FY15 Library LSTA EZ Innovation GrantGRANT AGREEMENT
LSTA 2014 -2015 EZ Innovation Grant
This is an agreement by and between New Hanover County Public Library, hereinafter referred to as "the
Library," and the State Library of North Carolina, Department of Cultural Resources, hereinafter referred
to as the "State Library."
The State Library has agreed to fund this grant with federal Library Services and Technology Act (LSTA)
funds in the amount of $9,700 to be disbursed through North Carolina Accounting System accounting
fund 46011495410145. The Catalog of Federal Domestic Assistance (CFDA) number for this grant is
45.310. This agreement is in effect upon signing by all parties, but no earlier than July 1, 2014, and will
terminate on June 30, 2015, unless amended by mutual consent.
Institution and /or Library Name: New Hanover County Public Library
Mailing Address:
,,.M 'City, State, ZIP: 4 O
Project manager name/title: hA , m .
Library fiscal year ending date: June 30
IN CONSIDERATION OF RECEIVING THE ABOVE REFERENCED GRANT FUNDING,
THE LIBRARY HEREBY AGREES TO:
1. Accept and administer an LSTA grant from the State Library in the amount of $9,700 for
costs associated with the project represented in the Library's grant application, grant award
letter, and any amendments thereto.
2. Abide by all Grant Provisions as certified in this document and the grant application; including any
certifications submitted with this grant agreement such as Children's Internet Protection Act (CIPA)
Compliance and Certification Regarding Debarment and Suspension; Lobbying, Federal Debt Status;
Nondiscrimination.
3. Regularly inform the State Library on the progress of project activities as defined in the grant
application.
4. Encumber and expend project funds (grant and matching)
• only upon or after the effective date of this grant agreement and before its termination;
• in accordance with the project budget as submitted with the project application, or as modified in
the grant award letter, or as amended and approved by the State Library; and
• in accordance with 1 applicable local, state and federal laws and regulations.
2014 -2015 LSTA Grant Agreement page 1 of 5
5. Expend project funds in a manner that ensures free and open competition.
6. Submit grant reimbursement requests with appropriate documentation of eligible project expenditures
(grant and matching) as defined in the grant application, at least quarterly, on or before October 15,
January 15, and April 15.
7. On or before April 15, 2015, request a minimum of seventy -five percent (75 %) of the award amount
and provide documentation for seventy -five percent (75 %) of the required match; provide a list of
remaining activities with an estimate of remaining grant and matching expenditures as defined in the
grant application.
S. Complete all project expenditures (grant and matching) by June 30, 2015, or by the termination date
of this agreement as amended by mutual consent.
9. On or before July 15, 2015, submit a final request for reimbursement.
10. If eligible, the Library and all subgrantees shall: (a) ask the North Carolina Department of Revenue
for a refund of all sales and use taxes paid by them in the performance of this Contract, pursuant to
N.C.G.S. 105- 164.14; and (b) exclude all refundable sales and use taxes from all reportable
expenditures before the expenses are entered in their reimbursement reports.
11. Request prior written approval from the State Library for any equipment with a per unit price above
$5,000. List this equipment on the State Library Annual Equipment Tracking Survey, provided each
January, for the remainder of its useful life. If fair market value at the time of surplus or disposal
exceeds $5,000, disposal must be cleared with the State Library.
12. Acknowledge the Institute of Museum and Library Services in all related publications and activities
in conjunction with the use of grant funds as follows: "This publication /activity /program/etc. was
supported by grant funds from the Institute of Museum and Library Services under the provisions of
the federal Library Services and Technology Act as administered by the State Library of North
Carolina, a division of the Department of Cultural Resources." Submit a copy of any publications or
materials produced under the grant to the State Library.
13. Provide library services resulting from the grant to all members of the community served, in
compliance with all Federal statutes relating to non - discrimination on the basis of race, color, national
origin, sex, handicap, or age.
14. Request prior written approval from the State Library for any subcontracting or assignment to any
subgrantee or assignee. Neither the Library nor any subgrantee or assignee is relieved of the duties
and responsibilities of this agreement. Subgrantees and assignees agree to abide by the terms of this
agreement and must provide all information necessary for the Library to comply with the terms of this
agreement.
15. Only approved, awarded expenditures are allowable; any funds not expended as defined in the grant
application will be repurposed by the State Library upon termination of this agreement.
16. Submit a final report to the State Library by September 30, 2015, providing a summary of project
expenditures, a narrative of project activities, evaluative elements, and an assessment of the goals
achieved as defined in the grant application.
17. Certify upon completion of the grant that grant funds were received, used, and expended for the
purposes for which they were granted.
2014 -2015 LSTA Grant Agreement page 2 of 5
18. Maintain adequate financial records to ensure complete reporting, and retain programmatic, financial,
and audit records relating to the grant for a minimum of three years from the due date of the final
grant report at the end of the Five Year Plan, or until all audit exceptions have been resolved,
whichever is longer. Provide access upon request to the Department of Cultural Resources, Office of
the State Auditor, Institute of Museum and Library Services and the Comptroller General or their
designees, to all records and documents related to the award, including audit work papers in
possession of any auditor of the Library.
19. Ensure that grant funds are audited in compliance with state and federal audit requirements for local
governments and public authorities, institutions of higher education, and non -profit organizations,
and, as applicable, according to the standards of the federal Single Audit Act of 1984 as amended
1996 and 2003, and Circular A -133 "Audits of States, Local Governments, and Non - Profit
Organizations" as supplied by the Executive Office of the President, Office of Management and
Budget, Washington, DC.
