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HomeMy WebLinkAboutR DEPENDABLE - BID DOCUMENTSEXPERIENCE STATEMENT To be responsive, the bidder must list below a minimum of three public agencies for which bidder has performed similar work within the past five years. Only projects in excess of $500,000 each qualify as similar for this project. 1. Project Title ROSEMEAD DOG PARK AT GARVEY PARK Contract Amount $ 640 , 000 . 00 CONSTRUCTION OF NEW DOG PARK, including: landscaping, site furnishings, plumbing Type of Work electrical, light poles, drinking fountains, fencing, shade structures Client City Of Rosemead Okan Demirci OD: 714-319-6137 Agency Project Manager Daniel Nguyen Phone 626-569-2117 Date Completed 12/19/2022 % Subcontracted 10 . 8-% 2. Project Title 15710-15718 RAUSCH ROAD BUILDING AND SITE IMPROVEMENTS Contract Amount $2 ,181, 788 . 58 TENANT SMPRO�Tll—NIV TllN/REI�fODEL, a fisting building end lot into n x pet animal shelter, including: electrical, plumbing, Type of Work door, a Erma, naH led lighting interior/exearldt W/ nee lighting con trals act ceiling,, CIE ...... te, landscnping, Fencing, palnxing, epoxy flooring, roofing, mini dog park in back a/ site Furishi ng, ligheing e c neX 1l a Client CITY OF INDUSTRY Agency Project Manager Gerry Perez, PE Phone CELL 626-945--0527 Date Completed 08/09/2023 % Subcontracted 4-% 3. Project Title Bonita Creek Park Community Center Improvements Contract Amount $532 , 897 .28 reovation of existing community center, Including: roofing, tile, plumping, Type of Work drinking fountain N/doggie bowl fountain, elctrical, led lights upgrade, painting, CIP concrete Client CITY OF NEWPORT BEACH- PUBLIC WORKS Agency Project Manager KHALIL OMAR Date Complp+pri 07/25/2024 Phone 949-644-3013 % Subcontracted 8. 4% NOTE: If requested by the City, the bidder shall furnish a certified financial statement, references, and other information sufficiently comprehensive to permit an appraisal of his current financial condition. Bidder's Sig nature s 1293492.1 Each bidder shall possess a valid Contractor's License issued by the Contractor's State License Board at the time his/her bid is submitted. The class of license.shall be applicable to the work specified in the contract. Each bidder shall also have no less than five (5) years of experience in the magnitude and character of the work bid. Bidder Qualifications called for to be submitted at time of bid include, but are not necessarily limited to: 1. The Contractor shall have been in business under the same name and California Contractors License for a minimum of five (5) continuous years prior to the bid opening date for this Project. The license used to satisfy this requirement shall be of same type required by the contract. 2. License classification shall be as required by the contract specifications 3. The Contractor shall have five (5) years of experience in the application of Polymer Modified Asphaltic Emulsion Chip Seal. 4. The Contractor shall perform at least 50% of contract with its own forces. 16. LISTING_ SUBCONTRACTORS: Each bidder shall submit a list of the proposed subcontractors on this project as required by the Subletting and Subcontracting Fair Practices Act (Government Code Section 4100 and following). Forms for this purpose are furnished with the contract documents. The name and location of business of any subcontractor who will perform work exceeding 1/2 of 1% of the prime contractor's total bid or ten thousand dollars ($10,000.00), whichever is greater, must be submitted with the bid. Any other information regarding_ the foregoing subcontractors that is required by City to be submitted may be submitted with the bid, or may be submitted to City up to 24 hours after the deadline established herein for receipt of bids. The additional information must be submitted by the bidder to the - same address and in the same form applicable to the initial submission of bid. 17. WORKER'S COMPENSATION: In accordance with the provisions of Section 3700 of the Labor Code, the Contractor shall secure the payment of compensation to his employees. The Contractor shall sign and file with the City the follo'Wing certificate prior toperformingthe work under this contract: " I am aware of the provisions of Section 3700 of the Labor Code which require compensation or to undertake self insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the work of this contract." The form of such certificate is included as part of the contract documents. 18, BID DEPOSIT RETURN: Deposits of three or more low bidders, the number being at the discretion of the City, will be held for ninety (90) days or until posting by the successful bidder of the Bonds required and return of executed': copies of the Agreement, whichever first occurs, at which time the deposits will be returned after consideration of the bids. 9 1293492.1 19. EXECUTION OF CONTRACT: The bidder to whom award is made shall execute a written contract with the City on the agreement form provided, and shall secure all insurance and bonds as herein provided within ten (10) days from the date of written notice of the award. Failure or refusal to enter into a contract as herein provided, or to conform to any of the stipulated requirements in connection therewith shall be just cause for the annulment of the award and the forfeiture of the proposal guarantee. If the successful bidder refuses or fails to execute the Contract, the City may award the Contract to the next lowest responsible bidder or re -advertise. On the failure or refusal of the lowest responsible bidder or next lowest responsible bidder to execute the Contract, such bidder's guarantees shall be likewise forfeited to the City. 20. "OR EQUAL": Pursuant to Division 5, Chapter 4, Article 4 (commencing at #4380) Government Code, all specifications shall be deemed to include the words "or equal", provided however that permissible exceptions hereto shall be specifically noted in the specifications. 21. EMPLOYMENT OF APPRENTICES: The Contractor, and all subcontractors, shall comply with the provisions in Sections 1777.5, (Chapter 1411, Statutes of 1968), and 1777.6 of the California Labor Code concerning the employment of apprentices. The Contractor and any subcontractor under him shall comply with the requirements of said sections in the employment of apprentices; however, the Contractor shall have full responsibility for compliance with said Labor Code section, for all apprenticeable occupations, regardless of any other contractual or employment relationships alleged to exist. In addition to the above State Labor Code Requirements regarding the - employment of apprentices and trainees, the Contractor and all subcontractors shall comply with Section 5 a. 3, Title 29 of the Code of Federal Regulations (29CFR). _ 22. EVIDENCE OF RESPONSIBILITY: Upon the request of the City, a bidder whose bid is under consideration for the award of the Contract shall submit promptly to the City satisfactory evidence showing the bidder's financial resources, his construction experience, and his organization and plant facilities available for the performance of the contract. 23. WAGE RATES: The Contractor and/or subcontractor shall pay wages as indicated in the "Notice Inviting Sealed Bids" section of these specifications. The Contractor shall forfeit as penalty to the City of Diamond Bar, two hundred dollars ($200.00) for laborers, workmen, or mechanics employed for each calendar day, or portion thereof, if such laborer, workman or mechanic employed is paid less than the general prevailing rate of wages herein referred to and stipulated for any work done under the proposed contract, by him, or by any subcontractor under him, in violation of the provisions of Labor Code, and in particular, Sections 1770 to 1781 inclusive. Copies of all collective bargaining agreements relating to the work as set forth in the aforementioned Labor Code are on file with the Department of Industrial Relations, Division of Labor Statistics and Research. 