Loading...
HomeMy WebLinkAbouthighway fac contracts-20150709155946.pdf Form W-9 Request for Taxpayer Give form to the (Rev.October 2007 Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Intemal Revenue Service - Name(as shown on your income tax return) a D.Hillman&Sons LLC co Business name,if different from above o_ c 0 0 o Check appropriate box: ElIndividual/Sole proprietor El Corporation El Partnership Exempt ,ta Limited liability company.Enter the tax classification(D=disregarded entity,C=corporation,P=partnership)► E?__ _ ❑ payee o ❑ Other(see instructions)► c Address(number,street,and apt.or suite no.) Requester's name and address(optional} a t�o 3190 Westland Drive 0 City,state,and ZIP code rn Bouckville,New York 13310 List account number(s)here(optional) V] _ 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 your social security number(SSN). However,for a 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. or 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. 22 3950814 9 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) `cti n page 4. Sign Signature of 7 Here U.S.person ► Date ► — � Z-ol General lnstructlo Definition of a U.S. person. For federal tax purposes, you are considered a U.S.person if you are: Section references are to the Internal Revenue Code unless otherwise noted. •An individual who is a U.S.citizen or U.S.resident alien, e A partnership, corporation, company, or association created or Purpose of Form organized in the United States or under the laws of the United A person who is required to file an information return with the States, IRS must obtain your correct taxpayer identification number(M) • An estate(other than a foreign estate), or to report, for example, income paid to you, real estate • A domestic trust(as defined in Regulations section transactions,mortgage interest you paid,acquisition or 301.7701-7). abandonment of secured property, cancellation of debt, or Special rules for partnerships.Partnerships that conduct a contributions you made to an IRA. trade or business in the United States are generally required to Use Form W-9 only if you are a U.S. person (including a pay a withholding tax on any foreign partners'share of income resident alien), to provide your correct TIN to the person from such business. Further,in certain cases where a Form W-9 requesting it(the requester)and, when applicable,to: has not been received, a partnership is required to presume that 1. Certify that the TIN you are giving is correct(or you are a partner is a foreign person, and pay the withholding tax. waiting for a number to be issued), Therefore, if you are a U.S.,person that is a partner in a 2. Certify that you are not subject to backup withholding,or partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. 3. Claim exemption from backup withholding if you area U.S. status and avoid withholding on your share of partnership exempt payee. If applicable,you are also certifying that as a income. U.S. person, your allocable share of any partnership income from The person who gives Form W-9 to the partnership for a U.S. trade or business is not subject to the withholding tax on purposes of establishing its'U.S. status and avoiding withholding foreign partners' share of effectively connected income. on its allocable share of net income from the partnership Note. If a requester gives you a form other than Form W-9 to conducting a'trade or business in the United States is in the request your TIN, you must use the requester's form if it is following cases: substantially similar to this Form W-9. •The U.S.owner of a disregarded entity and not the entity, Cat.No.10231X Form w-9 (Rev.10-2007) 0000 O O O LO M 00 lO to O r`, o .ti O' CN N r O O R eM 00 o 4 o f` O 00 O ti OD O O O 1,: O ti O L O LO 00 O tf) L M 00 L lO M M CA h O CN N 00 "t cM (6 DO N r O O O fV V} N'69- 6c} o r T- tF 6f r U) �' CO 6 69- Lo J H O H n O Z __wAA V y.� U O H a c w 0 O r ~ NO O O T- r- M C � O 00 00 co � � cy �' M o00 U N = 00 N r T-N r N Q e9- � } 11 �� .0 M I� N S O CR T J r o U) N l 6 w 3 CDN llco dam" N N N O) N 63 Ef3 { r fi4 LO r N d w M'' O ON cr) N U? co y=. Z N O 00 O -.. CA N M O LO� M ~ U) W) q 00 o Do Go co o (0 r rQ Q o � Lr M 61) v) o QQz z -� 0' r 0 O Q J Z w r (� U) 0 J N Q Z Q I oZS U) coZ w W r—)LU w Q < w w z 0 W Z CO m U) � Q a 0 OU w V o o Y w J a O) wZ O Q J � _ g � C7Zm (n x' o w w D > _ _ F- Ozw � 0 w Q � � 2',1 1<1 I lo _ U)I 1 0co2 < ocnz �- 1 ® F AM(MWODNYYY) A�?o' CERTIFICATE OF LIABILITY INSURANCE OPIDMY 04,2511 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). NAME: ..' PROWLER NAME ' PHONE -FAX Mang Ins Agy LLC Hamilton t AAL f)` ( c'No): 50 Utica Street ADDRESS: PRODUCER Hamilton NY 13346 CUSTOMER®s: DHILL-2 Phone: 315-824-3210 Fax: 315-824-0675 INSURERIS)AFFORORaS COVERAGE NAIC9 INSURED INSURER A: National-Grange Mutual - 14788 D. Hillman S Sons LLC INSURERB, 3190 Westland Dr Bouckville NY 13310 INSURERC: INSURER®: INSURERE: INSURER F:- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED-NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS - - CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, - EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MSR ADDL SUB R POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WI D POLICY NUMBER (MMrDDNYYY)... (MMFDD)YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 DAMAGE TO REa'NTED A X COMMERCIALGENERALUABILHY CPV7165D 04/22/11 04/22/12 PREMISES(Ea nce) '$ CLAIMS-MADE ❑X OCCUR NED EXP(Any Dire Pe—) $ X Owner/Cont Prot. PERSONAL B ADV INJURY $ GENERALAGGREGATE 5 2000000 HGEWL AGGREGATE LIMIT APPLIES PER: PRRODUCTS-CONPfOP AGOPOUCV X JPRO EC S T LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT- (Ea aatlerd) ANY AUTO BODILY INJURY(Pet Person) $- ALL OWNED AUTOS BODILY INJURY(Per amdeM). $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS NONOWNED AUTOS - $ UMBRELLA IIAB OCCUR EACH OCCURRENCE $ - EXCESS UP CV JMS-MADE - AGGREGATE $. DEDUCTIBLE $ RETENTION $ $ WORIO:RRS COMPENSATION - TOR WCY STA LDAITSFTS OTN AND EMPLOYERS'LIABILITT' YIN ER ANY PROPRIETOR/PARTNEWEXECUTNE ❑, EL EACH ACCIDENT $- OFFICERIMEMSER EXCLUDED? NIA (MarW—y in NH) E L DISEASE-EA EMPLOYEE $ If yes,desoiihe under DESCRIPTTONOFOPERATIONSbelow E1 DISEASE-POLICY LIMIT $ DESCRIPDON OF OPERATIONS I LOCATIONS I VEHICLES(A Ch ACORD III,Additional Remarks Schedule,ifLrlore spam',equire I Project: New Highway Garage, 475 Enfield main Rd., State Route 327, Ithaca NY 14850. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED.BEFORE .. THE E WMTION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS Town of Enfield AUTHOR=REPRESENTATIVE 168 Enfield Main Rd. Ithaca NY 14850 f) ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD