HomeMy WebLinkAboutPOUDRE VALLEY HEALTH SYSTEM FOUNDATION - CONTRACT - AGREEMENT MISC - POUDRE VALLEY HEALTH SYSTEM FOUNDATIONFort Collins
CAIR (Community AIR)
Pilot Micro -grant Program
Grant Contract
CLEANAIR
it's up to us
THIS AGREEMENT made and entered into on the date of signing by the City, is by and between the CITY OF FORT
COLLINS, COLORADO, a municipal corporation (hereinafter referred to as City) and Poudre Valley Health System
Foundation (non-profit group name), a non-profit organization (type of entity) whose address is 2315 East Harmony
Road Suite 200, Fort Collins, CO 80528 (hereinafter referred to as Group).
WHEREAS, the over -arching air quality principle adopted by City Council in City Plan is Principle ENV 8 —
Continually improve Fort Collins' air quality, and
WHEREAS, the City Plan policies adopted by the City Council includes Air Quality Policy ENV 8.7, "Involve and
Inform the Public About Air Quality"; and
WHEREAS, as a consequence of this policy, it is part of the mission of the Environmental Services Air Quality
Program to support our community's values and adopted policy goals by offering programs and services that
improve air quality; and
WHEREAS, City of Fort Collins Natural Resources Department has selected the Group's project, as described below
and in the Group's application and proposal (the Project); for funding support in accordance with the CAIR
(Community AIR) Grant Program.
NOW, THEREFORE, in consideration of their mutual promises contained herein, the parties agree as follows:
The Group has designated as its representative and authorized agent for the purpose of this Agreement, and as
Coordinator of the Project Kim Sharpe (hereinafter referred to as Coordinator), and has named Susannah
Wright as the alternative contact and representative (hereinafter referred to as Altercate Coordinator). In
addition to the authorized representative signing this Agreement on behalf of the Group, the Coordinator and
Altercate Coordinator have signed this Agreement to acknowledge the terms and requirements set forth herein.
In the event the Coordinator is unable to fulfill his or her responsibilities hereunder, and the Coordinator and
Alternate Coordinator shall provide written notice to the City of the Alternate Coordinator's assumption in such
event.
2. The Group shall use the funds provided under this Agreement in accordance with the Grant Application for the
Project, which is attached as the Application and Budget Sheet and incorporated herein by this reference, and in
accordance with the terms of this Agreement.
3. Any modification of the implementation of this project from that indicated in the Grant Application for the Project
must receive prior written approval of the City.
For implementation of the Project, the Group shall receive $M, in the following increments and on the following
schedule:
(together hereinafter referred to as the Grant Funds). The Grant Funds shall be expended by the
Group no later than 12/31/11 (within the calendar year 2011).
5. The Group shall provide the City with a written evaluation on the Project and copies of all receipts no later than
fourteen (14) days after the completion of the Project.
6. The Group agrees to make all records pertaining to activities carded out under this Agreement available to the
City for audit upon request for at least three (3) full calendar years after the year of the Grant..
Fort Collins
CAIR (Community AIR)
Pilot Micro -grant Program
Grant Contract
CLEANAIR
it's up to us
THIS AGREEMENT made and entered into on the date of signing by the City, is by and between the CITY OF FORT
COLLINS, COLORADO, a municipal corporation (hereinafter referred to as City) and Poudre Valley Health System
Foundation (non-profit group name), a non-profit organization (type of entity) whose address is 2315 East Harmony
Road Suite 200, Fort Collins, CO 80528 (hereinafter referred to as Group).
WHEREAS, the over -arching air quality principle adopted by City Council in City Plan is Principle ENV 8 —
Continually improve Fort Collins' air quality, and
WHEREAS, the City Plan policies adopted by the City Council includes Air Quality Policy ENV 8.7, "Involve and
Inform the Public About Air Quality"; and
WHEREAS, as a consequence of this policy, it is part of the mission of the Environmental Services Air Quality
Program to support our community's values and adopted policy goals by offering programs and services that
improve air quality; and
WHEREAS, City of Fort Collins Natural Resources Department has selected the Group's project, as described below
and in the Group's application and proposal (the Project); for funding support in accordance with the CAIR
(Community AIR) Grant Program.
NOW, THEREFORE, in consideration of their mutual promises contained herein, the parties agree as follows:
The Group has designated as its representative and authorized agent for the purpose of this Agreement, and as
Coordinator of the Project Kim Sharpe (hereinafter referred to as Coordinator), and has named Susannah
Wright as the alternative contact and representative (hereinafter referred to as Altercate Coordinator). In
addition to the authorized representative signing this Agreement on behalf of the Group, the Coordinator and
Altercate Coordinator have signed this Agreement to acknowledge the terms and requirements set forth herein.
