FY21 EWP State executed 19-091-4050 New Hanover County 2020.AWARDSteve Troxler North Carolina Department of Agriculture
Commissioner and Consumer Services
April 27, 2020
Ms. Dru Harrison
New Hanover County
230 Government Center Dr, Suite 100
Wilmington, NC 28403
ACCEPTANCE OF AWARD NOTIFICATION
Dear Ms. Harrison:
N. David Smith
Chief Deputy Commissioner
On behalf of Commissioner Steve Troxler and the North Carolina Department of Agriculture and Consumer
Services, we are pleased that you have accepted the Department's offer of $1,099,124.00 for Hurricane
Florence Watershed Restoration.
By accepting our offer of financial assistance, you have agreed to the specific stipulations, terms and
conditions, and reporting requirements contained in the contract that you signed. Enclosed is a fully
executed contract for your records.
If you have any questions regarding the contract, please feel free to contact Heather Reichert at (919) 707-
3768, or by email to Heather.Reichert@ncagr.gov. Invoices or matters regarding work to be performed
should also be directed to Ms. Reichert.
would like to take this time to wish you succe on your w tershed restoration project.
nce
N. David Smith
Chief Deputy Commissioner
Enclosure
Email: David,Smith@ncagr.gov
1001 Mail Service Center, Raleigh, North Carolina, 27699-1001
(919) 707-3033 0 Fax (919) 715-0026
An Equal Opportunity Affirmative Action Employer
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Steve Troxler North Carolina Department of Agriculture
Commissioner and Consumer Services
March 25, 2020
Ms.Dru Harrison
New Hanover County
230 Government Center Dr, Suite 100
Wilmington, NC 28403
NOTIFICATION OF FUNDING OFFER
Dear Ms. Harrison,
N. David Smith
Chief Deputy Commissioner
On behalf of Commissioner Steve Troxler and the North Carolina Department of Agriculture and Consumer
Services -- Division of Soil & Water Conservation, I am pleased to inform you that $1,099,124.00 for your
project, Watershed Restoration Project, was approved under the Hurricane Florence Emergency Response
Act.
Two original contract packets must be completed and returned to the NCDA&CS, making sure that the
contracts and certain forms have been signed, dated, and witnessed, as applicable, before they are returned
to the address provided below. By completing these documents, you are agreeing to the specific
stipulations, the general terms and conditions and specific reporting requirements. Please return the two
completed packets to:
Heather Reichert
NC Department of Agriculture & Consumer Services, Division of Soil & Water Conservation
1614 Mail Service Center
Raleigh, NC 27699-1614
All authorized re resentative signatures must be blue ink. Use the Contract Check Off List to ensure all
attachments are included and are in the correct order for each contract packet.
One fully executed, original contract will be returned to you for your records. If you have any questions
about your contract or any of the forms contained in your offer packet, please call Heather Reichert at 919-
707-3768, or feel free to send an email to Heather. Reichert@ncagr.gov.
I would like to take this opportunity to thank you for participating in the Watershed Restoration Project for
restoring drainage and securing streambanks fo ing regent storms.
C cer
N. David Smith'
Enclosures Chief Deputy Commissioner
cc: Tara Tyson, Grants Administrator
Email; David.Smith@ncagr.gov
1001 Mail Service Center, Raleigh, North Carolina, 27698-1001
(919) 707.3033 0 Fax (919) 715-0026
An Equal Opportunity Affirmative Action Employer
0
NORTH CAROLINA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
Steven W. Troxler, Commissioner
Contract Check Off List for Grantee (Government/University)
INSTRUCTIONS: Check the "Yes" boxes in the left column for the document titles that are being returned with the two signed, dated and witnessed copies of the
contract, with signatures in blue ink. Be sure to include all the other documents specified in your contract package. If "No" has been checked off for you, that
document is not required for this grant program or project.
GRANTEE ORGANIZATION NAME: New Hanover Co
PROJECT TITLEINAME: Watershed Restoration Prole
CONTRACT #: 19-091-4050
GO Entities Only
Check One Box
Document Title
Department Use—
Documents Attached
or On File
Grants and Contracts -
Documents Attached
or On File
Yes
No
Contractual "Check Off List for Grantee
Yes
No
Yes
No
Yes
No
Contract Cover To be signed, dated & witnessed
Yes
No
Yes
No
Yes
No
Attachment A — General Terms and Conditions — Government/University
Yes
No
Yes
No
Yes
No
Attachment B — Scope of Work includes Timeline and Line Item Budget)
Yes
No
/ Yes
No
Yes
No
Attachment C — Certifications and Assurances Section
Yes
No
/ Yes
No
Yes
No
Attachment D — NCO enBook Supplemental Information
es
No
/ Yes
No
Yes
No
Attachment E — Signature Card
Yes
No
i Yes
No
Yes
No
Attachment F — W-9 Tax Information
Yes
No
/ Yes
No
Yes
No
Attachment G — Vendor Electronic Payment Form
Yes
No
/ Yes
No
Yes
No
Attachment H — FFATA Data Reporting Requirements if applicable)
Yes
No
N Yes
No
Yes
No
Attachment I — Federal Regulations if applicable)
Yes
No
W Yes
No
Rev. 6117 f1
STATE OF NORTH CAROLINA
COUNTY OF WAKE
nm
Departmental Use Only
CENTER:
2985-1803
ACCOUNT:
536502
AMOUNT: 11,099,124.00
CENTER:
ACCOUNT:
536502
AMOUNT:
CENTER:
ACCOUNT:
536502
AMOUNT.
CENTER:
ACCOUNT:
536,502
AMOUNT:
.00
North Carolina Department of Agriculture and Consumer Services
Division of Soil & Water Conservation
Watershed Restoration Project - Governmental
CONTRACT # 19-091-4050
This Contract is hereby entered into by and between the North Carolina Department of Agriculture and
Consumer Services, Division of Soil & Water Conservation (the "Agency") and New Hanover County
("Grantee"), and referred to collectively as the "Parties". The Grantee's federal tax identification number is
56-6000324 and is physically located in New Hanover County, and is further located at 230 Government
Center Dr, Suite 100 Wilmington, NC 28403.
The purpose of this Contract is to implement needed repairs to streams and drainage ways resulting from
hurricanes and subsequent flooding. The Grantee's project title is Watershed Restoration Project. This
Contract is funded by state appropriations. Funds awarded under this Contract must be used for the
purposes for which they are intended.
The Grantee's fiscal year ends June 30 .
Contract Documents:
This Contract consists of the Grant Contract and its attachments, all of which are identified by name as
follows:
1. This Contract
2. General Terms and Conditions (Attachment A)
3. Scope of Work, including Timeline, Line Item Budget and Budget Narrative (Attachment B)
4. Certifications and Assurances Section (Attachment C)
5. NC Openbook Supplemental Information (Attachment D)
6. Signature Card (Attachment E)
7. W-9 Tax Information (Attachment F)
8. Vendor Electronic Payment Form (Attachment G)
These documents constitute the entire agreement between the Parties and supersede all prior oral or
written statements or agreements.
Precedence Among Contract Documents:
In the event of a conflict between or among the terms of the Contract Documents, the terms in the
Contract Document with the highest relative precedence shall prevail. The order of precedence shall
be the order of documents as listed in Paragraph 1, above, with the first -listed document having the
highest precedence and the last -listed document having the lowest precedence. If there are multiple
NCAA&CS (Govt Contract Cover) Rev. 7114;12114; 8117 Page 1 of 6
Contract Amendments, the most recent amendment shall have the highest precedence and the oldest
amendment shall have the lowest precedence.