24. PERMITS, FEES AND LICENSES: The Contractor shall possess a valid business license prior to the issuance of the first payment made under this Contract. Any work required within Caltrans right-of-way will require a separate permit to be obtained by 10 1293492.1 the Contractor. The Contractor shall obtain a no -fee Encroachment Permit from the City of Diamond Bar prior to the start of any work. 25. TIME OF COMPLETION AND LIQUIDATED DAMAGES: Bidder must agree to commence work on or before the date of written "Notice to Proceed" of the City and to fully complete the project within fifty (50) working days thereafter. Bidder must agree also to pay as liquidated damages, the sum of Five hundred dollars ($500.00) for each calendar day thereafter. 26. CLAIMS FILING AND PROCESSING: The City and Bidder agree to attempt to orally resolve any disputes which may give rise to a claim (hereafter, "Claim") that falls within the definition of Public Contract Code section 9204 (hereafter, "Section 9204"). If these efforts are unsuccessful, the City and Bidder shall process the Claim in accordance with Section 9204. In summary, if the Bidder decides to submit a Claim to the City; it shall be -sent by registered or certified mail, return receipt requested, together with reasonable documentation to support the Claim. A Claim may include a Claim by a subcontractor or a lower tier subcontractor meeting the requirements of Section 9204(d)(5). Within 45 days of receipt of the Claim, or any extension thereof agreed upon by the City and the Bidder, the City will conduct a reasonable review of the Claim and provide the Bidder with a written statement identifying what portion of the.Claim is disputed and what portion is undisputed. Payment of any undisputed portion of the Claim shall be made within 60 days after the City issues its written statement. If theCitydoes not provide a written statement within the time specified, the Claim shall be deemed rejected. If the Bidder disputes the City's written statement or if the Claim is deemed rejected, the Bidder may demand in writing by registered or certified mail to the City, return receipt requested, an informal conference to meet and confer in an effort to settle the disputed portion of any Claim. Within 30 days of receipt of such written demand, the City shall schedule a meet and confer conference. If any portion of the Claim remains in dispute after the conference, the City shall, within 10 City business days of the conclusion of the conference, provide the Bidder with a written statement identifying any portion that remains in dispute and any portion that is undisputed. Payment of any undisputed portion shall be made within 60 days after the City issues its written statement. Any remaining disputed portion shall be submitted to nonbinding mediation in accordance with Section 9204(c)(2)(B), unless the Bidder and City waive the mediation upon mutual written agreement. 27. CONFLICT OF INTEREST: In the procurement of supplies, equipment, construction and services by sub -recipients, the conflict of interest provisions in (State LCA-24 CFR 85.36 and Non -Profit Organizations — 24 CFR 84.4), OMB Circular A-110, and 24 CFR 570.611_, respectively, shall apply. No employee, officer or agent of the sub - recipient shall participate in selection or in award of administration of a contract supported by Federal funds if a conflict of interest, real or apparent, would be involved. r1 1293492.1 BIDDER'S PROPOSAL CITY OF DIAMOND BAR PANTERA PARK IMPROVEMENTS PROJECT CITY PROJECT NO. FP23503 Date FEBRUARY 27TH , 20 25 To the City Council of the City of Diamond Bar: The Undersigned hereby declares: (a) That the only persons or parties interested in this proposal as principals are the following: ROSEMARY PADILLA R DEPENDABLE CONST INC ROSEMARY PADILLA IS THE PRESIDENT, SECRETARY, TREASURER, & MANAGER (If the bidder is a corporation, give the name of the corporation and the name of its president, secretary, treasurer, and manager. If a co -partnership, give the name, under which the co -partnership does business, and the names and addresses of all co-partners. If an individual, state the name under which the contract is to be drawn.) (b) That this proposal is made without collusion with any person, firm or corporation. (c) That he has carefully examined the location of the proposed work and has familiarized himself with all of the physical and climatic conditions, and makes this bid solely upon his own knowledge. (d) That by submitting this Bidder's Proposal, he acknowledges receipt and knowledge of the contents of those communications sent by the City of Diamond Bar to him at the address furnished by him to the City of Diamond Bar when this proposal form was obtained. (e) That he has carefully examined the specifications, both general and detail, and the drawings attached hereto, and communications sent to him as aforesaid, and makes this proposal in accordance therewith. (f) That, if this bid is accepted he will enter into a written contract for the performance of the proposed work with the City of Diamond Bar. (g) That he proposes to enter into such Contract and to accept in full payment for the work actually done thereunder the prices shown in the attached schedule. It is understood and agreed that the quantities set forth are estimates and that the unit prices will apply to the actual quantities whatever they may be. Accompanying this proposal is a certified or cashier's check or bidder's bond, payable to the order of the City of Diamond Bar in the sum of 12 1293492.1 (10% OF TOTAL BASE BID) THIRTY SIX THOUSAND SEVEN HUNDRE❑ DOLLARS ($ 36,700,00), Said bidder's bond has been duly executed by the undersigned bidder and by a financially sound surety company authorized to transact business in this state, It is understood and agreed that should the bidder fail within ten (10) days after award of contract to enter into the contract and furnish acceptable surety bonds, then the proceeds of said check, or bidder's bond, shalt become the property of the City of Diamond Bar; but if this Contract is entered into and said bonds are furnished, or if the bid is not accepted then said check shall be returned to the undersigned, or the bidderwill be released from the bidder's bond. 1019 W. 3RD ST. Address of Bidder SAN BERNARDINO, CA 92410 City Zip Code !3 (909)381-2310 Telephone of Bidder BID SCHEDULE CITY OF DIAMOND BAR CONTRACT DOCUMENTS AND SPECIFICATIONS PANTERA PARK IMPROVEMENTS PROJECT CITY PROJECT NO. FP23503 ITEM NO. ESTIMATED QUANTITY UNIT DESCRIPTION WRITTEN IN WORDS UNIT PRICE AMOUNT 1 LS 1 MOBILIZATION $301000,00 $30,000.00 2 LS 1 SPORT COURT IMPROVEMENTS $157,200.00 $157,200.00 3 LS 1 DRINKING FOUNTAIN $21,880,00 $21,800,00 4 LS 1 LIGHTING IMPROVEMENTS $136,240.00 $136,240.00 ALTERNATE BID ITEM NO. ESTIMATED QUANTITY UNIT DESCRIPTION WRITTEN IN WORDS UNIT PRICE AMOUNT Al LS 1 FLAG POLE $21, 690.00 $21, 680.00 The BASIS OF AWARD shall be the sum of the BASE BID and the ALTERNATE BID. The City reserves the right to delete the ALTERNATE BID from the Award of Contract. TOTAL AMOUNT BID (IN FIGURES)-+ $367 , 000 , 00 TOTAL AMOUNT BID, (WRITTEN IN WORDS): THREE HUNDRED SIXTY SEVEN THOUSAND DOLLARS Bid Schedule Note: Bid Price indicated refers to all items illustrated on the plans and details, and delineated within the specifications installed and completely in place with all applicable portions of the construction documents and include all costs connected with such items including, but to necessarily limited to, materials, transportation, taxes, insurance, labor, overhead, and profit, for General Contractor and Subcontractors. All work called for on the construction documents are to provide a completed project with all systems operating properly and ready for use. 14 1293492.1 Award will be based on the items of Bid Schedule. Therefore, Contractor shall completely fill out Bid Schedule. Accompanying this proposal is BIDDERS BOND - (ten percent of total base bid) (I nsert I H -- - - - - a ° " " check" "certified check", or idder's bond" as the case may be) in the amount equal to at least ten p (10%) of the