primary Wording, Per Project Aggregate, GL/AU/WC (If no entry appears above, information required to complete this endorsement will be shown in the Declarations es applicable to this endonuementj The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMER- CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: VVe waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work"/done under contract with that person or organizmtion and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 240410 93 Copyright, Insurance Services Office, |nc.. 1992 Page 1of I POLICY NUMBER: 604233 a2 ASDA AU 07 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE NAMED INSURED: American Asphalt South, Inc 14436 Santa Ana Avenue Fontana CA 92337 ADDITIONAL INSURED: Re: 2014 -2015 Slurry Seal Furnishing /Application - Various Streets. Additional Insured Status Applies To City Of El Segundo, Its Officers, Officials, Emplooyees, Agents, Volunteers (GL /AU). Primary Wording, Per Project Aggregate, WHO IS AN INSURED (SECTION II) is amended to include as an insured the organization shown in the Schedule above, but only with respect to the operation of vehicles owned by the named insured and operated on behalf of the named insured. This endorsement does not apply to any operations for other than the named insured. Each person or organization named above is an insured for liability coverage, but only to the extent that person or organization qualifies as an insured under the Who Is An Insured provision of Section II Liability Coverage. The additional insured is not required to pay for any premiums stated in the policy or earned from the policy. Any return premium, if applicable, declared by us shall be paid to you. You are authorized to act for the additional insured in all mailers pertaining to this insurance. We will mail the additional insured notice of any cancellation of this policy. If the cancellation is by us, we will give thirty days notice to the additional insured. The additional insured will retain any right of recovery as a claimant under this policy. ASDA AU 07 01 Page 1 of 1 POLICY NUMBER: 60423382 ASDA AU 07 02 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE Name of Person or Organization: Re: 2014-2015 Slurry Seal Furnishing/Application - Various Streets. Additional Insured Status Applies To City Of El Segundo, Its Officers, Officials, Emplooyees, Agents, Volunteers (GL/AU). Primary The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV BUSINESS AUTO CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above be- cause of payments we make for bodily injury or property damage arising out of losses or accidents which occur during the policy period. This waiver applies only to liability you assume pursuant to a contract with the person or organization shown in the schedule. ASDA AU 07 02 Page 1 of 1 POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY CG 25 030397 r- 14k This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Mdalum Designated Construction Projects: ALL PROJECTS WITH THE POLICY PERIOD. (if no entry appears above, information required to complete this endorsement will beshown in the Declarations nm applicable bo this endorommentj A. For all sums which the insured becomes legally obligated to pay ao damages caused by ^ occurrences" under COVERAGE A(SECTION l). and for all medical expenses caused by acci- dents undarCDVEF0\GE C (SECTION V\.which can be attributed only bo ongoing operations ata single designated construction project shown in the Schedule above: 1. & separate Designated Construction Project General Aggregate Limit applies boeach designated construction project, and that limit is equal bu the amount wf the General Aggre- gate LimitahownintheDec|unaUuno 2. The Designated Construction Project General Aggregate Limit ie the most we will pay for the sum nf all damages under COVERAGE A' except damages because of "bodily injury" or "property damage" included inthe "products-comp|eted operations hazard".and for medical expenses under COVERAGE C regardless of the number of: m. Insureds; b. Claims made nr"uuUs" brought; or o. Persons o/ organizations making claims or bringing "suits". 3. Any payments made under COVERAGE A for damages or under COVERAGE Cfor medical expenses shall reduce the Desig- nated Construction Project General Aggre- gate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Decla- rations nor shall they reduce any other Des- ignated Construction Project General Aggre- gate Limit for any other designated construc- tion puojactohowninthmSnhedu|eabuve. 4^ The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Ex- pense ounUnuehoapp|y.Hownver,ins(eadof being subject to the General Aggregate Limit shown in the Declarations, such limits will bo subject to the applicable Designated Con- struction Project General Aggregate Limit, B. For all sums which the insured becomes legally obligated to pay oodamages caused by 'bocurrenuas~ under COVERAGE A(SECTION 1). and for all medical expenses caused by acci- dents undmrOOVERAGEC(SECT|ONQ.vvhimh cannot be attributed only tm ongoing operations ata single designated construction project shown in the Schedule above: 1. Any payments made under COVERAGE A for damages or under COVERAGE Cfor medical expenses shall reduce the amount available under the General Aggregate Limit or the Products-Completed Operations Ag- gregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate L/miL C. When coverage for liability arising out oYthe ''products-cnmp|aiedoperuUonnhezand"imprn- vided.enypaymentofordamageobooau000f "bodily injury" or "property damage" included in the "prod