Effective Period:
This Contract shall be effective on January 1. 2020 and shall terminate on December 31. 2022 with
the option to extend, if mutually agreed upon, through a written amendment as provided for in the
General Terms and Conditions as described in Attachment A.
III. Grantee's Duties:
The Grantee shall provide the services as described in the Attachment B: Scope of Work. The Grantee
shall be responsible to obtaining necessary landowner authorization Tor site access and all permits
needed to complete the planned work.
IV. Agency's Duties:
The Agency shall pay the Grantee in the manner and in the amounts specified in the Contract
Documents. The total amount paid by the Agency to the Grantee under this Contract shall not exceed
$1,099,124.00. This amount consists of: $1,099,124.00 in State funds.
[ ] a. There are no matching requirements from the Grantee.
[ ] b. There are no matching requirements from the Grantee; however, the Grantee has committed
the following match to this project:
[ X ] c. The Grantee's matching requirement is $3,627,109.20, which consists of:
[ a d. The Grantee has committed to an additional $ to complete the project as described in
Attachment B.
The total contract amount with matching funds is $4,726,233.20.
V. Conflict of Interest Policy:
The Agency has determined that the Grantee is a governmental agency and is not subject to N.C.G.S.
§ 143C -6-23(b). Therefore, the Grantee is not required to file a Conflict of Interest Policy with the
Agency prior to disbursement of funds.
VI. Statement of No Overdue Tax Debts:
The Agency has determined that Grantee is a governmental agency and is not subject to N.C.G.S. §
143C -6-23(c). Therefore, the Grantee is not required to file a Statement of No Overdue Tax Debts with
the Agency prior to disbursement of funds.
NCDA&C5 (Govt Contract Cover) Rev. 7114;12114; 8117 Page 2 of 6
VII. Reversion of Unexpended Funds:
Any unexpended grant funds shall revert to the Agency upon termination of this Contract.
VIII. Reporting Requirements:
(1) State [N.C.G.S. 143C-6-231:
The Agency has determined that the Grantee is a governmental entity and is not subject to the State
reporting requirements mandated by N.C.G.S. § 143C-6-23. Therefore, the Grantee does not have to
file annual electronic reports with the NC Office of State Budget & Management.
(2) Agency Reporting Requirements:
a) The Grantee shall submit quarterly progress reports, with each report due on or before the
last day of January, April, July, and October, continuing until the project is complete and final
project report is approved. The quarterly progress report is required even if no activity has
occurred for the quarter and no reimbursement is requested for the quarter.
b) The quarterly and final report shall include a narrative summary of the work completed each
quarter and for the project to date and a summary of cash and in-kind expenditures for the
quarter and total project.
c) Grantee shall submit a Final Financial report and Final Invoice not later than 60 days after the
expiration or termination of this Contract.
IX. Payment Provisions:
Upon execution of this Contract the Grantee shall submit to the Agency Contract Administrator a
completed Request for Payment form, to be provided by the Agency. All Request for Payment forms
should be received no more than monthly, with an invoice showing expenditures and matching funds,
if applicable, for the current period and cumulatively for the entire project. Upon approval by the
Agency, payment shall be made within 30 days. Twenty percent (20%) of the total funds awarded
under this Contract shall be retained by the Agency until both the final performance and financial
reports are submitted by the Grantee and approved by the Agency.
For sites for which this contract is supplementing USDA Emergency Watershed Protection Program
(EWPP) funding, completed work must also satisfy EWPP requirements prior to payment being
authorized.
Up to 16 percent (16%) of the funds awarded to the Grantee may be used to reimburse actual
documented engineering, technical assistance, and administrative expenses for the project, excluding
any expenses pledged by the Grantee as match for this project and salary, benefits, and operating
expenses that would normally have been paid by the Grantee.
The Grantee shall expend funds in accordance with G.S. 143C-6-23 (f1)(f2)0). The Grantee shall
account for any income earned, which may result from any funds awarded under this Contract, on the
Agency "Request for Reimbursement" form, Eligible uses of income earned are:
a) Expanding the project or program;
b) Continuing the project or program after grant ends; or
c) Supporting other projects or programs that further the broad objectives of the grant program.
If this Contract is terminated prior to the original end date, the Grantee may submit a final Request for
Payment form. All unexpended funds shall be returned by the Grantee to the Agency within 60 days
of the Contract termination date with a complete final financial report, accompanied by either a final
invoice or a refund of any funds received but not expended. The Agency shall have no obligation to
honor requests for payment based on expenditure reports submitted later than 60 days after
termination or expiration of the contract period.
Reimbursement requests shall be completed on a "Request for Reimbursement" form furnished to the
Grantee by the Agency. All reimbursement forms must include support documentation, including but
not limited to; copies of invoices, individual time sheets and travel logs that have been signed by the
NCDA&CS (Govt Contract Cover) Rev. 7!14;12114; 8117 Page 3 of 6
X.
XI
employee and supervisor; salary registers or payrolls that include fringe benefits, hourly rates of pay,
and signature of the Grantee's responsible financial person, cancelled checks and lease agreements.
Eligible expenditures for payment must be within the effective period noted in the
Contract. Reimbursement may not be considered prior to the submission and final execution of the
Contract.
All travel reimbursement shall be made in accordance with the current State rates, at the time of the
expenditure, and shall be made in accordance with the "State Budget Manual".
Staff from the Division of Soil and Water Conservation or its designated agent will conduct a site visit
and approve the work completed and submitted for reimbursement prior to releasing any payment to
the Grantee. The Agency must determine that all work has been completed satisfactorily in
accordance with the Best Management Practices for Selective Clearing and Snagging.
All matching funds, including in-kind and cash, must be spent concurrently with funds provided by the
Contract. Both types of matching funds expended shall be accounted for on the monthly invoices.
Indirect costs are not allowable expenditures under this Contract, except as described in paragraph
two of this section.
Contract Administrators:
All notices permitted or required to be given by one Party to the other and all questions about the
Contract from one Party to the other shall be addressed and delivered to the other Party's Contract
Administrator. The name, post office address, street address, telephone number, fax number, and email
address of the Parties' respective initial Contract Administrator are set out below. Either Party may
change the name, post office address, street address, telephone number, fax number, or email address
of its Contract Administrator by giving timely written notice to the other Party.
For the Agency:
IF DELIVERED BY US POSTAL SERVICE
David B. Williams, Deputy Director
Division of Soil & Water Conservation
1614 Mail Service Center
Raleigh, NC 27699-1614
Telephone: 919-715-6103
Email: David. B.Williams(&ncaar.00v
IF DELIVERED BY ANY OTHER MEANS
David B. Williams, Deputy Director
Division of Soil & Water Conservation
216 West Jones Street
Raleigh, NC 27603
For the Grantee:
Grantee Contract Administrator Grantee
Dru Harrison Same
New Hanover County
230 Government Center Dr, Suite 100
Wilmington, NC 28403
Telephone: 910-798-7135
Fax: 910-798-6049
Email: drharrison@nhcgov.com
Supplementation of Expenditure of Public Funds:
or Key Personnel
The Grantee assures that funds received pursuant to this Contract shall be used only to supplement,
not to supplant, the total amount of federal, state and local public funds that the Grantee otherwise
normally expends for salary and benefits for activities involved with specialty services and related
programs. Funds received under this Contract shall be used to provide additional public funding for
NCDA&CS (Govt Contract Cover) Rev. 7114;12114; 8117 Page 4 of 6
such services. The funds shall not be used to reduce the Grantee's total expenditure of other public
funds for such services.
