Sewer and Drain Maintenance including CCTV

expired opportunity(Expired)
From: Salem(Town)

Basic Details

started - 17 Dec, 2022 (15 months ago)

Start Date

17 Dec, 2022 (15 months ago)
due - 21 Feb, 2023 (13 months ago)

Due Date

21 Feb, 2023 (13 months ago)
Bid Notification

Type

Bid Notification

Identifier

N/A
Town of Salem

Customer / Agency

Town of Salem
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Request for Bids Sewer and Drain Maintenance including CCTV RFB (2022-010) Town of Salem NH SALEM PURCHASING Gia Faccadio, Purchasing Agent Nicole McGee, Finance Director Christopher Dillon, Town Manager Prepared for and in coordination with GENERAL TERMS AND CONDITIONS PREPARATIONS OF BIDS/PROPOSALS: Proposals shall be submitted on the forms provided and must be signed by the Bidder or his authorized representative. The person signing the proposal shall initial any corrections to entries made on the attached forms. Vendors must provide pricing on all items appearing on the bid forms unless specific directions in the advertisement, on the bid form or in the special provisions allowed for partial bids. Failure to provide pricing on all items may disqualify the bid. Alternative bids will be considered, unless otherwise stated, only if the alternate is described completely, including, but not limited to, sample, if requested and specifications sufficient so that a comparison to the
request can be made. Any questions or inquiries must be submitted in writing, and must be received by the Purchasing Department no later than seven (7) calendar days before the Request for Proposal due date to be considered. Any changes to the Request for Proposal will be provided to all bidders of record. The name of manufacturer, trade name, or catalog number mentioned in this request for bid description is for the purpose of designating a minimum standard of quality and type. Such references are not intended to be restrictive, although specified color, type of material and specified measurements may be mandatory. Proposals will be considered for any brand that meets or exceeds the quality of the specifications listed. On all such proposals, the bidder shall specify the product they are proposing and shall supply sufficient data to enable a comparison to be made with the particular brand or manufacturer specified. Failure to submit the above may be sufficient grounds for rejection of the proposal. SUBMITED BIDS/PROPOSALS: Proposals must be submitted as directed in the Notice to Qualified Firms, and on the forms provided unless otherwise specified. Proposals must be typewritten or printed in ink. Proposals must be mailed or delivered in person. Proposals that are faxed or emailed will not be accepted. WITHDRAWING BIDS/PROPOSALS: Proposals may be withdrawn prior to the opening date and time upon written request of the Proposer. Negligence on the part of the Proposer in preparing his/her proposal shall not constitute a right to withdraw a proposal subsequent to the proposal opening. PROPOSAL EVALUATION: The Town reserves the right to reject any and all proposals received for the following reasons including but not limited to: • Fails to adhere to one or more of the provisions established in the proposal. • Fails to submit its proposal at the time or in the format specified herein or to supply the minimum information requested herein. • Fails to meet the minimum evaluation criteria specified in this proposal. • Fails to submit its proposal to the required address on or before the deadline date established by the Town. • Misrepresents its services, experience and personnel by providing demonstrably false information in its proposal or fails to provide material information. • Fails to submit its cost on the enclosed bid form. • Refuses a reasonable request for an interview. • Refuses to provide clarification requested by the Town. RECEIPT AND OPENING OF PROPOSALS: Proposals shall be submitted prior to the time fixed in the Request for Sealed Bids/RFP. Proposals received after the time so indicated shall be returned unopened. PROPOSAL RESULTS: All sealed bids received will be considered confidential and not available for public review until after the bid opening is conducted. Bid and RFP openings will be scheduled and opened accordingly. Results will not be given over the phone. Please send your request in writing or send an email to gfaccadio@salemnh.gov to receive sealed bid results after the public opening. All Bids, RFP’s, and RFQ’s will remain unofficial and if applicable confidential until the award has been posted on the Town website. KNOWLEDGE AND EXPERIENCE: If and as requested per document, provide a description of the firm’s knowledge and experience in the industry. Highlight your company’s experience to provide the highest quality and effective product and reliable service and support. REFERENCES: If and as requested per document, projects within the past ten years best illustrating current qualifications for this project. AWARD OF CONTRACT; It is the policy of the Town of Salem, NH that contracts are awarded only to responsible bidders. In order to qualify as responsible, a prospective vendor must meet the following standards as they relate to this request: • Have adequate financial resources for performance or have the ability to obtain such resources as required during performance. • Have the necessary experience, organization, technical and professional qualifications, skills and facilities. • Be able to comply with the proposed or required time of completion or performance schedule; and • Have a demonstrated satisfactory record of performance. • Adhere to the specifications of this bid and provide all documentation required of this bid. The contract will be awarded to a responsive & responsible bidder based on best cost, including the qualifications and experience of the bidder, the quality of the equipment/product /materials/services to be provided and the support that the bidder offers during the duration of the contract terms. EXECUTION OF AGREEMENT: The successful proposer shall sign (execute) the necessary agreements for entering into the contract and return such signed agreements to the town within ten (10) calendar days from the date mailed or otherwise delivered to the successful Proposer. APPROVAL OF AGREEMENT: Upon receipt of the agreement that has been fully executed by the proposer, the owner will complete the execution of the agreement and return the agreement to the contractor. The Agreement accompanied by a Town issued purchase order will be delivered to the contractor and will constitute a mutual approval and agreement by both parties to abide by the terms and conditions of the agreement. FAILURE TO EXECUTE AGREEMENT: Failure of the successful proposer to execute the agreement at the date and time agreed upon by the Town and the successful Proposer shall be just cause for cancellation of the award and forfeiture of all deposits. CONTRACT TERMINATION: If at any time the proposer fails to provide proper services during the contract period, the Town of Salem, NH will have the option to terminate the contract at any time without notice. RIGHT TO REJECT BIDS: The Town reserves the right to reject any and all sealed bids, should the Town deem it to be in the best interest of the public. mailto:gfaccadio@salemnh.gov INSURANCE CERTIFICATES: Prior to award of this contract, the Contractor shall submit insurance certificates indicating coverage for all vehicles, public liability and property damage in the following amounts: Comprehensive General Liability Auto Liability: Property Damage Personal Injury $1,000,000/$ 1,000,000 $1,000,000/$ 1,000,000 $ 1,000,000/$ 1,000,000 Workmen’s Compensation as required by the State of New Hampshire PRICING: Unless otherwise specified all prices listed are firm for the term of the contract. All prices should include all labor and material costs, and any discounts offered. All fuel surcharges, delivery charges and miscellaneous charges that are not part of the terms and conditions of this contract will only hold up payment if they are added to the submitted invoice. INVOICING: Invoices must be physically mailed and/or submitted (emailed invoices unacceptable) to Accounts Payable at: Town of Salem c/o Accounts Payable 33 Geremonty Drive Salem NH 03079. The invoice must include an itemization of all items, supplies, repairs, labor furnished, including unit list pricing, and net pricing, as identified in the bid award. The total amount due shall be clear and apparent on the invoice for proper payment. Payment terms are net thirty (30) days from the date of the invoice. General terms as allowable: Invoices received before the twentieth of each month should get processed for said month with payment available through said month check disbursement. TAX: The Town is exempt from all sales and federal excise taxes. Our exemption number is 026000817 Please Invoice less these taxes. DELIVERY: Deliveries are to be made only to the department or division indicated on the order and in accordance with accepted commercial practices, without extra charge for packing or containers. GUARANTEES AND WARRANTIES: All parts and labor related to agreements must be guaranteed and include a warranty. If any work is unable to be guaranteed, the contractor must inform the Town, in writing, prior to the delivery of an item or any work being performed. FORCE MAJEURE: Neither party shall be liable for any inability to perform its’ obligations under any subsequent agreement due to war, riot, insurrection, civil commotion, fire, flood, earthquake, storm or any other act of God. POLICE DETAILS: Police Details shall be scheduled as required for safety, by and as required by Town, and will be paid by the Municipal Services Department. The Contractor shall coordinate and confirm work schedule with the Municipal Services Department, or the designee, discuss Police Detail, if approved, and if applicable, provide detail slips back to Municipal Services. REQUEST FOR PROPOSALS SEWER AND DRAIN MAINTENANCE SERVICES INCLUDING CCTV You are cordially invited to submit a proposal for Sewer and Drain Maintenance including CCTV in accordance with the attached specifications, terms, and conditions listed in RFB 2022-010 Sewer and Drain Maintenance including CCTV which can be obtained at https://www.townofsalemnh.org/purchasing. The Town of Salem, NH, is seeking a qualified contractor to provide equipment and labor for service, maintenance, inspection, and cleaning of the sewer and drain infrastructure throughout the town including sewer lift stations. Requirements and/or scheduled work under this contract include predominately wastewater operations and maintenance, also sanitary sewer pipeline cleaning, to be done on an annual basis. Emergency work and additional work including drain, hydro excavation, and CCTV inspection may be requested as well. Work will be performed with and/or through the Town and its Municipal Services staff. All proposals/bids must be received by February 21, 2022 at 10:00 AM EST. Two (2) copies of the BID package must be submitted in a sealed envelope, plainly marked: RFB 2022-010 Sewer and Drain Maintenance including CCTV Town of Salem Purchasing Office 33 Geremonty Drive Salem NH 03079 INTRODUCTION The Town of Salem intends to contract a qualified company for sewer and drain maintenance services. Prospective bidders shall furnish equipment and labor to clean Town sewer mains and drain lines (6” to 36”), service sewer lift stations, and provide color video inspections if applicable. Hydro digging may also be requested. This contract will be for annual maintenance service calls and to assist the Town with after-hour emergency services. Contract supervision shall be under the general guidance of the