20. Comply with the requirements of North Carolina General Statute 143C -6 -23: "State grant funds:
administration; oversight and reporting requirements" and the corresponding rules of North Carolina
Administrative Code, Title 9, Subchapter 03M, "Uniform Administration of State Grants," including
submission of required financial reports within six months (or nine months for $500,000 threshold) of
the end of the Library's fiscal year(s) in which grant funds are received.
21. The State Auditor and the using agency's internal auditors shall have access to persons and records as
a result of all contracts or grants entered into by State agencies or political subdivisions in accordance
with General Statute 147 -64.7 and Session Law 2010 -194, Section 21 (i.e., the State Auditors and
internal auditors may audit the records of the contractor during and after the term of the contract to
verify accounts and data affecting fees or performance).
22. File with the State Library a copy of the Library's policy addressing conflicts of interest that may
arise involving the Library's management employees and members of its board of directors,
commissions, or other governing body. The policy shall address situations in which any of these
individuals may directly or indirectly benefit, except as the Library's employees or members of its
board, commissions, or other governing body, from the Library's disbursing of grant funds and local
matching funds and shall include actions to be taken by the Library or the individual, or both, to avoid
conflicts of interest and the appearance of impropriety. (N.C.G.S. 143C- 6- 23(b)). The policy shall be
filed before the State Library may disburse the grant funds, unless the Library is covered by the
provisions of N.C.G.S. 160A- 479.11 and 14 -234.
23. File with the State Library the Library's sworn written statement completed by the Library's board of
directors or other governing body stating that, pursuant to N.C.G.S. 143C- 6- 23(c), the Library does
not have any overdue tax debts, as defined by N.C.G.S. 105- 243.1, at the federal, State, or local
level. The policy shall be filed before the State Library may disburse the grant funds, unless the
Library is covered by the provisions of G.S. 160A- 479.11 and 14 -234.
THE STATE LIBRARY AGREES TO:
1. Award LSTA grant funds to the Library in the amount and under the terms and conditions stated
above, subject to the availability of funds.
2. Pay LSTA grant funds upon receipt of reimbursement requests for approved, awarded expenditures
submitted quarterly by the Library. Pay by June 30, 2015, all approved requests received on or before
April 15, 2015, and by August 31, 2015, all approved requests received by July 15, 2015.
2014 -2015 LSTA Grant Agreement page 3 of 5
3. Assist the Library as appropriate and necessary with the implementation of this project. Provide
monitoring and oversight through a combination of periodic emails, calls, visits, and review of
reimbursement requests and reports.
4. Report on this project to the federal funding agency, the Institute of Museum and Library Services,
and the North Carolina Office of State Budget and Management in accordance with all applicable
federal and state requirements.
THIS AGREEMENT may be amended, if necessary, upon the mutual acceptance of a written
amendment to this agreement signed and dated by the Library and the State Library. Such amendment(s)
shall state any and/or all change(s) to be made. This agreement may be terminated by mutual consent
with 60 days' prior written notice or as otherwise provided by law.
Returning signed agreements signifies accepting the grant award; awards not accepted by September
30, 2014 may be withdrawn.
X Date 7 Pf —f
Signature, Local Government or Institutional Representative
(Printed Name / Title)
x
Signature, Cal Shepard, State Librarian
Date
Return tsAo complete sets of thr!� agreement with original signatures in blue ink to:
L STA Grant Agreemenis: Library Development Section. State Library of North Carolina,
4640 Mail SerVice Center; Raleigh, NC 27699- 4640
2014 -2015 LSTA Grant Agreement page 4 of 5
GRANT PROVISIONS
The following state and federal provisions apply to the LSTA
grant program. Libraries awarded grants must agree to comply
with these provisions.
1. Grant Agreement and Timinq of Expenditures
Official notification of the grant award must be received from the
State Library and a grant agreement (formal agreement between
the grantee and the State Library) signed by both the
representatives of the library and the State Librarian before any
funds may be encumbered or expended for the project.
2. Allowable and Unallowable Costs
Grantees must carry out the grant project according to the
approved grant proposal, and all federal funds must be
expended solely for the purpose for which a grant was awarded
The following costs are unallowable and may not be
proposed as grant project costs: bad debts, contingencies,
contributions and donations, entertainment, fines and penalties,
under recovery of costs under grant agreements (excess costs
from one grant agreement are not chargeable to another grant
agreement).
3. ac and Regulatory Compliance
Grantees must expend grant funds in accordance with all
applicable local, state, and federal laws and regulations.
4. Budget Revisions and Programmatic Chanaes
Grantees must not deviate from the approved budget and plan
for carrying out the grant project as contained in the approved
grant application unless prior approval is obtained from the State
Library.
5. Records Retention
Grantees must maintain adequate records to ensure complete
reporting, and retain programmatic and financial records relating
to the grant for a minimum of three years from the due date of
the final grant report at the end of the Five Year Plan, or until all
audit exceptions have been resolved, whichever is longer.
6._ Free and Open Comoetition
Purchases made from grant funds must be carried out to ensure
free and open competition to the extent possible. Libraries
eligible to purchase under state contract may use this option for
grant purchases.
7. Debarment & Suspension
Transactions for the purposes of this grant will not knowingly be
made with parties who have been debarred or suspended from
receiving Federal financial assistance under Federal programs
and activities (Debarment and Suspension Certification). See
Excluded Parties List System at https: / /www.sam.gov .