XII. Disbursements:
As a condition of this Contract, the Grantee acknowledges and agrees to make disbursements in
accordance with the following requirements:
a. Will implement or already have implemented adequate internal controls over disbursements
b. Pre -audit all invoices presented for payment to determine:
• Validity and accuracy of payment
• Payment due date
• Adequacy of documentation supporting payment
• Legality of disbursement
c. Assure adequate control of signature stamps/plates
d. Assure adequate control of negotiable instruments; and
e. Have procedures in place to ensure that account balance is solvent and to reconcile the account
monthly.
f.
XIII. Outsourcing:
The Grantee certifies that it has identified to the Agency all jobs related to the Contract that have been
outsourced to other countries, if any. Grantee further agrees that it will not outsource any such jobs
during the term of this Contract without providing prior notice to the Agency.
XIV. N.C.G.S. § 433-32 and Executive Order 24:
N.C.G.S. § 133-32 and Executive Order 24 prohibit the offer to, or acceptance by, any State employee
of any gift from anyone with a Contract with the State, or from any person seeking to do business with
the State. By execution of any response in this procurement or Contract, you attest, for your entire
organization and its employees or agents, that you are not aware that any such gift has been offered,
accepted, or promised by any employee of your organization.
[This Contract is continued on the next page]
NCDA&CS (Govt Contract Cover) Rev. 7!14;12114; 8117 Page 5 of
XV. Signature Warranty:
The undersigned represent and warrant that they are authorized to bind their principals to the terms of
this Contract.
IN WITNESS WHEREOF, the Grantee and the Agency execute this contract in two (2) originals, one
(1) of which is retained by the Grantee and one (1) which are retained by the Agency, the day and year
first above written.
Grantee: New Hanov County
Sig a of Authorized entative Date
✓`' S
Printed ame
Title
Witness:
V �1 /
Si nature
Date
c 1"k --
Printed Name
` Title
! North Carolina Department of Agriculture and Consumer Services
aignaiure of Authorized Represenfative
N. David Smith, Chief Deputy Commissioner
NCDA&C5 (Govt Contract Cover) Rev. 7114;12114; 8/17
Date
Page 6 of 6
ATTACHMENT B
SCOPE OF WORK
WATERSHED RESTORATION PROJECT
New Hanover County (the "GRANTEE") will complete watershed restoration activities
including cutting and removing downed trees, broken tops, woody/vegetative debris and
sediment that impede or potentially impede water flow in the streams and tributaries included in
Table B1 below (taken from the application submitted by the GRANTEE). For sites for which
this contract is supplementing USDA Emergency Watershed Protection Program (EWPP)
funding, completed work must also satisfy EWPP requirements prior to payment being
authorized.
TABLE
B1: Stream/Ditch Seents
to be repaired
ID
Segment Name
Planned Treatment
EWP Project
Linear
Feet
Planned
A
Bernards Creek
Removal of storm debris and
37-07-18-5038-200
9088
Water shed (Whiskey
sediment
Creek 1)
B
Dock Creek
Removal of storm debris and
37-07-018-5038-
2637
sediment
203
C
Everette Creek Water
Removal of storm debris and
37-07-18-5038-204
8260
Shed
sediment
D
Futch Creek
Removal of storm debris and
37-07-18-5038-205
5079
sediment
E
we Creek
Removal of storm debris and
37-07-18-5038-206
8148
sediment
F
Motts Creek
Removal of storm debris, grade
37-07-18-5038-210
14 447
and realign channel, reshape 2
drains and install rip rap under
eotextile
G
Ness Creek
Removal of storm debris and
37-07-18-5038-211
21221
sediment
H
Page Creek
Removal of storm debris and
37-07-18-5038-212
33511
Watershed
sediment
I
Prince George Creek
Removal of storm debris and
37-07-18-5038-213
48452
sediment
J
Cape Fear River
Removal of storm debris
37-07-18-5038-215
300
(Shipwatch Drive)
K
Smith Creek
Removal of storm debris and
37-07-18-5038-216
60462
Watershed
sediment
L
Whiskey Creek lI
Removal of storm debris and
37-07-18-5038-219
30153
sediment
M
Sneeden Drive -Pipe
Removal of storm debris and
37-07-18-5038-217
1
sediment
NCDA&CS
(Gov't Contract Cover - SO
& Water) Rev. 7114; 12114
Page 1 of 2
The GRANTEE will ensure that all required permits are secured for each site and
landowner permission is granted before any work proceeds for that site.
The GRANTEE will ensure that it and its contractors follow the Division of Water
Resources' Hurricane Matthew Stream and Wetland Cleanup/Restoration Guideline dated
October 2016. The GRANTEE shall also follow Best Management Practices for Selective
Clearing and Snagging to manage all woody debris removed from streams. These guidelines
can be downloaded at:
htt s://www.nca r. ov/SWC/disasterres onse/WatershedRecove Efforts.html
In the event the Grantee completes the work specified in the Scope of Work without exhausting
the funds in the Contract, the Agency Contract Administrator may issue a Work Authorization to
approve stream debris removal work for additional stream segments requested by the Grantee,
not to exceed the funds available in the Contract.
NCDA&CS (Gov't Contract Cover - Soil & Water) Rev. 7114; 12/14 Page 2 of 2
PUBLIC SECTOR CONTRACTS (Including Local Governments)
General Terms and Conditions
DEFINITIONS
Unless indicated otherwise from the context, the
following terms shall have the following meanings in
this Contract. All definitions are from 9 NCAC
3M.0102 unless otherwise noted. If the rule or
statute that is the source of the definition is changed
by the adopting authority, the change shall be
incorporated herein:
(1) "Agency" (as used in the context of the
definitions below) shall mean and include
every public office, public officer or official
(State or local, elected or appointed),
institution, board, commission, bureau,
council, department, authority or other unit of
government of the State or of any county,
unit, special district or other political
subagency of government. For other
purposes in this Contract, "Agency" shall
mean the entity identified as one of the
parties hereto.
(2) "Audit" means an examination of records or
financial accounts to verify their accuracy.
(3) "Certification of Compliance" means a report
provided by the Agency to the Office of the
State Auditor that states that the Grantee has
met the reporting requirements established
by this Subchapter and included a statement
of certification by the Agency and copies of
the submitted grantee reporting package.
(4) "Compliance Supplement" refers to the North
Carolina State Compliance Supplement,
maintained by the State and Local
Government Finance Agency within the
North Carolina Department of State
Treasurer that has been developed in
cooperation with agencies to assist the local
auditor in identifying program compliance
requirements and audit procedures for
testing those requirements.
(5) "Contract" means a legal instrument that is
used to reflect a relationship between the
agency, grantee, and subgrantee.
(6) "Fiscal Year" means the annual operating
year of the non -State entity.
(7) "Financial Assistance" means assistance that
non -State entities receive or administer in the
form of grants, loans, loan guarantees,
property (including donated surplus
property), cooperative agreements, interest
subsidies, insurance, food commodities,
direct appropriations, and other assistance.
Financial assistance does not include
amounts received as reimbursement for
services rendered to individuals for Medicare
and Medicaid patient services.
Attachment A
(8) "Financial Statement" means a report
providing financial statistics relative to a
given part of an organization's operations or
status.
(9) "Grant" means financial assistance provided
by an agency, grantee, or subgrantee to
carry out activities whereby the grantor
anticipates no programmatic involvement
with the grantee or subgrantee during the
performance of the grant.
(10) "Grantee" has the meaning in G.S. 143C -6-
23(a)(2): a non -State entity that receives a
grant of State funds from a State agency,
department, or institution but does not
include any non -State entity subject to the
audit and other reporting requirements of the
Local Government Commission. For other
purposes in this Contract, "Grantee" shall
mean the entity identified as one of the
parties hereto.