total bid. The undersigned further agrees that in case of default in executing the required contract, with necessary bond, within ten (10) days, not including Sundays and legal holidays, after having received notice that the Contract has been awarded and ready for signature, the proceeds of the security accompanying his bid shall became the property of the City of Diamond Bar, and this proposal and the acceptance thereof may be considered null and void. P (RQ���� ROSEMARY PADILLA 02/27/2025 NAME OF BIDDER (PRINT) 01 NATURE DATE 1019 W. 3RD ST. ADDRESS SAN BERNARDINO, CA 92410 92410 (909)381-2310 CITY ZIP CODE 944088 B - GENERAL BUILDING CONTRACTOR STATE CONTRACTOR LICENSE NO. AND CLASSIFICATION TELEPHONE I declare under penalty of Perjury of the laws of the State of California that the representations made he are true and correct in accordance with the requirements of California Business and Professional Code Section 7028.1 5---, CO 15 1293492.1 LIST OF SUBCONTRACTORS BID OPENING DATE 02/27/2025 Pantera Park Hardcourt Rehabilitation & C'IP FP23503 PROJECT LED Light Retrofit Project PROJECT NO. LOCATION 738 Pantera Dr. Diamond Bar 91765 CLIENT CITY OF DIAMOND BAR CONTRACTOR R DEPENDABLE CONST INC Name Under Which Subcontractor is Licensed License No, & D1R No. Address of Place of Business Percent of Total Contract Specific Description of Subcontract TRUELINE CONSTRUCTION & SURFACING 662 625 (A & C32) 1000006579 12397 Doherty Street 25.4 TENNIS/RASKETaALL CCMT R S=ACJNG TENNIS NETTING Riverside, CA 92503 sp°e�t;° i appcoveC apklicpatoc c[ elma,paavn .rdi.n In compliance with the provisions of the Public Contract Code Section 4104, the undersigned bidder herewith sets forth the name, location of the place of business, and California contractor license of each Subcontractor — who will perform work or labor or 16 1293492.1 render service to the Prime Contractor, specially fabricates and installs a portion of the work or improvement necessary to complete construction contained in the plans and specifications, in an amount in excess of one-half (1/2) of one percent (1 %) of the General Contractor's total base bid amount or, in the case of bids or offers for the construction of streets or highways, including bridges in excess of one-half of 1 percent (0.5%)of the Prime Contractor's total base bid or ten thousand ($10,000.00), whichever is greater, and the portion of the work which will be done by each Subcontractor. 17 1293492.1 DECLARATION OF ELIGIBILITY TO CONTRACT [Labor Code Section 1777.1; Public Contract Code Section 6109] The undersigned, a duly authorized representative of the contractor, certifies and declares that: 1. The contractor is aware of Sections 1777.1 and 1777.7 of the California Labor Code, which prohibit a contractor or subcontractor who has been found by the Labor Commissioner or the Director of Industrial Relations to be in violation of certain provisions of the Labor Code, from bidding on, being awarded, or performing work as a subcontractor on a public works project for specified periods of time. 2. The contractor is not ineligible to bid on, be awarded or perform work as a subcontractor on a public works project by virtue of the foregoing provisions of Sections 1777.1 or 1777.7 of.the California Labor Code or another provision of law. 3. The contractor is aware of California Public Contract Code Section 6109, which states: (a) A public entity, as defined in Section 1100 [of the Public Contract Code], may not permit a contractor or subcontractor who is ineligible to bid or work on, or be awarded, a public works project pursuant to Section 1777.1 or 1777.7 of the Labor Code to bid on, be awarded, or perform work as a subcontractor on, a public works project. Every public works project shall contain a provision prohibiting a contractor from performing work on a public works project with a subcontractor who is ineligible to perform work on the public works project pursuant to Section 1777.1 or 1777.7 of the Labor Code. (b) Any contract on a public works project entered into between a contractor and a debarred subcontractor is void as a matter of law. A debarred subcontractor may not receive any public money for performing work as a subcontractor on a public works contract, and any public money that may have been paid to a debarred subcontractor by a contractor on the project shall be returned to the awarding body. The contractor shall be responsible for the payment of wages to workers of a debarred subcontractor who has been allowed to work on the project. 4. The contractor has investigated the eligibility of each and every subcontractor the contractor intends to Use on this public works project, and determined that none of them is ineligible to perform work as a subcontractor on a public works project by virtue of the foregoing provisions of the Public Contract Code Sections 1777.1 or 1777.7 of the Labor Code, or any other provision of law. is 1293492.1 I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed this day of February 27th , 202X, at SAN BERNARDINO,CALIFORNIA (place of execution). (02/27/2025) 5 Signature Name: ROSEMARY PADILLA Title: PRESIDENT Name of Contractor: R DEPENDABLE CONST INC 19 1293492.1 BIDDER'S VIOLATION OF LAW/SAFETY QUESTIONNAIRE In accordance with Government Code Section 14310.5 and in conformance with Public Contract Code Section 10162, the Bidder shall complete, under penalty of perjury, the following questionnaire: QUESTIONNAIRE Has the Bidder, any officer, principal or employee of the Bidder who has a proprietary interest in the business of the Bidder, ever been disqualified, removed, or otherwise prevented from bidding on or completing a federal, state or local government project because of violation of law or a safety regulation? If the answer is yes, explain the circumstances in the following space: In conformance with Public Contract Code Section 10232, the Contractor, hereby states under penalty of perjury, that no more than on final unappealable finding of contempt of court by a federal court has been issued against the Contractor within the immediately preceding two-year period because of the Contractor's failure to comply with an order of a federal court which orders the Contractor to comply with an order of the National Labor Relations Board. NOTE: of this Statement and Questionnaire. 20 1293492.1 CONTRACTOR'S INDUSTRIAL SAFETY RECORD Project Identification CIP FP23503 Pantera Park Eardcourt Rehabilitation & LED Light Retrofit Project CIP FP23503 Bid Date 02/27/2025 This information must include all construction work undertaken in the State of California by the bidder and any partnership, joint venture or corporation that any principal of the bidder participated in as a principal or owner for the last five calendar years and the current calendar year prior to the date of bid submittal. Separate information shall be submitted for each particular partnership, joint venture, corporation or individual bidder. The bidder may attach any additional information or explanation of data, which he would like, taken into consideration in evaluating the safety record. An explanation must be attached of the circumstances surrounding any and all fatalities. ITEM 5 CALENDAR YEARS CURRENT PRIOR TO CURRENT YEAR YEAR 2020 2021 2022 2023 2024 TOTAL No. of Contracts 25 22 31 26 32 136 3 Total dollar amount of $4,214,332.00 $5,403,814.00 $4, 688, 687.00 $6,363,361.83 CPA STILL WORICSNC' DN TT 52i, 17o, 194_B3 EST:$152,950 contracts in 1,000's EST $6.5 MIL No. of lost workday 0 0 0 0 0 0 cases 0 No. of lost work day cases involving permanent 0 transfer to 0 0 0 0 0 0 another job or termination of employment No. of lost workdays 0 0 0 0 U 0 'The information required for this item is the same as required for columns 3 to 6, Code 10, Occupational Injuries, Summary - Occupational Injuries and Illnesses, OSHA No. 102. The above information was compiled from the records that are available to me at this time and I declare under penalty of perjury that the information is true and accurate within the limitations of these records. 