8. Equipment Purchases and inventory
Equipment with a per unit price above $5,000 requires advance
written approval from the State Library. If fair market value at the
time of surplus or disposal exceeds $5,000, disposal must be
cleared with the State Library.
9. Publicizinq & Acknowledging Funds
Grantees are required to credit IMLS /LSTA in all related
publications and activities in conjunction with the use of grant
funds. Grantees should publicize grant - supported activities in
available and appropriate media. The following
acknowledgement statement must be used when meeting these
requirements: 'This publication /activity /program was supported
by grant funds from the Institute of Museum and Library Services
under the provisions of the federal Library Services and
Technology Act as administered by the State Library of North
Carolina, a division of the Department of Cultural Resources."
Copies of any publications or materials produced under the grant
must be submitted to the State Library. IMLS logos are available at
http : / /www.imis.gov /recir)ients/imis acknowledgement. asp
10. Lobbvina
Grantees are prohibited by federal law from using grant funds to
pay costs associated with lobbying Congress or the public for
purposes of influencing elections, legislation, or the award of any
federal funds. Grantees receiving an award of over $100,000 must
file a certification regarding lobbying.
11. Non - discrimination
All library services provided as a result of federal grant funds must
be available without discrimination to all members of the community
served. Participation may not be denied on the basis of race, color,
national origin, handicap, age, or sex.
Relevant legislation includes but is not limited to the following:
Title VI of the Civil Rights Act of 1964, as amended (42 U.S.C. §
2000 etseq.); Section 504 of the Rehabilitation Act of 1973, as
amended (29 U.S.C. § §701 etseq.); Title IX of the Education
Amendments of 1972, as amended (20 U.S.C. § §1681 -83, and
1685 -86); the Age Discrimination in Employment Act of 1975, as
amended (42 U.S.C. § §6101 atseq.).
12. Trafficking in Persons
Grantees must comply with 22 U.S.C. § 7104(g) which prohibits
engaging in trafficking in persons, procuring a commercial sex act,
or using forced labor.
13. Audit and Financial Reporting Requirements
LSTA grants must be audited in compliance with federal and state
audit requirements for local governments and public authorities,
institutions of higher education, and non -profit organizations. The
following source documents outline the standards and
requirements:
• United States Office of Management and Budget: (OMB)
Circular A -133 - Audits of States, Local Governments, and
Non - Profit Organizations.
North Carolina General Statute 143C -6 -23 "State grant funds:
administration; oversight and reporting requirements," and the
corresponding rules of North Carolina Administrative Code,
Title 09, Chapter 03M, "Uniform Administration of State
Grants."
LEGAL REFERENCES:
• 2 CFR 220 - Cost Principles for Educational Institutions
(formerly OMB Circular A -21)
• 2 CFR 225 - Cost Principles for State, Local, and Indian Tribal
Governments (formerly OMB Circular A -87)
• 2 CFR 230 - Cost Principles for Non -Profit Organizations
(formerly OMB Circular A -122)
• 45 CFR 1110 - Nondiscrimination in Federally Assisted
Programs
• 45 CFR 1170 - Nondiscrimination on the Basis of Handicap in
Federally Assisted Programs and Activities
• 45 CFR 1183 - Uniform Administrative Requirements for
Grants and Cooperative Agreements to State and Local
Governments
• 45 CFR 1185 - Govermentwide Debarment and Suspension
(Nonprocurement) and Govemmentwide Requirements for
Drug -Free Workplace (Grants)
• OMB CircularA -102 — Grants and Cooperative Agreements
with State and Local Governments
• OMB Circular A-1 10 — Uniform Administrative Requirements
for Grants and Agreements with Institutions of Higher
Education, Hospitals, and Other Non -Profit Organizations
2014 -2015 LSTA Grant Agreement page 5 of 5
t F, , . .
FEDERAL ,, ; N w-
The grantee shall comply with 2 CFR Part 3185. The undersigned, on behalf of the grantee, certifies to
the best of his or her knowledge and belief that neither the grantee nor any of its principals.
(a) Are presently excluded or disqualified;
(b) Have been convicted within the preceding three years of any of the offenses listed in 2 CFR
section 180.800(a) or had a civil judgment rendered against you for one of those offenses within that
time period;
(c) Are presently indicted for or otherwise criminally or civilly charged by a governmental entity
(Federal, State or local) with commission of any of the offenses listed in 2 CFR section 180.800(x);
or
(d) Have had one or morupablic-traiisacions-( Federal,' State ; -or`local'))'termin0e'diuithin tlie`
preceding three years for cause or default.
Where the grantee is unable to certify to any of the statements in this certification, he or she shall
attach an explanation to this submission.
The grantee is required to communicate the requirement to comply with 2 CFR Part 180 Subpart C
(Responsibilities of Participants Regarding Transactions Doing Business With Other Persons) to persons
at the next lower tier with whom the grantee enters into covered transactions.
As required by Section 1352, Title 31 of the United States Code, and implemented for persons entering
into a grant or cooperative agreement over $100,000, the grantee certifies to the best of his or her
knowledge and belief that:
(a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned,
to any person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress
in connection with the awarding of a Federal contract, the malting of a Federal grant, the making of a
Federal loan, the entering into of a cooperative agreement, or the extension, continuation, renewal,
amendment, or modification of a Federal contract, grant, loan, or cooperative agreement.
(b) If any funds other than appropriated Federal funds have been paid or will be paid to any person
(other than a regularly employed officer or employee of the grantee) for influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with this Federal contract, grant,
loan, or cooperative agreement, the undersigned shall request, complete, and submit Standard Form
LLL, "Disclosure of Lobbying Activities," in accordance with its instructions.