(11) "Grantor" means an entity that provides
resources, generally financial, to another
entity in order to achieve a specified goal or
objective.
(12) "Non -State Entity" has the meaning in
N.C.G.S. 143C -1-1(d)(18): Any of the
following that is not a State agency: an
individual, a firm, a partnership, an
association, a county, a corporation, or any
other organization acting as a unit. The term
includes a unit of local government and
public authority.
(13) "Public Authority" has the meaning in
N.C.G.S. 143C -1-1(d)(22): A municipal
corporation that is not a unit of local
government or a local governmental
authority, board, commission, council, or
agency that (i) is not a municipal corporation
and (ii) operates on an area, regional, or
multiunit basis, and the budgeting and
accounting systems of which are not fully a
part of the budgeting and accounting
systems of a unit of local government.
(14) "Single Audit" means an audit that includes
an examination of an organization's financial
statements, internal controls, and compliance
with the requirements of federal or State
awards.
(15) "Special Appropriation" means a legislative
act authorizing the expenditure of a
designated amount of public funds for a
specific purpose.
(16) "State Funds" means any funds
appropriated by the North Carolina General
Assembly or collected by the State of North
Carolina. State funds include federal
NCDA&CS - General Terms and Conditions — Public - Local Governmental Entities
Eff, 07114;4115;1117 Page 1 of 4
PUBLIC SECTOR CONTRACTS (Including Local Governments)
financial assistance received by the State
and transferred or disbursed to non -State
entities. Both federal and State funds
maintain their identity as they are subgranted
to other organizations. Pursuant to N.C.G.S.
143C -6-23(a)(1), the terms "State grant
funds" and "State grants" do not include any
payment made by the Medicaid program, the
Teachers' and State Employees'
Comprehensive Major Medical Plan, or other
similar medical programs.
(17) "Subgrantee" has the meaning in G.S.
143C -6-23(a)(3): a non -State entity that
receives a grant of State funds from a
grantee or from another subgrantee but does
not include any non -State entity subject to
the audit and other reporting requirements of
the Local Government Commission.
(18) "Unit of Local Government has the meaning
in G.S. 143C -1-1(d)(29): A municipal
corporation that has the power to levy taxes,
including a consolidated city -county as
defined by G.S. 16013-2(1), and all boards,
agencies, commissions, authorities, and
institutions thereof that are not municipal
corporations.
Relationships of the Parties
Independent Contractor: The Grantee is and shall
be deemed to be an independent Contractor in the
performance of this Contract and as such shall be
wholly responsible for the work to be performed and
for the supervision of its employees. The Grantee
represents that it has, or shall secure at its own
expense, all personnel required in performing the
services under this agreement. Such employees shall
not be employees of, or have any individual
contractual relationship with, the Agency.
Subcontracting: The Grantee shall not subcontract
any of the work contemplated under this Contract
without prior written approval from the Agency. Any
approved subcontract shall be subject to all
conditions of this Contract. Only the subcontractors
or subgrantees specified in the Contract documents
are to be considered approved upon award of the
Contract. The Agency shall not be obligated to pay
for any work performed by any unapproved
subcontractor or subgrantee. The Grantee shall be
responsible for the performance of all of its
subgrantees and shall not be relieved of any of the
duties and responsibilities of this Contract.
Subgrantees: The Grantee has the responsibility to
ensure that all subgrantees, if any, provide all
information necessary to permit the Grantee to
comply with the standards set forth in this Contract.
Assignment: No assignment of the Grantee's
obligations or the Grantee's right to receive payment
hereunder shall be permitted. However, upon written
request approved by the issuing purchasing authority,
the State may:
(a) Forward the Grantee's payment check(s)
directly to any person or entity designated by
the Grantee, or
(b) Include any person or entity designated by
Grantee as a joint payee on the Grantee's
payment check(s).
In no event shall such approval and action obligate
the State to anyone other than the Grantee and the
Grantee shall remain responsible for fulfillment of all
Contract obligations.
Beneficiaries: Except as herein specifically
provided otherwise, this Contract shall inure to the
benefit of and be binding upon the parties hereto and
their respective successors. It is expressly
understood and agreed that the enforcement of the
terms and conditions of this Contract, and all rights of
action relating to such enforcement, shall be strictly
reserved to the Agency and the named Grantee.
Nothing contained in this document shall give or
allow any claim or right of action whatsoever by any
other third person. It is the express intention of the
Agency and Grantee that any such person or entity,
other than the Agency or the Grantee, receiving
services or benefits under this Contract shall be
deemed an incidental beneficiary only.
Indemnity
Indemnification: The Grantee agrees to indemnify
and hold harmless the Agency, including any of its
Divisions, and any of its officers, agents and
employees, from liability of any kind, and from any
claims of third parties arising out of any act or
omission of the Contractor in connection with the
performance of this Contract to the extent permitted
by law.
Default and Termination
Termination by Mutual Consent: The Parties may
terminate this Contract by mutual consent with 60
days notice to the other party, or as otherwise
provided by law.
Termination for Cause: If, through any cause, the
Grantee shall fail to fulfill its obligations under this
Contract in a timely and proper manner, the Agency
shall have the right to terminate this Contract by
giving written notice to the Grantee and specifying
the effective date thereof.
In that event, all finished or unfinished deliverable
items prepared by the Grantee under this Contract
NCDA&C5 - General Terms and Conditions — Public - Local Governmental Entities
Eff. 07114;4115;1117 Page 2 of 4
PUBLIC SECTOR CONTRACTS (including Local Governments)
shall, at the option of the Agency, become its
property and the Grantee shall be entitled to receive
just and equitable compensation for any satisfactory
work completed on such materials, minus any
payment or compensation previously made.
Notwithstanding the foregoing provision, the Grantee
shall not be relieved of liability to the Agency for
damages sustained by the Agency by virtue of the
Grantee's breach of this agreement, and the Agency
may withhold any payment due the Grantee for the
purpose of setoff until such time as the exact amount
of damages due the Agency from such breach can be
determined. The filing of a petition for bankruptcy by
the Grantee shall be an act of default under this
Contract.
Waiver of Default: Waiver by the Agency of any
default or breach in compliance with the terms of this
Contract by the Grantee shall not be deemed a
waiver of any subsequent default or breach and shall
not be construed to be modification of the terms of
this Contract unless stated to be such in writing,
signed by an authorized representative of the Agency
and the Grantee and attached to the Contract.
Availability of Funds: The parties to this Contract
agree and understand that the payment of the sums
specified in this Contract is dependent and contingent
upon and subject to the appropriation, allocation, and
availability of funds for this purpose to the Agency.
Force Majeure: Neither party shall be deemed to be
in default of its obligations hereunder if and so long
as it is prevented from performing such obligations by
any act of war, hostile foreign action, nuclear
explosion, riot, strikes, civil insurrection, earthquake,
hurricane, tornado, or other catastrophic natural
event or act of God.
Survival of Promises: All promises, requirements,
terms, conditions, provisions, representations,
guarantees, and warranties contained herein shall
survive the Contract expiration or termination date
unless specifically provided otherwise herein, or
unless superseded by applicable federal or State
statutes of limitation.
Intellectual Property Rights
Copyrights and Ownership of Deliverables: All
deliverable items produced pursuant to this Contract
are the exclusive property of the Agency. The
Grantee shall not assert a claim of copyright or other
property interest in such deliverables.
Compliance with Applicable Laws
Compliance with Laws: The Grantee shall comply
with all laws, ordinances, codes, rules, regulations,
and licensing requirements that are applicable to the
conduct of its business, including those of federal,
State, and local agencies having jurisdiction and/or
authority.