1 ROSEMARY PADILLA Name of Bidder (Print 1019 W. 3RD ST. Address SAN BERNARDINO, CA 92410 Signature 944088 B - 6�EEWRL BUILDING CONTRACTOR State Contractor's Lic. No. & Class (909) 381-2310 City Zip Code Telephone 21 1293492.1 CERTIFICATION OF NON-DISCRIMINATION AND AFFIRMATIVE ACTION As suppliers of goods or services to the City of Diamond Bar, the firm listed below certifies that it does not discriminate in its employment with regards to race, religion, sex, or national origin; that it is in compliance with all federal, state, and local directives and executive orders regarding non-discrimination in employment; and that it will pursue an affirmative course of action as required by the affirmative action guidelines. We agree specifically- 1. To establish or observe employment policies which affirmatively promote opportunities for minority persons at all job levels. 2. To communicate this policy to all persons concerned including all company employees, outside recruiting services, especially those serving minority communities, and to the minority communities at large. 3. To take affirmative steps to hire minority employees within the company. FIRM R DEPENDABLE CONST INC TITLE OF OFFICER SIGNING 6090M 111111 PRESIDENT DATE 02/27/2025 Please include any additional information available regarding equal opportunity employment programs now in effect within your company: R DEPENDABLE CONST INC IS AN EQUAL OPPORTUNITY EMPLOYER AFFIDAVIT FOR CORPORATION BIDDER STATE OF CALIFORNIA ) )SS COUNTY OF LOS ANGELES } ROSEMARY PADILLA , being first duly sworn, deposes and says: That he is PRESIDENT of, R DEPENDABLE CONST INC a corporation which is the party making the foregoing proposal or bid; that such bid is genuine and not collusive or sham; that said bidder has not colluded, conspired, connived or agreed, directly or indirectly, with any other bidder or person to put in a sham bid or that such other person shall refrain from bidding; and has not in any manner sought by collusion to secure any advantage against the City of Diamond Bar or any person interested in the proposed contract, for himself or for any other person. Signature j /J Subscribed and sworn to before me this day of , 20 Signature of Officer Administering Oath (Notary Public) 2; 1293492.1 CALIFORNIA JURAT CERTIFICATE A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of San Bernardino Subscribed and sworn to (or affirmed) before me on this 27th day of .February 20 25 by Rosemgy Padilla proved to me on the basis of satisfactory evidence to be the persort(s) who appeared before me. WITN MY H OFFICIAL SEAL. Si ire of Notary Public DA NIS ABIGAIL LARA R00863 w �; , . ' CONiM. #2448473 a NOTARY PUBLIC - CAI.IEORNIA SAN BERNARDINO COUNTY MY Comm Expires Ma, 36 7027 OPTIONAL INFORMATION (Notary Seal) Theivrat contained within this document is in accordance with California lam. Any affidavit subscribed and sworn to before a notanj shall use the preceding wording or substantintly similar worsting pursuant to Civil Code sections 1189 and 8202..4 jurai certificate cannot be a fixed to a docutnent seat by mail or otheiivise delivered to a notary public, including electronic means, whereby the signer did not personally appear before the norarypublic, even if the signer is known by the notary public. The seal and signature cannot be affixed to a document without the correct notarial wording. Rs an additional option an of tant can produce an affidavit on the same document as the notarial certificate wording to eliminate the use of additional documentation. DESCRIPTION OF ATTACHED DOCUMENT (Title of document) Number of Pages (Including jurat) Document Date (Additional Information) MMX V. BAN2 510.409.1334 www.BayAreablotary.com CAPACITY CLAIMED BY THE SIGNER Individual Corporate Officer Partner Attorney -In -Fact Trustee Other: KNOW ALL PERSONS BY THESE PRESENTS that, WHEREAS the City of Diamond Bar ("City"), has issued an invitation for bids for the work described as follows: Pantera Park Hardcourt Rehabilitation & LED Light Retrofit Project No. CIP FP23503 WHEREAS R Dependable Const Inc- 1019 W. 3rd Street, Ste B. San Bernardino CA 92410 (Name and address of Bidder) ("Principal"), desires to submit a bid to Public Agency for the work. WHEREAS, bidders are required under the provisions of the California Public Contract Code to furnish a form of bidder's security with their bid. NOW, THEREFORE, we, the undersigned Principal, and The Ohio Casualty Insurance Company- 100 Liberty Way Dover New Hampshire 03820 (Name and address of Surety) ("Surety") a duly admitted surety insurer under the laws of the State of California, as Surety, are held and firmly bound unto Public Agency in the penal sum of Ten Percent Amount of Bid Dollars($ 10°/0 0 ), being not less than ten percent (10%) of the total bid price, in lawful money of the United States of America, for the payment of which sum well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION IS SUCH THAT, if the hereby bounded Principal is awarded a contract for the work by City and within the time and in the manner required by the bidding specifications, entered into the written form of contract included with bidding specifications, furnishes the required bonds, one to guarantee faithful performance and the other to guarantee payment for labor and materials, and furnishes the required insurance coverages, then this obligation shall become null and void; otherwise, it shall be and remain in full force and effect. In case suit is brought upon this bond, Surety further agrees to pay all court costs incurred by City in the suit and reasonable attorneys' fees in an amount fixed by the court. Surety hereby waives the provisions of California Civil Code § 2845. 30 1293492.1 IN WITNESS WHEREOF, each of which shall for all purposes be deemed an original hereof, have been duly executed by Principal and Surety, on the date set forth below, the name of each corporate party being hereto affixed and these presents duly signed by its undersigned representative(s) pursuant to authority of its governing body, Dated: February 24, 2025 "Principal" "Surety" R Dependable Const Inc The Ohio Casualty Insurance Company ,s eyi2��,w-4�. Its Rosem P d' a, President Its shley N. Baker, Attorney -in -Fact By: Its Its Note: This bond must be dated, all signatures must be notarized, and evidence of the authority of any person signing as attorney -in -fact must be attached. (Seal) 31 1293492.1 (Seal) 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. Liberty Liberty Mutual insurance Company Mutual. The Ohio Casualty Insurance Company CertificateNc 8208023-987721 SURETYWest American Insurance Company POWER OF ATTORNEY KNOWN ALL PERSONS BY THESE PRESENTS: That The Ohio Casualty Insurance Company is a corporation duly organized under the laws of the State of New Hampshire, that Liberty Mutual Insurance Company is a corporation duly organized under the laws of the Slate of Massachusetts, and West American Insurance Company is a corporation duly organized under the laws of the State of Indiana {herein collectively called the 'Companies'), pursuant to and by authority herein set forth, does hereby name, constitute and appoint, Ashley N. Baker, Karen A. Eby, Kyle T. Baker, Timothy C. Baker all of the city of MurTieta state of CA each individually if there be more than one named, its true and lawful attorney -in -face to make, execute, seal, acknowledge and deliver, for and on its behalf as surety and as its act and deed, any and all undertakings, bonds, recognizances and other surely obligations, in pursuance of these presents and shall be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper persons. IN WITNESS WHEREOF, this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Companies have been affixed thereto this I I th day of May 2022 Liberty Mutual Insurance Company iNsu �� f INS& a INS11 - The Ohio Casually Insurance Company GoRpe`ts n gJP�a0OR4 `9y �C�P �OF. 0 411. West American Insurance Company U4 � 3 Fa m = ab LM1 1912 a 1919 „ 1991 /fir.? US sRCHU`�� da O h"HANFsa �Y " r Q1 a BY: m m tv David