In the event the Coordinator is unable to fulfill his or her responsibilities hereunder, and the Coordinator and
Alternate Coordinator shall provide written notice to the City of the Alternate Coordinator's assumption in such
event.
2. The Group shall use the funds provided under this Agreement in accordance with the Grant Application for the
Project, which is attached as the Application and Budget Sheet and incorporated herein by this reference, and in
accordance with the terms of this Agreement.
3. Any modification of the implementation of this project from that indicated in the Grant Application for the Project
must receive prior written approval of the City.
For implementation of the Project, the Group shall receive $M, in the following increments and on the following
schedule:
(together hereinafter referred to as the Grant Funds). The Grant Funds shall be expended by the
Group no later than 12/31/11 (within the calendar year 2011).
5. The Group shall provide the City with a written evaluation on the Project and copies of all receipts no later than
fourteen (14) days after the completion of the Project.
6. The Group agrees to make all records pertaining to activities carded out under this Agreement available to the
City for audit upon request for at least three (3) full calendar years after the year of the Grant..
Form W-9
Generally, individuals (including sole proprietors) are not exempt
from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
withholding.
The following payees are exempt from backup withholding:
1. An organization exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(b)(7) if the account
satisfies the requirements of section 401(f)(2),
2. The United States or any of its agencies or
instrumentalities,
3. A state, the District of Columbia, a possession of the United
States, or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding
include:
6. A corporation,
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register in
the United States, the District of Columbia, or a possession of
the United States,
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year under
the Investment Company Act of 1940,
12. A common trust fund operated by a bank under section
584(a),
13. A financial institution,
14. A middleman known in the investment community as a
nominee or custodian, or
15. A trust exempt from tax under section 664 or described in
section 4947.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt payees listed above, 1 through 15.
IF the payment is for ...
THEN the payment is exempt
for...
Interest and dividend payments
All exempt payees except
for 9
Broker transactions
Exempt payees 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Barter exchange transactions
Exempt payees 1 through 5
and patronage dividends
Payments over $600 required
Generally, exempt payees
to be reported and direct
1 through 72
sales over $5,000'
See Form 1099-MISC, Miscellaneous Income, and its instructions.
'However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 9045(Q, even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from
backup withholding: medical and health care payments, attorneys' fees, and
payments for services paid by a federal executive agency.
Part I. Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an SSN,
your TIN is your IRS individual taxpayer identification number
(ITIN). Enter it in the social security number box. If you do not
have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that you
use your SSN.
If you are a single -member LLC that is disregarded as an
entity separate from its owner (see Limited liability company
(LLC) on page 2), enter the owner's SSN (or EIN, if the owner
has one). Do not enter the disregarded entity's EIN. If the LLC is
classified as a corporation or partnership, enter the entity's EIN.
Note. See the chart on page 4 for further clarification of name
and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS-5, Application
for a Social Security Card, from your local Social Security
Administration office or get this form online at www.ssa.gov. You
may also get this form by calling 1-800-772-1213. Use Form
W-7, Application for IRS Individual Taxpayer Identification
Number, to apply for an ITIN, or Form SS-4, Application for
Employer Identification Number, to apply for an EIN. You can
apply for an EIN online by accessing the IRS website at
www.im.gov/businesses and clicking on Employer Identification
Number (EIN) under Starting a Business. You can get Forms W-7
and SS-4 from the IRS by visiting www.irs.gov or by calling
1-800-TAX-FORM (1-800-829-3676).
If you are asked to complete Form W-9 but do not have a TIN,
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 domestic 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 items 1, 4, and 5 below indicate
otherwise.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt payees, see Exempt
Payee on page 2.
Signature requirements. Complete the certification as indicated
in 1 through 5 below.
1. Interest, dividend, and barter exchange accounts
opened before 1984 and broker accounts considered active
during 1983. You must give your correct TIN, but you do not
have to sign the certification.
2. Interest, dividend, broker, and barter exchange
accounts opened after 1983 and broker accounts considered
inactive during 1983. You must sign the certification or backup
withholding will apply. If you are subject to backup withholding
and you are merely providing your correct TIN to the requester,
you must cross out item 2 in the certification before signing the
form.
Form W-9
Generally, individuals (including sole proprietors) are not exempt
from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
withholding.