(c) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly.
page 1 oft
I
The undersigned, on behalf of the grantee, certifies to the best of his or her knowledge and belief that the
grantee is not delinquent in the repayment of any Federal debt.
k � TM,
As required by the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Education Amendments
of 1972, and the Age Discrimination in Employment Act of 1975, as implemented at 45 C.F.R. Part
1180.44, the undersigned, on behalf of the grantee, certifies that the grantee will comply with the
following nondiscrimination statutes and their implementing regulations:
{a) Title VI of the Civil Rights Act of 1964, as amended (42 U.S.C. § 2000 et seq.), which provides
that no person in the United States shall, on the grounds of rare, color, or national origin, be
excluded from participation in, be denied the benefits of, or otherwise be subject to discrimination
under any program or activity receiving Federal financial assistance;
(b) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. § 701 ct seq.), which
prohibits discrimination on the basis -of disability in::Federally- assisted programs, (e). Title DC of the
Education Amendments of 1972, as amended (20 U.S.C. §§ 1681 -83, 1685- 86), which prohibits
discrimination on the basis of sex in education programs and activities receiving Federal financial
assistance;
(d) The Age Discrimination in Employment Act of 1975, as amended (42 U.S.C. § 6101 et seq.),
which prohibits discrimination on the basis of age in Federally - assisted programs;
The undersigned further provides assurance that it will include the Ianguage of these certifications in ail
subawards and that all subrecipients shall certify and disclose accordingly.
As the duly authorized representative of the grantee, I hereby certify that the grantee will comply with the
above certifications.
Print Name and Title of Authorized
Date
Certi$eation Regarding Debarment and Suspension; Lobbying; ate, page 2 of 2
s `
NEW t'fANOVER CC?ur rr f .� o
i! Ii:LIC E E E EIARY ='L
Conflict of Interest Policy
New Hanover County Public Library adheres to New Hanover County's policy regarding conflict
of interest as stated in the personnel policy section 6.3 to 6.7
6.3 Gifts and Favors
No employee of the County will accept any valuable gift, whether in the form of service, loan,
thing or promise from any person who to the employee's knowledge is interested directly or
indirectly in any manner whatsoever in business dealings with the County. No official or
employee will accept any gift, favor, or thing of value that may tend to influence that employee
in the discharge of duties. No officiator employee will•grantin•the discharge of-duties any
improper favor, service, or thing of value.
6.4 Solicitation Purpose and Applicability
The County fully supports the efforts of employees to raise fimds for charitable causes and non-
profit organizations, as long as these activities do not conflict with conducting County business
during regular hours of operation. Therefore, a policy has been developed with respect to
soliciting donations on County property or time. This policy applies to all employees.
6.4.1 Solicitation Policy
Employees shall not use the County e-mail system to broadcast solicitations for donations to a
charitable cause or non -profit organization, unless with prior approval by the County Manager.
However, employees may use the County intranet site to do so. Soliciting donations for
charitable causes or non - profit organizations within an employee's department is allowable with
prior approval of the department head. Soliciting donations from employees in other
departments must be approved by the County Manager or his designee. Soliciting, taking and
delivering orders, receiving payments and related activities shall not interfere with the
employee's work or the work of others. These activities should be restricted to employee
breaks and lunch times. There may be some fund- raising campaigns endorsed by the County
which may be exempt from the prohibitions in this policy.
6.5 Political Activity Restricted
Every employee has a civic responsibility to support good government by every available means
and in every appropriate manner. Employees may join or affiliate with civic organizations of a
partisan or political nature, may attend political meetings, may advocate and support the
principles or policies of civic or political organizations in accordance with the Constitution and
laws of the State of North Carolina and in accordance with the Constitution and laws of the
United States of America. However, no employee will: a. Engage in any political or partisan
activity while on duty (In addition to normal work, the words "on duty" shall be understood
to include attendance and participation in functions where political candidates or parties are
endorsed if County funds are used for expense of traveling or membership in such organization.);
b. Use official authority or influence for the purpose of interfering with or affecting the result of
an election or a nomination for office; c. Be required as a duty of office of employment or as a
condition for employment, promotion, or tenure of office to contribute funds for political or
partisan purposes; d. Coerce or compel contributions for political or partisan purposes by any
other employee of the County; or e. Use any supplies or equipment or "funds" of the County for
political or partisan purposes. County employees in certain federally -aided programs may be
covered by the Hatch Act as amended in 1975. This Federal Act, in addition to prohibiting (b),
(c), and (d) above, also prohibits candidacy for elective office in a partisan election. Any
violation of this section shall be deemed improper and shall subject such employee to dismissal
or other disciplinary action by the appointing authority.
6.6 Outside Employment Purpose and Applicability
The County recognizes that sometimes an employee may be employed outside of the County.
However, the work of the County will take precedence over other occupational interests or
employment and this policy provides guidelines for appropriate outside employment. This policy
applies to all County employees.
6.6.1 Outside Employment Policy
Employees may work in outside employment, if the employment is properly requested and
approved and it does not conflict with the employee's County job. Outside employment is self -
employment or any employment for salaries, wages, tips or commission other than the position
held with the County.