M. Carey, Assistant Secretary m State of PENNSYLVANIA i Ml County of MONTGOMERY ss o On This 11th day of May 2t122 before me personally appeared David M_ Carey, who acknowledged himself to be the Assistant Secretary of Libe ty Mutual Insurance 0 is Company, The Ohio Casualty Company, and West American Insurance Company, and that he, as such, being authorized so to do, execute the foregoing instrument for the purposes therein contained by signing on behalf of the corporations by himself as a duly authorized officer. �ro IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my notarial seal at King of Prussia, Pennsylvania, on the day and year first above written. c -� O U) 5p PASl ,kUr;W� �{ Commonwealth or Pemsylvarua- Notary StrW Teresa la, Notary Public rit0c � My mmrrnssipn expires Match 2a, 2925 By. Commissan number 11260444 — - q? LS Lr�4� ; Member, PennsyWama Msociatian or Nvtades Teresa Paslella, Notary Public CU a; This Power of Attorney is made and executed pursuant to and by authority of the following By -taws and Authorizations of The Ohio Casualty Insurance Company, Life ty Mutual •� Insurance Company, and West American Insurance Company which resolutions are now in full force and effect reading as follows: o ARTICLE IV -OFFICERS: Section 12. Power cfAftorney. Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President, and subject to such limitation as the Chairman or the n President may prescribe, shall appoint such attorneys -in -fact, as may be necessary to act in behalf of the Corporation to make, execute, seal, acknowledge and deliver as surely any and all undertakings, bonds, recognizances and other surety obligations. Such attorneys -in -fact, subject to the limitations set forth in their respective powers of attorney, shall o have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation. When so executed, such instruments shall he as binding as ff signed by the President and attested to by the Secretary. Any power or authority granted to any representative or attorney -in -fact under the provisions of this article may be revoked at any time by the Board, the Chairman, the President or by the officer or officers granting such power or authority, ARTICLE )III- Execution of Contracts: Section 5 Surety Bonds and Undertakings. Any officer of the Company authorized for that purpose in writing by the chairman or the president, and subject to such ilmilations as the chairman or the president may prescribe, shall appoint such attorneys -in -fact, as may be necessary to act in behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. Such attorneys -in -fact subject to the limitations set forth in their respective powers of attorney, shall have full power to bind the Company by their signature and execution of any such instruments and to attach thereto the seal of the Company. When so executed such instruments shall be as binding as if signed by the president and attested by the secretary. Certificate of Designation - The President of the Company, acting pursuant to the Bylaws of the Company, authorizes David M. Carey, Assistant Secretary to appoint such attorneys-0- fact as may be necessary to act on behalf of the Company to make, execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. Authorization - By unanimous consent of the Company's Board of Directors, the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the Company, wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds, shall be valid and binding upon the Company with the same force and effect as though manually affixed. I, Renee C. Lleweliyn, the undersigned, Assistant Secretary, The Ohio Casuatty Insurance Company, Liberty Mutuaf Insurance Company, and West American Insurance Company do hereby certify that the original power of attorney of which the foregoing is a foil, true and correct copy of the Power of Attorney executed by said Companies, is in full force and effect and has not been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seals of said Companies this 24th day of February , 2025 . 1NSU•p.p `11i INS&y9y 1NSUR FJ��pt�POq�r "F� ..00% 91 VPoO o'�r4�C, Fo Cl 4 a ob fi 1912 q o 0 1919 1991 yBy. O d O ,'SA CNUj aaa$ 0 yAM45aa'S �s �ArOrANP ,�a'� Renee C. Llewellyn, Assistant Secretary 7 LMS-12873 LMIC CCIC WAIC Mutts Co o2I21 C ro a) ZI: O Q Q [V p N CO 00 a� c cv — vro C U o m o rn �ro o� No. 5133-4 STATE OF CALIFORNIA DEPARTMENT OF INSURANCE SAN FRANCISCO Amended Certificate of Authority THIS IS TO CERTIFY, That pursuant to the Insurance Code of the State of California, The Ohio Casualty Insurance Company of New Hampshire, organized under the laws of New Hampshire, subject to its Articles oflncorporatlon or otherfundamenial organizational documents, is hereby authorized to transact within this State, subject io all provisions of this Certificate, thefollowing classes of insurance: Fire, Marine, Surety, Plate Glass, Liability, Workers' Compensation, Common Carrier Liability, Boiler and Machinery, Burglary, Credit, Sprinkler, Automobile and Miscellaneous as such classes are now or may hereafter he defined in the Insurance Laws of the State ofCalfornia. THIS CERTIFICATE is expressly conditioned upon the holder hereof now and hereafter being in full compliance with all, and not in violation ofany, ofthe applicable laws and lawful requirements made under authority of the laws of the State of California as long as such laws or requirements are in effect and applicable, and as such laws and requirements now are, or may hereafter be changed or amended. IN WITNESS WHEREOF, effeettve as of the 191h day of March, 2013,1 have hereunto set my hand and caused my offtclal seat to be affixed this 19`h day of March, 2013. Dave Jones tasuran" Commtsstoner By Valerie J. Sarfaty for Nettie Hoge Chief Deputy NOTICE: Qualification with the Secretary of State most be accomplished as required by the California Corporations Coda promptly after Issuance ofthis Certificate of Authority. pailureto do so will be violation oflasurance Code section 701 andwill be grounds for revoking this Certificate of Authority pursuant to the eovamans made in the application therefor and the conditions watched herein. CALIFORNIA ALL- PURPOSE CERTIFICATE OF ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Riverside On 24th February 2025 � before me, K.A. Eby, Notary Public ere insert name ard tifle of the earl personally appeared Ashley N. Baker who proved to me on the basis of satisfactory evidence to be the persons) whose name(} islafe subscribed to the within instrument and acknowledged to me that -he/she/t#ey executed the same in *a/her*e authorized capacityi and that by 4tis1herl r signature{%) on the instrument the person(-}, or the entity upon behalf of which the person(*acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITN is Sign I seal. (Notary Public Seal) ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT (Title or description of altached document) (Title or deseriplion of attached document continued) Number of Pages Document Date CAPACITY CLAIMED BY THE SIGNER ❑ Individual (s) 0 Corporate Officer (Title) ❑ Partner(s) © Attorney -in -Fact r� Trustee(s) ❑ Other 2015 Version www.NotaryClasses.com 300-E73-9565 . X EBY ComtA.F4 "Otmpubii _ ewitamia IVER51pE� omm.ESepAc2028 INK RUCTIONS FOR COMPLETING THIS FORM Thisfurrn complies wrih current Californiaslalnies regarding rralarr wordrng and, if needed/ should be cornpleied o and altached io the de)Lmnent. Aclataieledgmews from other states rear be completed fn documents being sent to that stale so long as the uwrding does not require the Calrfornia nomad, to violate Cal fount notary lmu- • Stale and County information must be the Stale and County where the document signcr(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date this the signer(%) personally appeared which must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her commission followed by a cotmna and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of nolarizalion. • Indicate the correct singular or plural forms by crossing off incorrect forms (i.e. ltelshelt#cy;-is 1$re) or circling the correct forts. failure to uorrectiy indicate this information may lead to rejeclion of document recording. • '13me notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, re -seal if a sufficient area permits, otherwise complete a different acknowledgment forth. • Signature of the notary public must match the signature an file with the ogee of the county clerk. Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. Indicate title or type of attachcd document, number of pages and date. Lrdicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CFO, CFU, Secretary). • Securely attach this document to the signed document with a staple CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of San Bernardino On February 27th. 2025 before me, Damaris Abigail Lara Ramos (Here insert name and title of the officer) personally appeared Rosemary Padilla } who proved to me on the basis of satisfactory evidence to be the person(s) whose names) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITN S in a of Icial seal. OAyiARISABIGAIL LARA RAMOS COMM. #2448473 „ NOTARY PUBLIC -CALIFORNIA m SAN BERNARDINO COUNTY (Notary Seal) lJly Comm. Expires May 30. 2027 re o No ubIic ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT (Title or description of attached document) (Title or description of attached document continued) Number of Pages Document Date (Additional information) CAPACITY CLAIMED BY THE SIGNER ❑ Individual (s) ❑ Corporate Officer (Title) ❑ Partner(s) ❑ Attorney -in -Fact ❑ Trustee(s) ❑ Other INSTRUCTIONS FOR COMPLETING THIS FORM Any acknowledgment completed in California Hurst contain verbiage exactly as appears above in the notmy section or a separate acknowledgment form must be properly completed and attached to that document. The only exception is if a document is 10 be recorded outside of California. !n such instances, any alternative acknowledgment verbiage as may be printed on such a document .so long as the verbiage does not require the irvtary to do something that is illegal.for it notary in California (i,e, certifying the authorized capacity of the signer). Please check the document carefidly fiir proper notarial wording and attach this form if required. • State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her com inission followed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarization. • Indicate the correct singular or plural forms by crossing off utcorrect forms (i.e. lIshe/tk is /are-) or circling the correct forms. Failure to correctly indicate this information may lead to rejection of document recording. • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, re -seal if a sufficient area permits, otherwise complete a different acknowledgment form. • Signature of the notary public must match the signature on file with the office of the county clerk. Additional infonnation is not required but could help to ensure this acknowledgment is not misused or attached to a different document. Indicate title or type of attached document, number of pages and date. Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e, CEO, CFO, Secretary). • Securely attach this document to the signed document 2008 Version CAPA v12,10.07 800-873-9865 www.NotaryClasses.com CERTIFICATION WITH REGARD TO THE PERFORMANCE OF PREVIOUS CONTRACTS OR SUBCONTRACTS SUBJECT TO THE EQUAL OPPORTUNITY CLAUSE AND THE FILING OF REQUIRED REPORTS The bidder ✓, proposed subcontractor , hereby certifies that he has ✓, has not , participated in a previous contract or subcontract subject to the Equal Opportunity Clause, as required by Executive Orders 10925, 11114, or 11246, and that he has V, has not , filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance, a Federal Government contracting or administering agency, or the former President's Committee on Equal Employment Opportunity, all reports due under the applicable filing requirements. R DEPENDABLE CONST INC (COMPANY) BY: PRESIDENT (TITLE) DATE; FEBRUARY 27TH. 20 2$ NOTE: The above certification is required by the Equal Employment Opportunity Regulations of the Secretary of Labor (41 CFR 60-1.7 (b) (1), and must be submitted by bidders and proposed subcontractors only in connection with contracts and subcontracts which are subject to the Equal Opportunity Clause. Contracts and subcontracts which are exempt from the Equal Opportunity Clause are set forth in 41 CFR 60-1.5. (Generally only contracts or subcontracts of $10,000 or under are exempt). Currently, Standard Form 100 (EEO-1) is the only report required by the Executive Orders or their implementing regulations. Proposed prime contractors and subcontractors who have participated in a previous contract or subcontract subject to the Executive Orders and have not filed the required reports should note that 41 CFR 60-1.7 (b) (1) prevents the award of contracts and subcontracts unless such contractor submits a report covering the delinquent period of such other period specified by the Federal Highway Administration or by the Director, Office of Federal Contract Compliance, U.S. Department of Labor. 33 1293492.1 NON -COLLUSION AFFIDAVIT TO: THE CITY OF DIAMOND BAR. - STATE OF CALIFORNIA ) )SS COUNTY OF LOS ANGELES ) ROSEMARY PADILLA , being first duly sworn, deposes and says that he or she is PRESIDENT of R DEPENDABLE CONST INC , the party making the foregoing bid, that the bid is not made in the interest of or on behalf of, any undisclosed person, partnership, company association, organization, or corporation, that the bid is genuine and not collusive or sham; that the bidder has not directly or indirectly induced or solicited another bidder to put in a false or sham bid, and has not directly or indirectly colluded, conspired, connived, or agreed with any bidder or anyone else to put in a sham bid, or that anyone shall refrain from bidding; that the bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of the bidder or any other bidder, or to fix any overhead, profit, or cost element of the bid price, or of that of any other bidder, or to secure any advantage against the public body awarding the contact or anyone interested in the proposed contract, that all statements contained in the bid are true; and further, that the bidder has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership, company association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid, j1 Signature of Bidt STATE OF CALIFORNIA } )SS COUNTY OF LOS ANGELES ) Subscribed and sworn to before me this _ day of ,20_. Notary Public in and for the County of State of California 34 1293492.1 CALIFORNIA JURAT CERTIFICATE A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of San Bernardino Subscribed and sworn to (or affirmed) before me on this 27th day of February zo 25 by Rosemau Padilla proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me. 4717-...'DAIARIS ARJ51 LAMA RAMOS comm. #24484i� WITNESS MY HA ND OFFICIAL SEAL. NOTARY PUBLIC CALIFORNIA 5AN BERNARDINO COUNTY My Comm. Expires May 30, 2027 y Sia a ure ary Public (Notary Seal) OPTIONAL INFORMATION The jurat contained within this docirarrent is in accordance with California law. Any affidavit subscribed and sworn: to before a notary shall use Ow preceding warding or sabstantially similar wording pitrsa[ant to Civil Code sections 1789 and 8202. A jurat certificate cannot be axed to a document sent by mail or otherwise delivered to a notary public, including electronic means, whereby the signer did not personally appear before the notary public, every if'the signer is known by the notary public. The seal and signature cannot be affixed to a document without the correct notarial wording. As an additional option an afJiant can produce an affidavit on the same document as the notarial certificate wording to eliminate the use of additional documentation. DESCRIPTION OF ATTACHED DOCUMENT (Title of document) Number of Pa. -Cs (Including.jurat) Document Date (Additional Information) ND/IX V. BAN2 510.409.1334 www.BayAre:iNotary.com CAPACITY CLAIMED BY THE SIGNER Individual Corporate Officer Partner Attorney -In -Fact Trustee Other: Request for Taxpayer Give Form to the Form (Rev. October2018) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ► Go to www.frs.gov/Fornl for instructions and the latest information. 