Equal Employment Opportunity: The Grantee
shall take affirmative action in complying with all
federal and State statutes and all applicable
requirements concerning fair employment of people
with disabilities, and concerning the treatment of all
employees without regard to discrimination by reason
of race, color, religion, sex, national origin or
disability. For additional information see Title VI of the
Civil Rights Act of 1964 (42 U.S.C., 2000d, 2000e-
16), Title XI of the Education amendments of 1972,
as amended (20 U.S.C. 1681-1683 and 1685-1686),
and section 504 of the Rehabilitation Act of 1973 as
amended (29 U.S.C. 794).
Executive Order 24: In accordance with Executive
Order 24, issued by Governor Perdue, and N.C.G.S.§
133-32, a vendor or contractor (i.e. architect, bidder,
contractor, construction manager, design
professional, engineer, landlord, offeror, seller,
subcontractor, supplier, vendor, or grantee), is
prohibited from making gifts or giving favors to any
employee of the Agency of Agriculture and Consumer
Services. This prohibition covers those vendors,
contractors, and/or grantees who:
(a) have a Contract with a governmental
Agency; or
(b) have performed under such a Contract within
the past year; or
(c) anticipate bidding on such a Contract in the
future.
For additional information regarding the specific
requirements and exemptions, vendors, contractors,
and/or grantees are encouraged to review Executive
Order 24 and N.C.G.S. § 133-32.
Confidentiality
Confidentiality: Any information, data, instruments,
documents, studies or reports given to or prepared or
assembled by the Grantee under this agreement
shall be kept as confidential and not divulged or
made available to any individual or organization
without the prior written approval of the Agency. The
Grantee acknowledges that in receiving, storing,
processing or otherwise dealing with any confidential
information it will safeguard and not further disclose
the information except as otherwise provided in this
Contract.
Oversight
Access to Persons and Records: The State Auditor
and the using agency's internal auditors shall have
NCDA&CS - General Terms and Conditions — Public - Local Governmental Entities
Eff. 07/14:4115;1/17
Page 3 of 4
PUBLIC SECTOR CONTRACTS (Including Local Governments)
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 the term of
the Contract to verify accounts and data affecting
fees or performance).
Record Retention: Records shall not be destroyed,
purged or disposed of without the express written
consent of the Agency. State basic records retention
Policy requires all grant records to be retained for a
minimum of five years or until all audit exceptions
have been resolved, whichever is longer. If the
Contract is subject to federal policy and regulations,
record retention may be longer than five years since
records must be retained for a period of three years
following submission of the final Federal Financial
Status Report, if applicable, or three years following
the submission of a revised final Federal Financial
Status Report. Also, if any litigation, claim,
negotiation, audit, disallowance action, or other
action involving this Contract has been started before
expiration of the five-year retention period described
above, the records must be retained until completion
of the action and resolution of all issues which arise
from it, or until the end of the regular five-year period
described above, whichever is later.
Miscellaneous
Choice of Law: The validity of this Contract and any
of its terms or provisions, as well as the rights and
duties of the parties to this Contract, are governed by
the laws of North Carolina. The Grantee, by signing
this Contract, agrees and submits, solely for matters
concerning this Contract, to the exclusive jurisdiction
of the courts of North Carolina and agrees, solely for
such purpose, that the exclusive venue for any legal
proceedings shall be Wake County, North Carolina.
The place of this Contract and all transactions and
agreements relating to it, and their situs and forum,
shall be Wake County, North Carolina, where all
matters whether sounding in Contract or tort, relating
to the validity, construction, interpretation, and
enforcement shall be determined.
Headings: The Section and Paragraph headings in
these General Terms and Conditions are not material
parts of the agreement and should not be used to
construe the meaning thereof.
Time of the Essence: Time is of the essence in the
performance of this Contract.
Care of Property: The Grantee agrees that it shall
be responsible for the proper custody and care of any
property furnished to it for use in connection with the
performance of this Contract and will reimburse the
Agency for loss of, or damage to, such property. At
the termination of this Contract, the Grantee shall
contact the Agency for instructions as to the
disposition of such property and shall comply with
these instructions.
Amendment: This Contract may not be amended
orally or by performance. Any amendment must be
made in written form and executed by duly authorized
representatives of the Agency and the Grantee.
Severability: In the event that a court of competent
jurisdiction holds that a provision or requirement of
this Contract violates any applicable law, each such
provision or requirement shall continue to be
enforced to the extent it is not in violation of law or is
not otherwise unenforceable and all other provisions
and requirements of this Contract shall remain in full
force and effect.
Travel Expenses: Reimbursement to the Grantee
for travel mileage, meals, lodging and other travel
expenses incurred in the performance of this
Contract shall be reasonable and supported by
documentation. State rates shall be used.
International travel shall not be reimbursed under this
Contract.
Sales/Use Tax Refunds: if eligible, the Grantee 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 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.
Advertising: The Grantee shall not use the award of
this Contract as a part of any news release or
commercial advertising.
Indirect Costs Policy: The Agency has adopted a
"Zero" policy that indirect costs are unallowable
expenditures in all State funded grant applications
and/or grant guidance, informational or directional
documents.
Allowable Uses of State Funds: Expenditures of
State funds by any grantee shall be in accordance
with the Cost Principles outlined in the Office of
Management and Budget (OMB) CFR Title 2, Part
200 Uniform Administrative Requirements, as
applicable. if the grant funding includes federal
sources, the grantee shall ensure adherence to the
cost principles established by the Federal Office of
Management and Budget. [09 NCAC 03M.020]
NCDA&CS - General Terms and Conditions — Public - Local Governmental Entities
Eff. 07114;4115;1117
Page 4 of 4
Attachment C
Certifications and Assurances
CERTIFICATIONS REGARDING LOBBYING, NONPROCUREMENT, DEBARMENT,
SUSPENSION AND DRUG-FREE WORKPLACE
Applicants should refer to the regulations cited below to determine the certification to which they are
required to attest. Signature of this form provides for compliance with certification requirements under 2
CFR, Subtitle B, Chapter IV, Part 417, "Nonprocurement Debarment and Suspension," Part 418, "New
Restrictions on Lobbying," and Part 421, "Requirements for Drug -Free Workplace (Financial Assistance),"
and 2 CFR Part 180. The certifications shall be treated as a material representation of fact upon which
reliance will be placed when the Department of Agriculture & Consumer Services determines to award the
covered transaction, grant, or cooperative agreement.
1. LOBBYING
As required by authority: 31 U.S.C. 1352 and U.S.C. 301 and implemented at 2 CFR Part 180, for persons
entering into a grant or cooperative agreement over $100,000, as defined at 2 CFR Section 418.110, the
applicant certifies that to the best of their knowledge and belief, that:
1) 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 an 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 any Federal contract, the making of any Federal
contract, the making of any Federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan,
or cooperative agreement.
2) If any funds other than Federal appropriated funds have been paid or will be paid 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 this Federal contract, grant, loan, or cooperative agreement, the undersigned shall
complete and submit Standard Form -LLL, "Disclosure Form to Report Lobbying" in accordance
with its instructions.
3) 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.
This certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for
each such failure.
2. NONPROCUREMENT DEBARMENT AND SUSPENSION
As required by Executive Order 12549, Debarment and Suspension, and implemented at 2 CFR Part 180
and 2CFR Part 417, for prospective participants in primary covered transactions, as defined at 2 CFR
180.435 and Subpart C, 417.332, the applicant certifies that it and its principals:
a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
b) Have not within a three-year period preceding this application been convicted of or had a civil
judgment rendered against them for commission of fraud or a criminal offense in connection with
obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or
contract under a public transaction; violation of Federal or State antitrust statutes or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
NCDA&CS Certifications & Assurances Page 1 of 3
Rev 9112, 10112, 11113;1117
c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity
(Federal, State, or local) with commission of any of the offenses enumerated in paragraph 2. (a)
(b) of this certification.
d) Have not within a three-year period preceding this application had one or more public transaction
(Federal, State, or local) terminated for cause or default.
e) Agree to include a term or condition in lower tier covered transactions requiring lower tier
participants to comply with subpart C of the OMB guidance in 2 CFR part 180, as supplemented by
subpart C of Part 417.
Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach
an explanation to this certification.
3. DRUG-FREE WORKPLACE (GRANTEES OTHER THAN INDIVIDUALS)
As required by the Drug -Free Workplace Act of 1988, and implemented at 2 CFR Part 182, Subparts B,
and C, for grantees:
The applicant certifies that it will:
a) Make a good faith effort, on a continuing basis, to maintain a drug-free workplace. You must
agree to do so as a condition for receiving any award covered by this part.
b) Publish a drug-free workplace statement and establish a drug-free awareness program for your
employees (see Sections 182.205 through 182.220); and
c) Take actions concerning employees who are convicted of violating drug statutes in the workplace
(see Section 182.225), including notification to any Federal agency on whose award the convicted
employee was working and within 30 days take appropriate personnel action against the
employee, up to and including termination, consistent with the requirements of the Rehabilitation
Act of 1973 (29 U.S.C. 794), as amended; or require the employee to participate satisfactorily in a
drug abuse assistance or rehabilitation program approved for these purposes by a Federal, State
or local health, law enforcement, or other appropriate agency.
d) You must identify all known workplaces under your Federal awards (see Section 182.230).
The grantee must provide the location site(s) for the performance of work done in connection with the
specific grant.
Place(s) of Performance (Street address, city, county, state, zip code)
various county water sheds as listed in project scope
DRUG-FREE WORKPLACE (GRANTEES WHO ARE INDIVIDUALS)
As required by the Drug -Free Workplace Act of 1988, and implemented at 2 CFR Part 182:
A. As a condition of the grant, I certify that I will comply with drug-free workplace requirements in
Subpart B (or Subpart C, if the recipient is an individual) of part 421, which adopts the Government -
wide implementation (2 CFR part 182) of sec. 5152-5158 of the Drug Free Workplace Act of 1988
(Pub.1-100-690, Title V, Subtitle D; 41 U.S.C. 701-707).
NCDA&CS Certifications & Assurances Page 2 of 3
Rev 9112, 10112, 11!13;1117
B. I agree to notify the agency as required by 2 CFR 182.300(b) of any conviction for a criminal drug
offense within ten days.
Notice shall include the identification number(s) of each affected grant.
As the duly authorized representative of the Grantee, I hereby certify and state to the best of my
knowledge and belief, that the Grantee will comply with the above certifications.
New Hanover Coynty
,-i r rganizatio e
Signature of Authorized Representative Date
Chris Coudriet County Manager
Printed Name of Authorized Representative Title
NCDA8CS Certifications & Assurances Page 3 of 3
Rev 9/12, 10112, 11113;1117
Attachment D
NC OpenBook Supplemental Information
Instructions: Complete the information below and return it to the Contract Administrator identified in your
original contract. This information must be submitted as part of your contract. If you have questions,
please contact the Contract Administrator or the Alternate Contact as reflected in your contract.
DUNS Number:
0400029563
Contract Number:
19-091-4050 Amendment Number:
Grantee Name:
New Hanover Countv
TAX ID Number:
56-6000324
Fiscal Year Ends:
June 30th
1. Brief Description and Background/History of your Organization.
Be sure to include the number of years In existence, number of employees, mission and goals of your
organization.
soun
2. Current project timeline: Begin 04/07/2020 End 11/13/2020
3. Expected outcomes and specific deliverables.
4. The Grantee's WEB URL: nhcgov.com
5. * Grantee County of Residence: New Hanover Congressional District#: 7
(CONGRESSIONAL DISTRICT # MUST BE IDENTIFIED)
6. "County of Benefit: Single County: 0 Yes ❑ No County Name: New Hanover
Statewide: ❑ Yes ❑■ No
Regional: ❑ Yes ❑ No
7. If the answer to question number 6 is more than one county or "Regional", list the counties receiving
benefit.
New Hanover
*Grantee County of Residence: County in which grantee is located.
**County of Benefit: List only county or counties in which funding will be spent and/or food commodities will
be received.
NCDAWS NC OpenBook Supplemental Information Page 1 of 1
Rev 07114; 4117
r%LLC1%A 11 1 FGI FL L
Signature Card
CONTRACT & FINANCIAL DOCUMENTS
INSTRUCTIONS: Please read and fill in the required information to the right of each field where applicable. Signatures
must match the Contract signatures. In the event the affixed signature(s) are no longer valid, a revised form must
be submitted prior to processing any contractual documents or submitting "Request for Payments" or any other
financial documents. If more than two people will sign for the organization, this form may be duplicated.
SECTION I.
Date: jApril 7, 2024
Legal Applicant Organization/Agency Name: I New Hanover County
Federal Tax Identification Number: 56-6000324
SECTION II.
Certification:
By affixing my signature below, I certify that person(s) identified are designated having legal authorization to sign on
behalf of the organization named in Section I., above, for purposes of executing contractual documents and preparing,
approving and executing all financial documents; including "Requests for Payments." I understand the legal implications
of any and all misrepresentation, which include but are not limited to defrauding the State of North Carolina, and certify
that the person signing below has full authority to execute this Agreement on behalf of the named organization.
NUN -GOVERNMENTAL ORGANIZATIONS ONLY Must match Contract signature)
Board Chair, Executive Director, etc. Financial Representative, Treasurer, etc.
Print Name & Title: I Print Name & Title:
Signature:
Signature:
GOVERNMENTAL ENTITIES Must match Contract signature
Authorized Governmental Official Chief Fiscal Officer
-Print Name &Title: Print Name &Title:
Chris Coudriet, qty Manag r Lisa Wurtzbacher, Chief Financial Officer
Sig
NCAA&CS - Signature Card — NGO & Governmental
Rev 7114; 1117;11117
re:
Page 1 of 1
Form
W 9 Request for Taxpayer
Attachment F
{Rev.
November 2017} Identification Number and Certification
sotsrm
Do not
Department
of the Treasury
etqu
Internal
Revenue Service ► Go to www.irs.gov/FormW9 for instructions and the latest information.
send to the IRS.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
New Hanover County
2 Business name/disregarded entity name, ii different Irom above
`-15
3 Check appropriate
ppro riate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
4 Exemptions (codes apply only to
Cr
C
o
Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
certain entities, not individuals; see
instructions on page 3):
ti e
single -member LLC
a o
rr '�
`o
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P -Partnership) ►
Exempt payee code (if any)
C N
Note; Check the appropriate box in the tine above for the tax classification of the single -member owner. De not check
LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the
Exemption from FATCA reporting
d o
owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that
is disregarded from the owner should check the appropriate box for
coda (it any)
the tax classification of its owner.
✓ Other
m
(see instructions)1
GfMpi+e
5 Address (number, street, and epi. or suite no.) See instructions.
ra eeeounh ma,nr•ii.ad oursitl• Ih• U S.)
230 Government Center Drive Requester's name and address (optional)
c8
B City, state, and ZIP code
—.Wilmington, NC 28403
7 List account number(s) here (optional)
Number
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid s
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other C
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later,
or
Note: if the account is in more than one name, see the instructions for line 1. Also see What Name and F
Number To Give the Requester for guidelines on whose number to enter. 7
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 for Part 11, later.