6.6.2 Outside Employment Procedures
Any employee considering outside employment shall report to the responsible supervisor his/her
intentions prior to the beginning of the job, occupation or self - employment. The responsible
supervisor shall review the outside employment and assure that it does not:
a. Coincide or conflict with hours of scheduled work with the
County;
b. Conflict with job responsibilities or affect the employee's ability
to perform satisfactorily at in the County job;
c. Cause an employee to arrive late for, or leave early from, any
scheduled shift or work hours in the County job; or
d. Constitute a conflict of interest with the County.
The supervisor will then forward the request through appropriate routes to the Human Resources
Director (or elected official), who will review the request for potential conflicts of interest or
liabilities with the County in general and give final approval (or denial). Failure to seek approval
for outside employment as outlined above or to maintain such employment when not approved
shall be cause for disciplinary action up to and including dismissal. If attendance or work
performance is determined to be compromised by outside employment, approval for outside
employment may be withdrawn.
6.7 Prohibited Board, Commission or Committee Service
Persons employed by New Hanover County may not serve on any board, committee or
commission established by resolution or State statutes in the agency or department for which
they work and receive wages. Prior to accepting such an appointment, the employee must
terminate his/her employment with the respective agency or department.
Established May 1977
Last Revised March 12, 2012
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I`iT.U� Ji . l'�:I�; IC4j�T''� l ", ' '` 'D , iFt. t "` Dxlla'`' Ii"'F"n,, 6tJ
As the duly authori7ed u_- prescntati,,-c; of applicam' library. 1 ^t I—Id y dlai the
library is (ch,!ck only of the fullowing boxes)
CIFA Compliant
(The applicaitt library has complie(l with the requirements of
Section 913.169(I) of the Library Services and Technoloky.l(t.)
No
la. El The CIPA roquirwmcnts do not apply because no funds tirade available
under the LSTA program are being used to purchase computers to access
the Internet, or to pay for direct costs associated wiih accessing the
Internet.
Signature ofAuth4izi d,Representative
Harry Tuchmayer
Printed Name ofAuthorizud Representative
Library Director
Title of Authorized Rcpmsuntative
February 25, 2013
Date
New Hanover County Public Lii4
Namo of Applicant Library/Progam
TO: i Dept.
r i 1
UNNEMEUM
I' : 9 request
Attached you will find a Grant Agreement paperwork for the LSTA EZ Innovation
Grant.
• The signature on the No Overdue Tax Debts Statement must be in
INK only.
• We will also need a current W -9 form.
Please return all enclosed forms to Yvette Mays at the Main Library so that she can
submit the completed package to the State Library of NC.
Thank you.
Co
,wP
N E%V It',l:,0VERCOUNil',:-
In
PULLic LISRAKY
No Overdue Tax Debts' Statement
Certification Statement
We certify that the New Hanover County Public Library does not have any overdue tax debts, as
defined by N.C.G.S. 105- 243.1, at the federal, State, or local level. We further understand that any
person who makes a false statement in violation of N.C.G.S. 143C- 6-23(c) is punishable as provided
by N.C.G.S. 143- 34(b).
If there are any questions, please contact the state agency that provided your grant. If needed, you may
contact the North Carolina Office of State Budget and Management at NCGrants @osbm.nc.gov or
919 -807 -4795.
Certification and Signatures (Please sign below in blue ink.)
We confirm that the foregoing certification is true, accurate, and complete to the best of our
knowledge. We also acknowledge and understand that any misuse of State funds will be reported to
the appropriate authorities for further action.
,l
State Library of North Carolina
1 G.S. 105 -243.1 defines: "Overdue tax debt. — Any part of a tax debt that remains unpaid 90 days or more after the notice of final
assessment was mailed to the taxpayer. The tern does not include a tax debt, however, if the taxpayer entered into an installment agreement
for the tax debt under G. S. 105 -237 within 90 days after the notice of final assessment was mailed and has not failed to make any payments
due under the installment agreement."
Form Request for Taxpayer Give Form to the
(Rev. August 2013) tII t1 r n Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service
Name (as shown on your income tax 'um)
N Business name/disregarded entity name, if different from $above
m
rn
ai
Q Check appropriate box for federal tax classification: Exemptions (see instructions):
0
H ❑Individual /sole proprietor ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
o Exempt payee code (f any)_
1 ❑ Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= partnership) ► Exemption from FATCA reporting
code (if any)
CL v Other (see Instructions) ►
Address (number, street, and apt. or suite no.) Requester's name and address (optional)
co 1
m City, state, and ZI code
Lisf a%count number(A) here (optional)
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the.name-given on.the "Name" line-, Social security number
to avoid backup withholding. For individuals, this is your social security number However, for a
peg —m —�
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer Iderdiflcatfon number
number to enter. FTI +0101cbblall
rOMM Certification
Under penalties of perjury, I certify that:
-1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S. person (defined below), and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
,Ijgn Signature of
Here I U.S. person ► t 9i�,� t. Date ► v -�
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. The IRS has created a page on IRS.gov for information
about Form W -9, at www.irs.gov1w9. Information about any future developments
affecting Form W -9 (such as legislation enacted after we release it) will be posted
on that page.
Purpose of Form
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.
Note. If you are a U.S. person and a requester gives you a form other than Form
W -9 to request your TIN, you must use the requester's form if it is substantially
similar 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:
A person who is required to file an information return with the IRS must obtain your ' An individual who Is a U.S. citizen or U.S. resident alien,
correct taxpayer Identification number (TIN) to report, for example, income paid to • A partnership, corporation, company, or association created or organized in the
you, payments made to you in settlement of payment card and third party network United States or under the laws of the United States,
transactions, real estate transactions, mortgage interest you paid, acquisition or
. An estate (other than a foreign estate), or
abandonment of secured property, cancellation of debt, or contributions you made
to an IRA.