Town of Salem Municipal Services Department, Utilities Division, but also includes Public Works and Engineering. This is a support services contract that will work with and for Municipal Services as needed. SCOPE OF WORK The Town of Salem seeks qualified bidders to contract with the Municipal Services Department for service, maintenance, inspection, and cleaning of the sewer and drain infrastructure throughout the town including sewer lift stations. Requirements and/or scheduled work under this contract include predominately wastewater operations and maintenance and sanitary sewer pipeline cleaning to be done on an annual basis. Emergency work and additional work including drain and CCTV inspection will be requested so the contractor shall have the ability to meet those expectations as well. The duration of the contract will be for (3) three years from date of award with the Towns option of extending (1) additional year. The contractor will provide the necessary time, material (unless otherwise supplied) and labor for the maintenance to complete work as specified or directed by the Municipal Services Department. The contractor will also maintain a 24 hour available emergency response number for the entirety of the contract. The Town of Salem https://www.townofsalemnh.org/purchasing will be responsible for traffic control, back up to the contractor, or for hiring details required by the Salem Police Department as necessary to ensure the safety of the public and crew while performing work. The Town will supply a water hook up and the contractor may be allowed to discharge waste at a designated Town-owned facility however some materials may be requested to be taken off site and handled/disposed of accordingly by contractor. Work will be classified as e ither general scheduled maintenance or emergency work as below. GENERAL SCHEDULED MAINTENANCE: • Annual preventative maintenance cleaning of wet wells for ten (10) sewer lift stations throughout the town. The contractor will be required to schedule accordingly and with the Towns current sewer station general contractor. • Flushing, jetting, and cleaning of both sewer and drain lines • Removing blockages caused by foreign debris • Inspection and camera of compromised lines • Other work as directed and specified – eight (8) hours scheduled work. EMERGENCY WORK: • (24) Twenty four hours a day (365) Three hundred and sixty five days a year emergency response for all needed services. • Ability to respond to emergency calls within one (1) hour of notification. • Town will be notified of arrival to emergencies and departure once work is complete. • Non-emergency after hours are considered responses prior to 7:00AM on weekdays and after 4:00PM. All weekend and holiday hours recognized by the Town of Salem are considered after work hours. Minimum four (4) hours. REQUIREMENTS The Town of Salem services include scheduled septic pumping for tasks associated with the wastewater collection system. Tasks such as cleaning pump station wet wells and pumping of materials associated with cleaning sewer force mains are required. Service will be for scheduled preventative maintenance cleaning of 10 wastewater wet wells. The contractor will be required to schedule accordingly and with the Towns current sewer station maintenance general contractor. Contractor will be required to do confine space entries to remove grease, grit, rags, and debris from the wet wells including clearing grinders or racks. There will be emergency work when the contractor will be called, and they must respond in route within one (1) hour. Work may include but is not limited to maintaining wet well levels during major power outages or failures due to pumps so the contractor should have multiple septic pumping trucks available if necessary. The sewer line cleaning shall remove foreign materials from the lines and restore the sewer to a minimum of 95 percent of the original carrying capacity. It is recognized that there are some conditions such as broken pipe and major blockages that prevent cleaning from being accomplished or where additional damage would result if cleaning were attempted or continued. Should such conditions be encountered, the contractor will not be required to clean those specific sections. If in the course of normal cleaning operations, damage does result from pre-existing and unforeseen conditions such as broken pipe, the contractor will not be held responsible. The designated sewer sections shall be cleaned using high-velocity jet equipment. The equipment shall be capable of removing dirt, fats, oils, grease, rocks, sand, and other materials and obstructions from the sewer lines and manholes. If cleaning of an entire section cannot be successfully performed from one manhole, the equipment shall be set up on the other manhole and cleaning again attempted. If, again, successful cleaning cannot be performed or the equipment fails to traverse the entire section, it will be assumed that a major blockage exists and the cleaning effort shall be abandoned. Contractor shall provide proper equipment including appropriately sized steel cutter heads as needed to clear roots and blockages. Contractor shall determine the location of major blockage(s) by measuring length of hose or rod inserted from manholes at each end and record/report location of blockage(s) to the town. Additional work covered under this contract is for the internal closed circuit television (CCTV) inspection, sewer rodding, of sewer pipes but may include drain pipes. The contractor shall perform televising work as necessary to thoroughly document the condition of requested drain, sewer, and service lateral connections. The pipeline shall be carefully inspected to determine alignment, grade variations, separated joints, location and extent of any deterioration, breaks, obstacles, obstructions, debris, quantities of infiltration/inflow