The following payees are exempt from backup withholding:
1. An organization exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(b)(7) if the account
satisfies the requirements of section 401(f)(2),
2. The United States or any of its agencies or
instrumentalities,
3. A state, the District of Columbia, a possession of the United
States, or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding
include:
6. A corporation,
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register in
the United States, the District of Columbia, or a possession of
the United States,
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year under
the Investment Company Act of 1940,
12. A common trust fund operated by a bank under section
584(a),
13. A financial institution,
14. A middleman known in the investment community as a
nominee or custodian, or
15. A trust exempt from tax under section 664 or described in
section 4947.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt payees listed above, 1 through 15.
IF the payment is for ...
THEN the payment is exempt
for...
Interest and dividend payments
All exempt payees except
for 9
Broker transactions
Exempt payees 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Barter exchange transactions
Exempt payees 1 through 5
and patronage dividends
Payments over $600 required
Generally, exempt payees
to be reported and direct
1 through 72
sales over $5,000'
See Form 1099-MISC, Miscellaneous Income, and its instructions.
'However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 9045(Q, even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from
backup withholding: medical and health care payments, attorneys' fees, and
payments for services paid by a federal executive agency.
Part I. Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an SSN,
your TIN is your IRS individual taxpayer identification number
(ITIN). Enter it in the social security number box. If you do not
have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that you
use your SSN.
If you are a single -member LLC that is disregarded as an
entity separate from its owner (see Limited liability company
(LLC) on page 2), enter the owner's SSN (or EIN, if the owner
has one). Do not enter the disregarded entity's EIN. If the LLC is
classified as a corporation or partnership, enter the entity's EIN.
Note. See the chart on page 4 for further clarification of name
and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS-5, Application
for a Social Security Card, from your local Social Security
Administration office or get this form online at www.ssa.gov. You
may also get this form by calling 1-800-772-1213. Use Form
W-7, Application for IRS Individual Taxpayer Identification
Number, to apply for an ITIN, or Form SS-4, Application for
Employer Identification Number, to apply for an EIN. You can
apply for an EIN online by accessing the IRS website at
www.im.gov/businesses and clicking on Employer Identification
Number (EIN) under Starting a Business. You can get Forms W-7
and SS-4 from the IRS by visiting www.irs.gov or by calling
1-800-TAX-FORM (1-800-829-3676).
If you are asked to complete Form W-9 but do not have a TIN,
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 domestic 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 items 1, 4, and 5 below indicate
otherwise.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt payees, see Exempt
Payee on page 2.
Signature requirements. Complete the certification as indicated
in 1 through 5 below.
1. Interest, dividend, and barter exchange accounts
opened before 1984 and broker accounts considered active
during 1983. You must give your correct TIN, but you do not
have to sign the certification.
2. Interest, dividend, broker, and barter exchange
accounts opened after 1983 and broker accounts considered
inactive during 1983. You must sign the certification or backup
withholding will apply. If you are subject to backup withholding
and you are merely providing your correct TIN to the requester,
you must cross out item 2 in the certification before signing the
form.
Form W-9 (Rev. 10-2007)
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
(including payments to corporations), payments to a
nonemployee for services, payments to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(ncluding 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), 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:
Give name and SSN of:
1. Individual
The individual
2. Two or more individuals aoint
The actual owner of the account or,
account)
if combined funds, the first
individual on the account'
3. Custodian account of a minor
The minor'
(Uniform Gift to Minors Act)
4. a. The usual revocable savings
The grantor -trustee'
trust (grantor is also trustee)
b. So-called trust account that is
The actual owner
not a legal or valid trust under
state law
5. Sole proprietorship or disregarded
The owner'
entity owned by an individual
For this type of account:
Give name and EIN of:
6. Disregarded entity not owned by an
The owner
individual
7. A valid trust, estate, or pension trust
Legal entity'
8. Corporate or LLC electing
The corporation
corporate status on Form 8832
9. Association, club, religious,
The organization
charitable, educational, or other
tax-exempt organization
10. Partnership or multi -member LLC
The partnership
11. A broker or registered nominee
The broker or nominee
12. 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
' List first and circle the name of the person whose number you furnish. If only one person
on a pint account has an SSN, that person'%number must Im furnished.
Circle the minor's name and furnish the minor's SSN.
%You must show your indivitlual name and you may also enter your business or'DBA"
me on the second name line. You may use either your SSN or EIN (it 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 rules for partnerships on page 1.