• A domestic trust (as defined in Regulations section 301.7701 -7).
Use Form W -9 only if you are a U.S. person (including a resident alien), to
Special rules for partnerships. Partnerships that conduct a trade or business in
provide your correct TIN to the person requesting it (the requester) and, when
the United States are generally required to pay a withholding tax under section
applicable, to:
1446 on any foreign partners' share of effectively connected taxable income from
1. Certify that the TIN you are giving is correct (or you are waiting for a number
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
to be issued),
foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
2. Certify that you are not subject to backup withholding, or
U.S. person that is a partner in a partnership conducting a trade or business in the
3. Claim exemption from backup withholding If you are a U.S. exempt payee. If
United States, provide Form W -9 to the partnership to establish your U.S. status
applicable, you are also certifying that as a U.S. person, your allocable share of
and avoid section 1446 withholding on your share of partnership income.
any partnership income from a U.S. trade or business is not subject to the
Cat. No. 10231X Form W -9 (Rev. 8 -2013)
Form W -9 (Rev. 8 -2013)
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 Publication 515, Withholding of Tax
on Nonresident Aliens and Foreign Entities).
Nonresident alien who becomes a resident alien. Generally, only a nonresident
alien Individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on
certain types of income. However, most tax treaties contain a provision known as
a "saving clause." Exceptions specified in the saving clause may permit an
exemption from tax to continue for certain types of income even after the payee
has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who Is relying on an exception contained in the
caving 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 savfrig
clause and its exceptions.
4. The type and amount of income that qualifies for the exemption from tax.
5. Sufficient facts to justify the exemption from tax under the terms of the treaty
article.
Example. Article 20 of the U.S. -China Income tax treaty allows an exemption
from tax for scholarship income received by a Chinese student temporarily present
in the United States. Under U.S. law, this student will become a resident alien for
tax purposes if his or her stay in the United States exceeds 5 calendar years.
However, paragraph 2 of the first Protocol to the U.S. -China treaty (dated April 30,
1984) allows the provisions of Article 20 to continue to apply even after the
Chinese student becomes a resident alien of the United States. A Chinese student
who qualifies for this exception (under paragraph 2 of the first protocol) and is
relying on this exception to claim an exemption from tax on his or her scholarship
or fellowship income would attach to Form W -9 a statement that includes the
information described above to support that exemption.
If you are a nonresident alien or a foreign entity, give the requester the
appropriate completed Form W -8 or Form 8233.
What is backup withholding? Persons making certain payments to you must
under certain conditions withhold and pay to the IRS a percentage of such
payments. This is ca[fed "backup withholding." Payments that may be subject to
backup withholding include interest, tax - exempt interest, dividends, broker and
barter exchange transactions, rents, royalties, nonempfoyee 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 Part 11 instructions on page
3 for details),
3. The IRS tells the requester that you furnished an incorrect TIN,
4. The IRS tells you that you are subject to backup withholding because you did
not report all your interest and dividends on your tax return (for reportable interest
and dividends only), or
5. You do not certify to the requester that you are not subject to backup
withholding under 4 above (for reportable interest and dividend accounts opened
after 1983 only).
Certain payees and payments are exempt from backup withholding. See Exempt
payee code on page 3 and the separate Instructions for the Requester of Form
W -9 for more Information.
Also see Special rules for partnerships on page 1.
What is FATCA reporting? The Foreign Account Tax Compliance Act (FATCA)
requires a partfclpating 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 on
page 3 and the Instructions for the Requester of Form W -9 for more information.
Paget
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 fall to furnish your correct TIN to a requester, you are
subject to a penalty of $50 for each such failure unless your failure is due to
reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you make a
false statement with no reasonable basis that results in no backup withholding,
you are subject to a $500 penalty.
Criminal penalty for falsifying Information. Willfully falsifying certifications or
affirmations may subject you to criminal penalties including fines and/or
imprisonment.
Misuse of TINS. If the requester discloses or uses TI Ns in violation of federal law,
the requester may be subject to civil and criminal penalties.
Specific instructions
Name
If you are an individual, you must generally enter the name shown on your income
tax.return. Howaver;.if you: have changed your Iastname,.for instance, due to .. _
marriage without Informing the Social Security Administration of the name change,
enter your first name, the last name shown on your social security card, and your
new last name.
If the account is in joint names, list first, and then circle, the name of the person
or entity whose number you entered in Part I of the form.
Sole proprietor. Enter your Individual name as shown on your income tax return
on the "Name" line. You may enter your business, trade, or "doing business as
(DBA)" name on the "Business name/disregarded entity name" line.
Partnership, C Corporation, or S Corporation. Enter the entity's name on the
"Name" line and any business, trade, or "doing business as (DBA) name" on the
"Business name/disregarded entity name" line.
Disregarded entity. 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
Regulation section 301.7701- 2(c)(2)(111). Enter the owner's name on the 'Name'
line. The name of the entity entered on the "Name" line should never be a
disregarded entity. The name on the "Name" line must be the name shown on the
income tax return on which the income 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's name is required to be
provided on the "Name" line. If the direct owner of the entity Is also a disregarded
entity, enter the first owner that Is not disregarded for federal tax purposes. Enter
the disregarded entity's name on the "Business name/disregarded entity name"
line. If the owner of the disregarded entity is a foreign person, 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.