Cinn
bignature of i '
Here U.S. person ► L 7r -
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.im.gov/FormWg.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (FIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
■ Form 1099 -INT (interest earned or paid)
Date ► April 7, 2020
• Form 1099 -DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-5 (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-C (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 Farm W-9 (Rev. 11-2017)
Form W-9 (Rev. 11-2017)
By signing the filled-out form, you:
Page 2
1. Certify that the TIN you are giving is correct (or you are waiting for a
Example. Article 20 of the U.S.-China income tax treaty allows an
exemption from tax for scholarship income received by a Chinese
number to be issued),
student temporarily present in the United States. Under U.S. law, this
2. Certify that you are not subject to backup withholding, or
student
the United lSlates exceeds 5 calendar years. Hl become a resident alien for tax oweveroses in
ara graph 2
3. Claim exemption from backu withhold'in If ou are a U.S. exempt
p g y
, paragraph of
the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows
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
the provisions of Article 20 to continue is apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
or business
is not subject to the withholding tax on foreign partners' share of
effectively connected income, and
Protocol) and isalifies relying on this exception toder clapm anararaxemptionhfrofim tax
4, Certify that FATCA code(s) entered on this form (if any) indicating
on his or her scholarship or fellowship income would attach to Form
W-9 a statement that includes the information described above to
that you are exempt from the FATCA reporting, is correct. See What is
support that exemption.
FATCA reporting, later, for further information.
If you are a nonresident alien or a foreign entity, give the requester the
Note: If you are a U.S. parson and a requester gives you a form other
appropriate completed Form W-8 or Form 8233.
than Form W-9 to request your TIN, you must use the requester's form it
it is substantially similar to this Form W-9.
Backup Withholding
Definition of a U.S. person. For federal tax purposes, you are
y
What is backup withholding? Persons making certain payments to you
considered a U.S. person if you are:
must under certain conditions withhold and pay to the IRS 28% of such
• An individual who is a U.S. citizen or U.S. resident alien;
payments. This is called "backup withholding." Payments that may be
subject to backup withholding include interest, tax-exempt
• A partnership, corporation, company, or association created or
interest,
dividends, broker and barter exchange transactions, rents, royalties,
organized in the United States or under the laws of the United States;
nonemployee pay, payments made in settlement of payment card and
• An estate (other than a foreign estate); or
third party network transactions, and certain payments from fishing boat
• A domestic trust (as defined in Regulations section 301.7701-7).
withholdingeat estate transactions are not subject to backup
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to
You will not be subject to backup withholding on payments you
receive if
pay a withholding
tax under section 1446 on any foreign partners' share of effectively
you give the requester your correct TIN, make the proper
certifications, and report all your taxable interest dividends
connected taxable income from such business. Further, in certain cases
where a Form W-9 has not been received, the rules
and on your
tax return.
under section 1446
require a partnership to presume that a partner is a foreign person, and
Payments you receive will be subject backup withholding it:
pay the section 1446 withholding tax. Therefore, if you are a U.S. person
that is a partner in a partnership conducting a trade business
1 You do not furnish your TIN to the requester,
a
2, You
or in the
United States, provide Form W-9 to the partnership to establish your
do not certify your TIN when required (see the instructions for
Part II for details),
U.S. status and avoid section 1446 withholding on your share of
partnership income.
3. The IRS tells the requester that you furnished an incorrect TIN,
In the cases below, the following person must give Form W-9 to the
partnership for purposes of establishing Its U.S. status
4. The IRS tells you that you are subject to backup withholding
because you did not report all your interest and dividends on tax
and avoiding
withholding on its allocable share of net income from the partnership
your
return (for reportable interest and dividends only), or
conducting a trade or business in the United States.
5. You do not certify to the requester that you are not subject to
• In the case of a disregarded entity with a U.S. owner, the U.S. owner
backup withholding under 4 above (for reportable interest and dividend
of the disregarded entity and not the entity;
accounts opened after 1983 only).
• 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 the
Certain payees and payments are exempt from backup withholding.
See Exempt payee code, later, and the separate Instructions for the
of grantor trust and
not the trust; and not
of Form W-9 for more Information.
• In the case of a U.S. trust (other than a grantor trust), the U.S. trust
Also see Special rules for partnerships, earlier.
(other than a grantor trust) and not the beneficiaries of the: trust.
Foreign
What is FATCA Reporting?
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
The Foreign Account Tax Compliance Act (FATCA) requires a
Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see
Participating foreign financial institution report all United States
Pub, 515, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
account holders that are specified United States persons. Certain
d
payees are from
Nonresident alien who becomes a resident alien. Generally,
exempt FATCA reporting. See Exemption from FATCA
reporting code, later, and the Instructions for the Requester of Form
only a
nonresident alien individual may use the terms of a tax treaty to reduce
W-9 for more information.
or eliminate U.S. tax on certain types of income. However, most tax
treaties
Updating Your Information
contain a provision known as a "saving clause." Exceptions
specified in the saving clause may permit an exemption from tax to
You must provide updated information to any person to wham you
continue for certain types of income even after the payee has otherwise
become a U.S. resident alien for tax purposes.
claimed to
at an exempt payee if you are no longer an exempt payee
and anticipate receiving reportable payments in the future
If you are a U.S. resident alien who is relying on an exception
from this
person. For example, you may need to provide updated information if
contained in the saving clause of a tax treaty to claim an exemption
from U.S. tax certain types of income, you must attach a statement
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
to Form W-9 that specifies the following five items.
the name or TIN changes for the account; for example, if the grantor of a
1. The treaty country. Generally, this must be the same treaty under
which you claimed exemption from tax as a
grantor trust dies.
nonresident alien.
2. The treaty article addressing the income.
Penalties
3. The article number (or location) in the tax treaty that contains the
saving clause and its exceptions.
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
4. The type and amount of income that qualifies for the exemption
from tax.
unless your failure is due to reasonable cause and not to willful neglect.
5. Sufficient facts to justify the exemption from tax under the terms of
Civil penalty for false information with respect to withholding. If you
make a false statement with no reasonable basis that results in no
the treaty article.
backup withholding, you are subject to a $500 penalty.
Form W-9 (Rev. 11-2017)
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 security card, and your new last name.
Note: ITIN applicant: Enter your individual name as it was entered on
your Form W-7 application, line 1 a. This should also be the same as the
name you entered on the Form 104011040A/1040EZ you filed with your
application.
b. Sole proprietor or single -member LLC. 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 S corporation, 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 entities. Enter your name as shown on required U.S. federal
tax documents on line 1. 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 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)(iff). 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's name 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 B832 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 tine 4 any code(s) that may apply to
yo u.
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.
a 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 10$9-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(%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
B—Areal 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. 11-2017)
Page 4
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
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
1 through 5?
$5,000'
Payments made in settlement of
Exempt payees 1 through 4
Payment card or third party network
transactions
See Form 1099-MISC, Miscellaneous Income, and its instructions.
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 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 Regulattons
section 1.1472-1(c)(1){i)
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)(i)
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
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 mail your information
returns. It 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 payer 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 (fTIN). 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 1-500-772-1213.
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.ir;.gov/Businesses and
clicking on Employer Identification Number (EIN) under Starting a
Business. Go to www.irs.govlFbrms to view, download, or print Form
W-7 and/or Form SS -4. Or, you can go to wwwJrs.gcvlOrderForms 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 Exempt payee
code, earlier.
Signature requirements. Complete the certification as indicated in
items 1 through 5 below.
Form W-9 (Rev. 11-2017)
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. It
you are subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2 in the
certification before signing the form.