and the locations of service connections. The contractor shall inspect the pipeline interior using a color closed circuit television camera (CCTV) and document the inspection on a digital recorder. Digital photographs (.JPG files), inspection reports (.PDF files) and any handwritten inspection logs or field maps shall accompany the video inspections if requested for each sewer reach (manhole-to-manhole) or lateral inspected. The contractor shall provide comments as necessary to fully describe the existing condition of the sewer on the inspection forms. All of the APPENDICES listed must be completed for consideration of BID • APPENDIX A - Knowledge and Experience • APPENDIX B - References • APPENDIX C - Equipment List • APPENDIX D - Acknowledgment Forms BID FORM Equipment price includes operator Total lowest cost YEARS 1 – 3 combined is the consideration PART A: GENERAL SCHEDULED MAINTENACE: CATEGORY YEAR 1 YEAR 2 YEAR 3 JET VAC TRUCK $_____________HR $_____________HR $_____________HR VACUUM PUMP TRUCK $_____________HR $_____________HR $_____________HR CAMERA TRUCK $_____________HR $_____________HR $_____________HR LABORER $_____________HR $_____________HR $_____________HR TOTAL $_____________ $_____________ $_____________ TOTAL BID ADD YEARS 1-3 ABOVE $___________________ PART B: EMERGENCY WORK: CATEGORY YEAR 1 YEAR 2 YEAR 3 JET VAC TRUCK $_____________HR $_____________HR $_____________HR VACUUM PUMP TRUCK $_____________HR $_____________HR $_____________HR CAMERA TRUCK $_____________HR $_____________HR $_____________HR LABORER $_____________HR $_____________HR $_____________HR TOTAL $_____________ $_____________ $_____________ TOTAL BID ADD YEARS 1-3 ABOVE $___________________ MINIMUM NUMBER OF CALL OUT HOURS __________________________________________ The undersigned certifies under penalties of perjury that this proposal has been made and submitted in good faith and without collusion or fraud with any other person. As used in this certification, the word “person” shall mean any natural person, business, partnership, corporation, union, committee, club, or other organization, entity, or group of individuals. APPENDIX A: KNOWLEDGE AND EXPERIENCE Appendix A KNOWLEDGE AND EXPERIENCE Section 1: Previous Experience in providing a level of service on like-sized public and/or private projects. Please answer the following: 1. How many years has your company been in business under its present business name? ______________________________________________________________________________ 2. Describe your previous experience providing sewer and drain maintenance services. for like- sized jurisdictions. ______________________________________________________________________________ 3. Describe management personnel's experience with accounts of similar size and scope, company structure, and staff assigned to the resulting agreement. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4. State any and all instances of being disqualified, removed, or otherwise prevented from completing the terms of any previous contracts over the past five (5) years. Give names, street addresses, and phone numbers and explain the circumstances. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ APPENDIX B: REFERENCES REFERENCES: Assessment of Work Quality, Performance and Working Relationships with Current and Recent Clients List three (3) like-sized customers that you have provided ongoing sewer and drain maintenance services to within the last three (3) years. Provide the following information for each contact: a. Customer Name:______________________________________________________________ b. Customer Contact Name:_______________________________________________________ c. Phone Number:_______________________________________________________________ d. Number of years your firm has provided traffic signal services:_________________________ e. Number of facilities/locations where services have been provided:_______________________ a. Customer Name:______________________________________________________________ b. Customer Contact Name:_______________________________________________________ c. Phone Number:_______________________________________________________________ d. Number of years your firm has provided traffic signal services:_________________________ e. Number of facilities/locations where services have been provided:_______________________ a. Customer Name:______________________________________________________________ b. Customer Contact Name:_______________________________________________________ c. Phone Number:_______________________________________________________________ d. Number of years your firm has provided traffic signal services:_________________________ e. Number of facilities/locations where services have been provided:_______________________ Appendix B REFERENCES APPENDIX C: EQUIPMENT LIST Appendix C EQUIPMENT LIST ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ APPENDIX D: ACKNOWLEDGEMENT FORMS SIGNATORY DECLARATION I, the undersigned, acknowledge completion and receipt of the Authorized Signatory Declaration Form, and fully understand my responsibility as an Authorized Signatory on this document and all subsequent forms thereof requiring signature. In particular I understand rules regarding the referencing, checking, and verification as necessary for disclosure to award this bid or proposal as requested and defined within this document. The bid document as submitted has not been altered knowing all information must be filled out correctly for consideration. It is hereby understood that the Town of Salem reserves the right to reject any and all proposals or parts of proposals; to waive any defects, information, and minor irregularities; to accept exceptions to these specifications; to award contracts, or to cancel this request, if it is in the Town’s best interest to do so. Written Name of Authorized Signatory: _________________________________________ Title: _____________________________________________________________________ Signature: _________________________________________________________________ Date: _____________________________________________________________________ Company: _________________________________________________________________ Address: __________________________________________________________________ __________________________________________________________________ Phone: ____________________________________________________________________ Email: ____________________________________________________________________ NON-COLLUSION STATEMENT By Submission of the Bid or Proposal, the Bidder Certifies that: 1. This bid or proposal has been independently arrived at without collusion with any other competitor or potential competitor; 2. This bid proposal has not been knowingly disclosed and will not be knowingly disclosed prior to the opening of bids or proposals for this project, to any other bidder, competitor, or potential competitor; 3. No attempt has been made to induce any other person, partnership or corporation to submit or not to submit a bid or proposal; 4. The person signing this bid or proposal certifies that he has fully informed himself regarding the accuracy of the statements contained in this certification, and under the penalties of perjury, affirms the truth thereof, such penalties being applicable to the bidder as well as to the person signing in its behalf; 5. That attached hereto (if a corporate bidder) is a certified copy of a resolution authorizing the execution of the certificate by the signatory of this bid or proposal on behalf of the corporate bidder. Signature: Date: _ INDEMNIFICATION AGREEMENT The successful vendor agrees to indemnify, investigate, protect, defend, and save harmless the Town of Salem, NH, it’s officials, officers, agents, and employees from any and all claims and losses accruing or resulting to any and all contractors, subcontractors, suppliers, laborers and any other person, firm or corporation furnishing or supplying work, services, materials, equipment or supplies in connection with the performance of this contract and from any and all claims and losses accruing or resulting to any person, firm or corporation which may be injured or damaged by the vendor in the performance of this contract. In any case, the forgoing provisions concerning indemnification shall not be construed to indemnify the Town for damage arising out of bodily injury to persons or damage to property caused by or resulting from the sole negligence of the Town or its employees. This indemnification shall survive the expiration or early termination of this contract. Signature: Date: _______________________________________________________ NO BID QUESTIONNAIRE If you choose not to bid, please complete the questionnaire below and return it with your response by the bid opening date. Your assistance in helping us to analyze no bid rationale is very much appreciated. A no bid is submitted in reply to the Town of Salem, NH invitation in reference to: ___________________________________________________________________________ Given the following: Item not supplied by our company Bid Specification (Provide reason) Profit Margin too low Past experience with the Town of Salem (Provide reason) ________________________________________________________________ _____Insufficient time allowed to prepare and respond to bid request Bid requirements (Provide reason) _________________________________________________________________ Priority of other business opportunities limits time. Other reason(s): ____ __________________________________________________________________ __________________________________________________________________ Signature: Date: _ Form W-9 (Rev. October 2018) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification ▶ Go to www.irs.gov/FormW9 for instructions and the latest information. Give Form to the requester. Do not 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. 2 Business name/disregarded entity name, if different from above 3 Check appropriate 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 certain entities, not individuals; see instructions on page 3): Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate Exempt payee code (if any) Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ▶ Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the 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 the tax classification of its owner. Other (see instructions) ▶ Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.) 5 Address (number, street, and apt. or suite no.) See instructions. Requester’s name and address (optional) 6 City, state, and ZIP code 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid 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 entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Social security number – – or Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I 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. I 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 II, later. 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.irs.gov/FormW9. 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 (TIN) 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) • 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-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-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 Form W-9 (Rev. 10-2018) Sign Here Signature of U.S. person ▶ Date ▶ Pr in t o r t yp e. Se e Sp ec ifi c In st ru ct io ns o n pa ge 3 . Employer identification number – http://www.irs.gov/FormW9 http://www.irs.gov/FormW9

33 Geremonty Drive Salem NH 03079Location

Address: 33 Geremonty Drive Salem NH 03079

Country : United StatesState : New Hampshire

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