Note. Check the appropriate box for the U.S. federal tax classification of the
person whose name is entered on the "Name" line (Individual/sole proprietor,
Partnership, C Corporation, S Corporation, Trust/estate).
Llmlted Liabi'llty Company (LLC). If the person identified on the "Name" line is an
LLC, check the "Limited liability company" box only and enter the appropriate
code for the U.S. federal tax classification in the space provided. If you are an LLC
that Is treated as a partnership for U.S. federal tax purposes, enter "P" for
partnership. If you are an LLC that has filed a Form 8832 or a Form 2553 to be
taxed as a corporation, enter "C" for C corporation or "S" for S corporation, as
appropriate. If you are an LLC that is disregarded as an entity separate from its
owner under Regulation section 301.7701 -3 (except for employment and excise
tax), do not check the LLC box unless the owner of the LLC (required to be
identified on the "Name" line) is another LLC that is not disregarded for U.S.
federal tax purposes. If the LLC is disregarded as an entity separate from its
owner, enter the appropriate tax classification of the owner Identified on the
'Name" line.
Other entities. Enter your business name as shown on required U.S. federal tax
documents on the "Name" line. This name should match the name shown on the
charter or other legal document creating the entity. You may enter any business,
trade, or DBA name on the "Business name/disregarded entity name" line.
Exemptions
If you are exempt from backup withholding and /or FATCA reporting, enter in the
Exemptions box, any code(s) that may apply to you. See Exempt payee code and
Exemption from FATCA reporting code on page 3.
Form W -9 (Rev. 8 -2013) Page 3
Exempt payee code. Generally, individuals (including sole proprietors) are not
exempt from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends. Corporations are
not exempt from backup withholding for payments made in settlement of payment
card or third party network transactions.
Note. If you are exempt from backup withholding, you should still complete this
form to avoid possible erroneous backup withholding.
The following codes identify payees that are exempt from backup withholding:
1 —An organization exempt from tax under section 601(a), any I RA, 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 possession of the United States, or any of
their political subdivisions or instrumentalities
4 —A foreign government or any of its political subdivisions, agencies, or
instrumentalities
5 —A corporation
6 —A dealer in securities or commodities required to register in the United
States, the District of Columbia, or a possession of the United States
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
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
Ail 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 noncovered 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 $5,0001
1 through 52
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
1099 -MISC are not exempt from backup withholding: medical and health care
payments, attorneys' fees, gross proceeds paid to an attorney, and payments for
services paid by a federal executive agency.
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 —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
Q—A state, the District of Columbia, a possession of the United States, 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 Reg. 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 Reg. section 1.1472- 1(c)(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
I —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(8) plan
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 Now to get a TIN below.
If you are a sole proprietor and you have an EIN, you may enter either your SSN
or EIN. However, the IRS prefers that you use your SSN.
If you are a single - member LLC that is disregarded as an entity separate from Its
owner (see Limited Liability Company (LLC) on page 2), enter the owner's SSN (or
EIN, if the owner has one). Do not enter the disregarded entity's EIN. If the LLC is
classified as a corporation or partnership, enter the entity's EIN.
Note. See the chart on page 4 for further clarification of name and TIN
combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately. To apply
for an SSN, get Form SS -5, Application for a Social Security Card, from your local
Social Security Administration office or get this form online at www.ssagov. You
may also get this form by Galling 1- 800 = 772 - 1213: We Fbrm W -7, Application for
IRS Individual Taxpayer Identification Number, to apply for an ITIN. or Form SS -4,
Application for Employer Identification Number, to apply for an EIN. You can apply
for an EIN online by accessing the IRS website at www.irs.gov /businesses and
clicking on Employer Identification Number (EIN) under Starting a Business. You
can get Forms W -7 and SS -4 from the IRS by visiting iRS.gov or by calling 1-800 -
TAX -FORM (1 -800- 829 - $876).
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 chat 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
items 1, 4, or 5 below Indicate otherwise.
For a joint account, only the person whose TIN Is shown in Part I should sign
(when required). In the case of a disregarded entity, the person identified on the
"Name" line must sign. Exempt payees, see Exempt payee code earlier.
Signature requirements. Complete the certification as Indicated in items 1
through 5 below.
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.
& Real estate transactions. You m ust sign the certification. You may cross out
Rem 2 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).
S. Mortgage interest paid by you, acquisition or abandonment of secured
property, cancellation of debt, qualified tuition program payments (under
section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct TIN, but you
do not have to sign the certification.
Form W -9 (Rev. 8 -2013)
What Name and Number To Give the Requester
For this type of account:
Give name and SSN of:
1. Individual
The individual
2. Two or more individuals Qoint
The actual owner of the account or,
account)
if combined funds, the first
individual on the account'
3. Custodian account of a minor
The minor'
(Uniform Gift to Minors Act)
4. a. The usual revocable savings
The grantor- trustee'
trust (grantor is also trustee)
b. So- called trust account that is
The actual owner'
not a legal or valid trust under
state law
5. Sole proprietorship or disregarded
The owner'
entity owned by an individual
6. Grantor trust filing under Optional
The grantor"
Form 1099 Filing Method 1 (see
Regulation section 1.671- 4(b)(2)(i)(A))
For this type of account
Give name and EIN oft
7. Disregarded entity not owned by an
The owner
individual
8. A valid trust, estate, or pension trust
Legal entity °
9. Corporation or LLC electing
The corporation
corporate status on Form 8832 or
Form 2553
10. Association, club, religious,
The organization
charitable, educational, or other
tax - exempt organization
11. Partnership or multi- member LLC
The partnership
12. A broker or registered nominee
The broker or nominee
13. Account with the Department of
The public entity
Agriculture In the name of a public
enttty (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
14. Grantor trust filing under the Form
The trust
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulation section 1.671- 4(b)(2)(i)(B))
' Ust 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.