1 Name (as shown on your Income tax return), Name is required on this line; do not leave this line blank. ROSEMARY PADILLA 2 Business name/disregarded entity name, if different from above R DEPENDABLE CONST INC m yp 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check one one of the Y 4 Exemptions codes apply only to P ( PP Y Y I following seven boxes. certain entities, not individuals; see n p ❑ Individual/sole proprietor or ❑ C Corporation S Corporation El Partnership ❑ TrusUestate instructions on page 3): 6 single member LLG Exempt payee code (if any) ❑ Limited liability company. Enter the tax classification (C=C corporation, S-S corporation, P=Partnership) ► `p Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting •' N C LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is LLC is disregarded from for code (if any} a another that not the owner U.S. federal tax purposes. Otherwise, a single -member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. y ❑ Other (see instructions) ► (Applies US) fn 7 List account numbers) here (optional) 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 (SHowever, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later, For other -[I] entities, it is your employer identification number (EIN). If you do not have a number, see Now to Get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1 or Also see What Name and I Employer identification number Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or 1 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) enteredonthis 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, contirilbouana4o an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Farm 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-0 (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S, person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form YY-U (Rev. 10-2018) Form W-9 (Rev, 10-2018) Page 2 By signing the filled -out form, you: 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 withhojding 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 Is not subject to the withholding tax on foreign partners' share of -- effectively connected Income, and 4. Certify that FATCA code(s) entered on this form (if any) Indicating that you are exempt from the FATCA reporting, is correct. See What Is FATCA reporting, later, for further information. Note: If you are a U.S. person and a requester gives you a form other then -Form -W-9 to request your TIN, you must use the requester's form If It Is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • 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 under section 1446 onanyforeign partners' share of effectively connected taxable Income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner Is a foreign person, and pay the section 1446 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 section 1446 withholding on your share of partnership Income. In the cases below, the following person must give 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. In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity; • In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, 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 grantor trust) -and -not the beneficiaries of the trust. Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S, person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entitles). 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 are a.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. Sufflclent 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, give the requester the appropriate completed Form W-8 or Form 8233. Backup Withholding What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 24% of such payments. This Is called "backup withholding." Payments that may be subject to backup withholding Include Interest, tax-exempt interest, dividends, broker andbarterexchange transactions, rents, royalties, nonemployee pay, payments made In settlement of payment card and third party network transactions, 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 instructions for Part II 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). Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information. Also see Special rules forpartnerships, earlier. What is FATCA Reporting? The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more Information. 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. Form W-9 (Rev. 10-2018) 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 Line 1 You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return. If this Form W-9 is for a joint account (other than an account maintained by a foreign financial Institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered In Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9. 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) of the name change, enter your first name, the last name as shown on your social securitycard, and your new last name. Note: ITIN applicant: -Enter -your -Individual name asItwas-entered-on— your Form W-7 application, line la. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application. b. Sole proprietor or single -member I.I.C. Enter your Individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or "doing business as" (DBA) name on line 2. c. Partnership, LLC that is not a single -member LLC, C corporation, or Scorporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2. d. Other entitles. Enter your name as shown on required U.S. federal tax documents on Ilne 1. This name should match the name shown on the charter or other legal document creating the entity. Youmayenter any business, trade, or DBA name on line 2. e. Disregarded entity.. For U.S. federal tax purposes, an entity that Is disregarded as an entity separate from its owner Is treated as a "disregarded entity." See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that Is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the. U.S, owner'sname is required to be provided on line 1. 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 line 2, "Business name/disregarded entity name." If the owner of the disregarded 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. Line 2 If you have a business name, trade name, DBA name, or disregarded entity name, you may enter It on line 2. Line 3 Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3. Page 3 IF the entity/person on line 1 Is THEN check the box for ... a(n) ... • Corporation Corporation • Individual Individual/sole proprietor or single- • Sole proprietorship, or member LLC • Single -member limited liability company (LLC) owned by an individual and disregarded for U.S. federal tax purposes. • LLC treated as a partnership for Limited liability company and enter U.S, federal tax purposes, the appropriate tax classification. • LLC that has filed Form 8832 or (P= Partnership; C= C corporation; 2553 to be taxed as a corporation, or S= S corporation) or • LLC that Is disregarded as an entity separate from its owner but the owner is another LLC that Is not disregarded for U.S. federal tax purposes. • Partnership Partnership • Trust/estate Trust/estate Line 4, Exemptions If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you. Exempt payee code. • Generally, individuals (Including sole proprietors) are not exempt from backup withholding. • Except as provided below, corporations are exempt from backup withholding for certain payments, Including Interest and dividends. • Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions. • Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC. The following codes Identify payees that are exempt from backup withholding. Enter the appropriate code in the space In line 4. 