uctx-nomp|etmd operations hazard" will reduce the Products-Completed Operations Ag- gregate Limit, and not reduce the General Ag- gregate UmitnorthaDmsignahadConstrucUnn Project General Aggregate Limit. CG 25 03 03 97 Copyright, Insurance Services Office, |nc,1996 Paae I of 2 D. If the applicable designated construction project has been abandoned, delayed, orabandoned and then restated, orif the authorized contract- ing partk*odeviete from plans, blueprints, dn' migna,upeoifinaUonmortimetab|ea.thapnoject will still be deemed tobe the same construction project. E. The provisions of Limits OfInsurance (SECTION |10 not otherwise modified bv this endorsement shall continue ho apply awstipulated. P=�7 nfn Cnnvrinht|mnmsnce Spmices Office. |mc..1Q96 CG 25 03 03 97 COMMERCIAL GENERAL LIABILITY CG 20 21 01196 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART WHO IS AN INSURED (Section 11) is amended to include as an insured any person(s) who are volun- teer worker(s) for you, but only while acting at the direction of, and within the scope of their duties for you. However, none of these volunteer worker(s) are insureds for: 1. 'Bodily injury" or "personal injury": a. To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability com- pany), to your other volunteer worker(s) or to your "employees" arising out of and in the course of their duties for you; b. To the spouse, child, parent, brother or sister of your volunteer worker(s) or your "employees" as a consequence of para- graph 1.a. above; c. For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in paragraphs 1.a. or b. above; or d. Arising out of his or her providing or failing to provide professional health care serv- ices. 2. 'Property damage" to property: a. Owned, occupied, or used by, b. Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your other volunteer workers, your "employees ", any partner or member (f you are a partnership or joint venture), or any member (if you are a limited liability company). CG 20 21 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 9 of 1 ❑ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) POLICY NUMBER: ZAWC19342800 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due on such remuneration. JOB DESCRIPTION ANY PERSON OR ORGANIZATION WHERE ALL JOBS UNDER CONTRACT WAIVER OF OUR RIGHT TO RECOVER IS PERMITTED BY LAW AND IS REQUIRED BY WRITTEN CONTRACT PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO DATE OF LOSS This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (Tile information below is requilred only when this endorwment is Issued Su ent to preparation of the policy.) Endorsement Effective 04-01-15 Policy No. ZAWC19342800 Endorsement No. Insured AMERICAN ASPHALT Premium $ INCL. Insurance Company ARCH INSURANCE COMPANY Countersigned By DATE OF ISSUE. 03-23-15 J 1998 by the Workers' Cornpensaflon Insurance Rafing Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual @ 1999. Form Request for Taxpayer Give Form to the (Rev. December 2011) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service Name (ass wn on your income tax urn} C\i Business name /disregarded entity naTne, if different from above rn CO c Check appropriate box for federal tax classification: ❑ Individual /sole proprietor ❑ C Corporation S Corporation ❑ Partnership ❑ Trustlestate N W . c 3 GL E] Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= partnership) ® -------------"'-----"'------- ❑Exempt payee L c (Lv ❑ Other (see instructions) r U Address (numiler, street, an a no Requester's name and address (optional) m a City, state, and ZIP code e-41 List account num er(s) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line Social security number to avoid backup withholding. For individuals, this is your social security number However, for a - m _ F pag 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 Now 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 Employer identification number number to enter. F99 J;MM 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). 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 4. Sign Signature of lla� Here U.S. person ► ► Date General instructi S 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 return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W -9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. if 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 • An individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701 -7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. 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, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W -9 to the partnership to establish your U.S. 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. 12 -2011) Form W -9 (Rev. 12 -2011) The person who gives Form W -9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases: • The U.S. owner of a disregarded entity and not the entity, • The U.S. grantor or other owner of a grantor trust and not the trust, and • The U.S. trust (other than a grantor trust) and not the beneficiaries of the trust. Foreign person. If you are a foreign person, do not use Form W -9. Instead, use the appropriate Form W -8 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. If you area U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W -9 that specifies the following five items: 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S. -China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S. -China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W -9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester the appropriate completed Form W -8. What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS a percentage of such payments. This is called "backup withholding." Payments that may be subject to backup withholding include interest, tax- exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester, 2. You do not certify your TIN when required (see the Part II instructions on page 3 for details), 3. The IRS tells the requester that you furnished an incorrect TIN, 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Page 2 Certain payees and payments are exempt from backup withholding. See the instructions below and the separate Instructions for the Requester of Form W -9. Also see Special rules forpartnerships on page 1. Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W -9 if the name or TIN changes for the account, for example, if the grantor of a grantor trust dies. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and /or imprisonment. Misuse of TINS. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties. Specific Instructions Name If you are an individual, you must generally enter the name shown on your income tax return. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name. If the account is in joint names, list first, and then circle, the name of the person or entity whose number you entered in Part I of the form. Sole proprietor. Enter your individual name as shown on your income tax return on the "Name" line. You may enter your business, trade, or "doing business as (DBA)" name on the "Business name /disregarded entity name" line. Partnership, C Corporation, or S Corporation. Enter the entity's name on the "Name" line and any business, trade, or "doing business as (DBA) name" on the "Business name/disregarded entity name" line. 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 disregarded entity. The name on the "Name" line must be the name shown on the income tax return on which the income will be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a domestic owner, the domestic owner's name is required to be provided on the "Name" line. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on the "Business name /disregarded entity name" line. If the owner of the disregarded entity is a foreign person, you must complete an appropriate Form W -8. Note. Check the appropriate box for the federal tax classification of the person whose name is entered on the "Name" line (Individual /sole proprietor, Partnership, C Corporation, S Corporation, Trustlestate). Limited Liability Company (LLC). If the person identified on the "Name" line is an LLC, check the "Limited liability company" box only and enter the appropriate code for the tax classification in the space provided. If you are an LLC that is treated as a partnership for federal tax purposes, enter "P" for partnership. If you are an LLC that has filed a Form 8832 or a Form 2553 to be taxed as a corporation, enter "C" for C corporation or "S" for S corporation. If you are an LLC that is disregarded as an entity separate from its owner under Regulation section 301.7701 -3 (except for employment and excise tax), do not check the LLC box unless the owner of the LLC (required to be identified on the "Name" line) is another LLC that is not disregarded for federal tax purposes. If the LLC is disregarded as an entity separate from its owner, enter the appropriate tax classification of the owner identified on the "Name" line. Form W -9 (Rev. 12 -2011) Other entities. Enter your business name as shown on required federal tax documents on the "Name" line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the "Business name/ disregarded entity name" line. Exempt Payee If you are exempt from backup withholding, enter your name as described above and check the appropriate box for your status, then check the "Exempt payee" box in the line following the "Business name/ disregarded entity name," sign and date the form. Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. The following payees are exempt from backup withholding: 1. An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(0(2), 2. The United States or any of its agencies or instrumentalities, 3. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities, 4. A foreign government or any of its political subdivisions, agencies, or instrumentalities, or 5. An international organization or any of its agencies or instrumentalities. Other payees that may be exempt from backup withholding include: 6. A corporation, 7. A foreign central bank of issue, 8. A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States, 9. A futures commission merchant registered with the Commodity Futures Trading Commission, 10. A real estate investment trust, 11. An entity registered at all times during the tax year under the Investment Company Act of 1940, 12. A common trust fund operated by a bank under section 584(a), 13. A financial institution, 14. A middleman known in the investment community as a nominee or custodian, or 15. A trust exempt from tax under section 664 or described in section 4947. The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 15. IF the payment is for ... THEN the payment is exempt for... Interest and dividend payments All exempt payees except for 9 Broker transactions Exempt payees 1 through 5 and 7 through 13. Also, C corporations. Barter exchange transactions and Exempt payees 1 through 5 patronage dividends Payments over $600 required to be Generally, exempt payees reported and direct sales over 1 through 7 z $5,000' 'See Form 1099 -MISC, Miscellaneous Income, and its instructions. 2 However, the following payments made to a corporation and reportable on Form 1099 -MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency. Page 3 Part 1. Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number ([TIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below. If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN. If you are a single- member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on page 2), enter the owner's SSN (or EIN, if the owner has one). Do not enter the disregarded entity's EIN. If the LLC is classified as a corporation or partnership, enter the entity's EIN. Note. See the chart on page 4 for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS -5, Application for a Social Security Card, from your local Social Security Administration office or get this form online at www.ssa.gov. You may also get this form by calling 1- 800 - 772 -1213. Use Form W -7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS -4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov /businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W -7 and SS -4 from the IRS by visiting IRS.gov or by calling 1 -800 -TAX -FORM (1- 800 - 829 - 3676). If you are asked to complete Form W -9 but do not have a TIN, write "Applied For" in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally 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 not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester. Note. Entering "Applied For" means that you have already applied for a TIN or that you intend to apply for one soon. Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W -8. Part II. Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W -9. You may be requested to sign by the withholding agent even if item 1, below, and items 4 and 5 on page 4 indicate otherwise. For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on the "Name" line must sign. Exempt payees, see Exempt Payee on page 3. Signature requirements. Complete the certification as indicated in items 1 through 3, below, and items 4 and 5 on page 4. 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. 3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification. Form W -9 (Rev. 12 -2011) 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. "Other payments" include payments made in the course of the requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations). 5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification What Name and Number To Give the Requester For this type of account Give name and SSN of: 1. Individual The individual 2. Two or more individuals (joint The actual owner of the account or, account) if combined funds, the first individual on the account' 3. Custodian account of a minor The minor' (Uniform Gift to Minors Act) 4. a. The usual revocable savings The grantor- trustee' trust (grantor is also trustee) b. So- called trust account that is The actual owner' not a legal or valid trust under state law 5. Sole proprietorship or disregarded The owner' entity owned by an individual 6. Grantor trust filing under Optional The grantor" Form 1099 Filing Method 1 (see Regulation section 1.671- 4(b)(2)(i)(A)) For this type of account: Give name and EIN of: 7. Disregarded entity not owned by an The owner individual 8. A valid trust, estate, or pension trust Legal entity' 9. Corporation or LLC electing The corporation corporate status on Form 8832 or Form 2553 10. Association, club, religious, The organization charitable, educational, or other tax - exempt organization 11. Partnership or multi- member LLC The partnership 12. A broker or registered nominee The broker or nominee 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 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulation section 1.671 4(b)(2)(i)(B)) List first and circle the name of the person whose number you fumish. If only one person on a joint account has an SSN, that person's number must be fumished. 2 Circle the minor's name and furnish the minor's SSN. ' You must show your individual name and you may also enter your business or "DBA" name on the "Business nameldisregarded entity" name line. You may use either your SSN or EIN (if 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 forparmerships on page 1. `Note. Grantor also must provide a Form W -9 to trustee of trust. Privacy Act Notice Page 4 Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed. Secure Your Tax Records from Identity Theft Identity theft occurs when someone uses your personal information such as your name, social security number (SSN), or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund. To reduce your risk: • Protect your SSN, • Ensure your employer is protecting your SSN, and • Be careful when choosing a tax preparer. If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter. If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1 -800- 908 -4490 or submit Form 14039. For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance. Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll -free case intake line at 1- 877 - 777 -4778 or TTY/TDD 1 -800- 829 -4059. Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft. The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts. If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing @irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration at 1- 800 - 366 -4484. You can forward suspicious emails to the Federal Trade Commission at: spam @uce.gov or contact them at www.ffc.gov /idtheff or 1- 877- IDTHEFT (1- 877 -438- 4338). Visit IRS.gov to learn more about identity theft and how to reduce your risk. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, 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.