8 You must show your Individual name and you may also enter your business or "DBA" name on
the "Businees name/disregarded entity" name line. You may use either your SSN or EIN Of you
have one), but the IRS encourages you to use your SSN.
e 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 inthe account
title.) Also sea Special rules for partnerships on page t.
*Note. Grantor also must provide a Form W -9 to trustee of trust.
Privacy Act Notice
Page 4
Note. If no name is circled when more than one name is listed, the number will be
considered to be that of the first name listed.
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal information such as your
name, social security number (SSN), or other identifying Information. without your
permission, to commit fraud or other crimes. An identity thief may use your SSN to
get a job or may file a tax return using your SSN to receive a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax preparer.
If your tax records are affected by Identity theft and you receive a notice from
the IRS, respond right away to the name and phone number printed on the IRS
notice or letter.
If your tax records are not currently affected by Identity theft but you think you
are at risk due to a lost or stolen purse or wallet, questionable credit card activity
or credit report, contact the IRS Identity Theft Hotline at 1- 800- 908 -4490 or submit
Form 14039.
For more information, see Publication 4535, Identity Theft Prevention and Victim
Assistance.
Victims of identity theft who are experiencing economic harm or a system
problem, or are seeking help in resolving tax problems that have not been resolved
through normal channels, may be eligible for Taxpayer Advocate Service (TAS)
assistance. You can reach TAS by calling the TAS toll -free case intake line at
1 -677- 777 -4778 orT1-Y/TDD 1 -800- 829 -4059.
Protect yourselF from suspiclous •emalls•orphlshinggschemes. Phishingisthe
creation and use of email and webstes designed to mimic legitimate business
emails and websites. The most common act is sending an email to a user falsely
claiming to be an established legitimate enterprise in an attempt to scam the user
into surrendering private Information that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does
not request personal detailed information through email or ask taxpayers for the
PIN numbers, passwords, or similar secret access information for their credit card,
bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS, forward this
message to phishing@irs.gov. You may also report misuse of the IRS name, logo,
or other IRS property to the Treasury Inspector General for Tax Administration at
1 -800- 366 -4484. You can forward suspicious emails to the Federal Trade
Commission at: spam @uce.gov or contact them at www.ftc.goWidtheff or 1-877 -
IDTHEFT (1- 877 - 438 - 4338).
Visit IRS.gov to learn more about identity theft and how to reduce your risk.
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (Including federal agencies) who are required to file information returns with
the IRS to report interest, dividends, or certain other income paid to you; mortgage Interest you paid; the acquisition or abandonment of secured property; the cancellation
of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS,
reporting the above information. Routine uses of this information include giving It to the Department of Justice for civil and criminal litigation and to cities, states, the District
of Columbia, and U.S. 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.
Grant Agreement Documents Checklist
Review the following documents, sign where-required in blue ink, and mail together in one packet
with this checklist to the State Library:
New Hanover County Public Library
2014 -2015 LSTA EZ Innovation Grant
Mary Nolan
910 -798 -6358
Mnolan@nhcgov.com
"Green Power to Learn!"
,/or N/A
Document
LSTA Grant Agreements
Grant Agreement -- print and sign two complete copies
Library Development Section, Suite 310
Library Development Section
�(
Vendor Electronic Payment Form *, attached
Archives & State Library Building
4640 Mail Service Center
109 E. Jones Street
Certification Regarding Debarment and Suspension; -Lobbying,• Federal Debt- Status;
Raleigh, NC 27601
Nondiscrimination b—q://statelibroa.ncdcr.gov/ld/zrants/Ista/14 15/FormslCertDebarEtc. df
Attn: Vicki Wheeler
,Conflict of Interest Policy
ocate your institution's policy; copy and paste it onto letterhead.
A
No Overdue Tax Debts Statement
bqp://statelibLaa.neder.gov/ld/grants/Ista/14 15/FormslNoOverdueTaxDebts.docx
-9 Request for Taxpayer Identification Number and Certification, attached
Instructions and other infonnation are available at: h : / /ww-w.irs. ov/ ub /irs- df /fw9. df
CIPA Compliance Certification Form, public libraries only
http://stateliboa.neder.gov/IcVgEantsAstoJI4 15/FormsICIPACert. df
LSTA Partner Statement, if applicable
btp:HstatelibLM.ncdcr.gov/ld/grants/Ista/14 15/17ormsTartnerState.docx
* ePayment is available to any payee and is processed much faster than check payments. If the library is
interested in ePayment and is not already in the system, complete and mail to the address on the form.
To assure prompt receipt of your documents by the State Library, libraries may prefer to use a commercial
service for delivery to the Jones Street address. Packages sent via US Postal Service to the Mail Service Center
address (even Express Mail) frequently encounter delivery delays; the US Postal Service will not deliver to the
Jones Street address.
Commercial Service Address
(e.g. FedEx, UPS, or physical delivery)
Postal Service Address
LSTA Grant Agreements
LSTA Grant Agreements
Library Development Section, Suite 310
Library Development Section
State Library of North Carolina
State Library of North Carolina
Archives & State Library Building
4640 Mail Service Center
109 E. Jones Street
Raleigh, NC 27699 -4640
Raleigh, NC 27601
Attn: Vicki Wheeler