3. Real estate transactions. You must sign the certification. You may
cross out item 2 of the certification,
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 (ncluding 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 Clive name and SSN of:
' """•""'a'
the individual
2. Two or more individuals 6oint
The actual owner of the account or, if
account) other than an account
combined funds, the first individual on
maintained by an FFI
the account'
3. Two or more U.S. persons
Each holder of the account
Qoint account maintained by an FFI)
4, Custodial account of a minor
The minor'
(Uniform Gift to Minors Act)
5. a. The usual revocable savings trust
The grantor -trustee'
(grantor is also trustee)
b. So-called trust account that is not
The actual owner'
a legal or valid trust under state law
6. Soto proprielorship or disregarded
The owner'
entity owned by an individual
7. Grantor trust filing under Optional
The grantor'
Form 1099 Filing Method 1 (see
Regulations section 1.671-4(b)(2)(i)
(A))
For this type of account:
Give name and EIN of. -
8. Disregarded entity not owned by an
The owner
individual
9. A valid trust, estate, or pension trust
Legal entity
10. Corporation or LLC electing
Tho 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 multi member LLC The pannership
13. A broker or registered nominee I
I The broker or nominee
Page 5
For this type of account: Gyve name and EIN of:
14. Account with the Department of The public entity
Agriculture In the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
15. Grantor trust filing under the Form The trust
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulations section 1.671-4(b)(2)(i)(B))
' 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.
3 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.
List first and circle the name of the trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the
legal entity itself is not designated in the account title.) Also see Special
ales 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 t -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 emalis or phishing schemes.
Phishing is the creation and use of email and websites designed to
mimic legitimate business emails and websites. The most common act
is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
private information that will be used for identity theft.
Form W-9 (Rey. 11-2017)
Page 6
Th IRS d
eoes not initiate contacts with taxpayers via emaits. 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 (TIGTA) at 1-800-366-4484. You can
forward suspicious emaits to the Federal Trade Commission at
spam@uce.gov or report them at www. ffc.gov/complaint. You can
contact the FTC at www.ftc.goWidtheft or 877-IDTHEFT (877-438-4338).
If you have been the victim of identity theft, see www.identilyTheft.gov
and Pub. 5027.
Visit www.irs.gov/ldentityThefi 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 EISA. 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 11 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.
Office of the State Controller
Return to: OSC Support Services Center
Address: 1410 Mail Service Center
Raleigh, NC 27699-1410
Email: osc,support, servicesciiosc.nc. ov
Telephone: 919-707-0795
HlldUl III SCI II l7
Vendor Electronic Payment Form
Jr '` ❑ New Add Request
" . ''_ ❑
Change/Update Existing Account
�� ❑ Inactivate Existing Account
- *Denotes a required field
The State of North Carolina offers payees the opportunity to receive payments electronically through U.S. based banks. In addition to
having the funds deposited electronically, you will also receive remittance information by e-mail.
We require you to submit a copy of a voided check, bank statement, or a letter from your bank for account verification.
*TAX ID # or SSN 5 1 6 1 6 1 0 1 0 0 3 2 4
-PAYEE NAME New Hanover County
*REMITTANCE ADDRESS 230 Government Center Drive Ee 165
(AS PRINTED ON STREET SUITE/ROOM #
YOUR INVOICE) Wilmington
NC 28403
CITY STATE ZIP CODE
CONTACT Teresa Hewett, Grants & Project Analyst 910-798-7408
NAME & TITLE PHONE NUMBER
NEW FINANCIAL INFORMATION
*FINANCIAL INSTITUTION NAME:
*NAME ON ACCOUNT:
*NEW ROUTING NUMBER:
*NEW ACCOUNT NUMBER:
*ACCT TYPE:
*REMIT E-MAIL ADDRESS
Branch Banking & Trust
New Hanover County
0 1 5 1 3 1 11 0 1 1 .11 2 1
01 "1 01 51 11 01 81 11 71 11 31 21 6
■
Savi
thewett@nhcgov.com
New add requests MUST include contact information for the state agency with which you are doing business.
*Agency Name: Division of SOII & Water *Agency Contact Name:
David Williams
*Agency Contact Email Address: *Agency Contact Phone Number:
David.B.WiIIiams@ncagr.gov 919-715-6103
PRIOR FINANCIAL INFORMATION (only required for updates)
FINANCIAL INSTITUTION NAME:
NAME ON ACCOUNT:
ROUTING NUMBER:
ACCOUNT NUMBER:
ACCT TYPE:
Savinqs
REMIT E-MAIL ADDRESS
* ALL BOXES BELOW MUST BE REVIEWED AND CHECKED
❑I acknowledge that electronic payments to the designated account must comply with the provisions of U.S. law, and the requirements of
the Office of Foreign Assets Control (OFAC). I affirm the entire amount of the payment will not be transferred to a foreign bank account.
❑I authorize the Office of the State Controller to initiate ACH payments, and if necessary, adjustments for any ACH payments in error, to
the financial institution and account identified on the attached certification document. This authority will remain in effect until i, the vendor,
cancel it in writing or the authority is terminated by the NC Office of the State Controller.
I have attached a copy of a current voided check, current bank statement or included a bank letter on bank letterhead.
*PRINT NAME: Lisa Wurtzbacher, Chief Financial Officer *DATE: t.
*SIGNATURE: *PHONE NUMBER: 910-798-7187
Revised May 2018
Instructions * Denotes a required field on the form
1. `Check the appropriate box at the top of the form:
■ New Add Request — Vendor would like to begin receiving payments via ACH.
• Change/Update Existing Account — Vendor's account number, routing number, or remittance email address
has changed.
■ Inactivate Existing Account — Vendor no longer wants to receive payments via ACH.
2. Enter the vendor's Tax Identification Number or Social Security Number.
3. *Enter the Payee Name —The name of the person or business receiving payment.
4. "Enter the vendor's remittance address. The remittance address is the address printed on your invoice where
payments should be sent.
5. 'Enter the vendor's contact name, title, and phone number.
6. `Enter the vendor's financial information:
■ Financial Institution Name — Name of the financial institution.
■ Name on Account — The account owner's name.
• Routing Number — Nine -digit number identifying the financial institution.
■ Account Number — The bank account number where the funds should be deposited.
■ Account Type — Is this a checking or savings account? Check the appropriate box.
■ Remit E-mail address - Enter the email address to which the remittance advices should be sent.
7. 'For a new add request only, provide the following:
■ Agency Name — The state agency the vendor is doing business with.
{ Agency Contact Name — The vendor's contact person name at the state agency.
• Agency Contact Email Address — The contact person's email address at the state agency.
Agency Contact Phone Number -- The contact person's phone number at the state agency.
NOTE: New add requests MUST include contact information for the state agency with
which you are doing business.
8. Prior Financial Information —this is required if the vendor's bank account, routing number, or remittance email
address has changed.
• Financial Institution Name — Name of the financial institution.
■ Name on Account — The account owner's name.
• Routing Number — Nine -digit number identifying the financial institution.
■ Account Number — The bank account number where the funds should be deposited.
■ Account Type — Is this a checking or savings account? Check the appropriate box.
■ Remit E-mail address - Enter the email address to which the remittance advices should be sent.
*Review all the information in the 3 attestation boxes located above the signature area. All 3 boxes must be
checked — otherwise the form will not be processed.
10. *Print Name —Print the name of the authorized signee on the form.
"Date — Date of signature.
'Signature — The authorized signee's signature.
*Phone Number—The authorized signee's phone number.
Return to: OSC Support Services Center
Address:
1410 Mail Service Center
Raleigh, NC 27699-1410
Email: osc.su ort.services osc.nc. ov
Please allow up to 30 days for processing.
Revised May 2018