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(f)(2) 2—The United States or any of its agencies or Instrumentalities 3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities _ 4—A foreign government or any of its political subdivisions, agencies, or instrumentalities 5—A corporation 6—A dealer in securities or commodities required to register In the United States, the District of Columbia, or a U.S. commonwealth or possession 7—A futures commission merchant registered with the Commodity Futures Trading Commission 8—A real estate investment trust 9—An entity registered at all times during the tax year under the Investment Company Act of 1940 10—A common trust fund operated by a bank under section 584(a) 11—A financial institution 12—A middleman known In the Investment community as a nominee or custodian 13—A trust exempt from tax under section 664 or described in section 4947 Form W-9 (Rev. 10-2018) 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 13. IF the payment is for ... THEN the payment is exempt for... Interest and dividend payments All exempt payees except for 7 Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of _. noncoverad securities acquired prior to 2012. Barter exchange transactions and Exempt payees 1 through 4 patronage dividends --- - Payments over $600 required to be Generally, exempt payees reported and direct sales over 1 through 6' $5,0001 Payments made In settlement of Exempt payees 1 through 4 payment card or third -party -network transactions 1 See Form 1099-MISC, Miscellaneous Income, and Its Instructions. 2 However, the following payments made to a corporation and reportable on Form 10 MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency. Exemption from FATCA: reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial Institutions. Therefore, if you are only submitting this form for an account you hold In the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial Institution is subject to these requirements. A requester may Indicate that a code is not required by providing you with a Form W-9 with "Not Applicable" (or any similar indication) written or printed on the line for a FATCA exemption code. A —An organization exempt from tax under section -501(a) or any Individual retirement plan as defined In section 7701(a)(37) B—The United States or any of Its agencies or instrumentalities C-A-state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities D—A corporation the stock of which Is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(1) E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(1) F—A dealer in securities, commodities, or derivative financial Instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state G—A real estate Investment trust H—A regulated Investment company as defined In section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940 1—A common trust fund as defined In section 584(a) J—A bank as defined in section 581 K—A broker L—A trust exempt from tax under section 664 or described In section 4947(a)(1) M—A tax exempt trust under a section 403(b) plan or section 457(g) plan Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed. Line 5 Enter your address (number, street, and apartment or suite number). This Is where the requester of this Form W-9 will mall your Information returns. If this address differs from the one the requester already has on file, write NEW at the top. If a new address is provided, there Is still a chance the old address will be used until the payor changes your address in their records. Line 6 Enter your city, state, and ZIP code. Part I. 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 (ITIN). 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. If you are a single -member LLC that is disregarded as an entity separate from its owner, 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 What Name and Number To Give the Requester, later, 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 SSA 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.1ts.gov/Businesses and clicking on Employer Identification Number (EIN) under Starting a Business. Go to www.irs.gov/Forms to view, download, or print Form W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderFonns to place an order and have Form W-7 and/or SS-4 mailed to you within 10 business days. If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and 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 U.S. 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, 4, or 5 below Indicates 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 line 1 must sign. Exempt payees, see Exemptpayee code, earlier. Signature requirements. Complete the certification as Indicated In Items 1 through 5 below. Form W-9 (Rev. 10-2018) 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 outItem of the certification. 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 made In settlement of payment card and third party network transactions, 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), ABLE accounts (under section 529A), 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: I Give name and SSN of: 2. Two or more Individuals 001m account) other than an account maintained by an FFI 3. Two or more U.S. persons (joint account maintained by an FFI) 4. Custodial account of a minor (Uniform Gift to Minors Act) - -- - 5. a. The usual revocable savings trust (grantor Is also trustee) b. So-called trust account that Is not a legal or valid trust under state law 6. Sole proprietorship or disregarded entity owned by an Individual_ 7, Grantor trust filing under Optional Form 1099 Filing Method i (sae Regulations section 1.671-4(b)(2)(1) The actual owner of the account or, If combined funds, the first Individual on the accounts Each holder of the account The mino� The grantor -trustees The actual owners The owners The grantor" -- For this type of account: I Give name and EIN of: 8. Disregarded entity not owned by an The owner Individual 9. A valid trust, estate, or pension trust Legal entlty4 10. Corporation or LLC electing The corporation corporate status on Form 8832 or Form 2553 11. Association, club, religious, The organization charitable, educational, or other tax- exempt organization 12. Partnership or muitl-member LLC The partnership 13. A broker or registered nominee The broker or nominee For 14. Account with the Department of Agriculture In the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments 15. Grantor trust filing undsrthe Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Reaulations section 1.6714(bIf211111E Page 5 Give name and EIN of: The public entity The trust ' 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. ' 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 name/disregarded entity" name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN. 4 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 Specfal rules for partnerships, earlier. "Note: The grantor also must provide a Form W-9 to trustee of trust. 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, 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 Pub. 5027, Identity Theft Information for Taxpayers. Victims of Identity theft who are experiencing economic harm or a systemic 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 smalls or phishing schemes. Finishing Is the creation and use of email and websites designed to mimlc legitimate business smalls 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. Form W-9 (Rev. The IRS does not initiate contacts with taxpayers via emalls. 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 small 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 (TIGTA) at 1-800-366-4484. You can forward suspicious smalls to the Federal Trade Commission at spam®uce.gov or report them at www.ftc.govlcomplaint. You can contact the FTC at www.ffc.gov/idtheft or 877-IDTHEFT (877-438-4338). If you have been the victim of identity theft, see www.identityThef.gov and Pub. 5027. Visit www.lrs.govildentityTheft to learn more about Identity theft and how to reduce your risk. 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 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. commonwealths and 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.