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
Privacy Act Notice
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal
information such as your name, social security number (SSN), or
other identifying information, without your permission, to commit
fraud or other crimes. An identity thief may use your SSN to get
a job or may file a tax return using your SSN to receive a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax preparer.
Call the IRS at 1-800-829-1040 if you think your identity has
been used inappropriately for tax purposes.
Victims of identity theft who are experiencing economic harm
or a system problem, or are seeking help in resolving tax
problems that have not been resolved through normal channels,
may be eligible for Taxpayer Advocate Service (rAS) assistance.
You can reach TAS by calling the TAS toll -free case intake line
at1-877-777-4778 or TTY/TDD 1-800-829-4059.
Protect yourself from suspicious emails or phishing
schemes. Phishing is the creation and use of email and
websites designed to mimic legitimate business smalls and
websites. The most common act is sending an email to a user
falsely claiming to be an established legitimate enterprise in an
attempt to scam the user into surrendering private information
that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails.
Also, the IRS does not request personal detailed information
through email or ask taxpayers for the PIN numbers, passwords,
or similar secret access information for their credit card, bank, or
other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishing@irs.gov. You may also report
misuse of the IRS name, logo, or other IRS personal property to
the Treasury Inspector General for Tax Administration at
1-800-366-4484. You can forward suspicious emails to the
Federal Trade Commission at: spam@uce.gov or contact them at
www.consamer.gov/Idtheft or 1-877-IDTHEFT(438-4338).
Visit the IRS website at www.irs.gov to learn more about
identity theft and how to reduce your risk.
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest,
dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA, or Archer NSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your lax return.
The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and stale agencies to enforce federal
nonlax 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. Payers must generally withhold 28% of taxable interest, dividend, and certain other
payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
Form W-9 (Rev. 10-2007)
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
(including payments to corporations), payments to a
nonemployee for services, payments to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(ncluding 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), 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:
Give name and SSN of:
1. Individual
The individual
2. Two or more individuals aoint
The actual owner of the account or,
account)
if combined funds, the first
individual on the account'
3. Custodian account of a minor
The minor'
(Uniform Gift to Minors Act)
4. a. The usual revocable savings
The grantor -trustee'
trust (grantor is also trustee)
b. So-called trust account that is
The actual owner
not a legal or valid trust under
state law
5. Sole proprietorship or disregarded
The owner'
entity owned by an individual
For this type of account:
Give name and EIN of:
6. Disregarded entity not owned by an
The owner
individual
7. A valid trust, estate, or pension trust
Legal entity'
8. Corporate or LLC electing
The corporation
corporate status on Form 8832
9. Association, club, religious,
The organization
charitable, educational, or other
tax-exempt organization
10. Partnership or multi -member LLC
The partnership
11. A broker or registered nominee
The broker or nominee
12. 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
' List first and circle the name of the person whose number you furnish. If only one person
on a pint account has an SSN, that person'%number must Im furnished.
Circle the minor's name and furnish the minor's SSN.
%You must show your indivitlual name and you may also enter your business or'DBA"
me on the second name line. You may use either your SSN or EIN (it 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 rules for partnerships on page 1.
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
Privacy Act Notice
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal
information such as your name, social security number (SSN), or
other identifying information, without your permission, to commit
fraud or other crimes. An identity thief may use your SSN to get
a job or may file a tax return using your SSN to receive a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax preparer.
Call the IRS at 1-800-829-1040 if you think your identity has
been used inappropriately for tax purposes.
Victims of identity theft who are experiencing economic harm
or a system problem, or are seeking help in resolving tax
problems that have not been resolved through normal channels,
may be eligible for Taxpayer Advocate Service (rAS) assistance.
You can reach TAS by calling the TAS toll -free case intake line
at1-877-777-4778 or TTY/TDD 1-800-829-4059.
Protect yourself from suspicious emails or phishing
schemes. Phishing is the creation and use of email and
websites designed to mimic legitimate business smalls and
websites. The most common act is sending an email to a user
falsely claiming to be an established legitimate enterprise in an
attempt to scam the user into surrendering private information
that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails.
Also, the IRS does not request personal detailed information
through email or ask taxpayers for the PIN numbers, passwords,
or similar secret access information for their credit card, bank, or
other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishing@irs.gov. You may also report
misuse of the IRS name, logo, or other IRS personal property to
the Treasury Inspector General for Tax Administration at
1-800-366-4484. You can forward suspicious emails to the
Federal Trade Commission at: spam@uce.gov or contact them at
www.consamer.gov/Idtheft or 1-877-IDTHEFT(438-4338).
Visit the IRS website at www.irs.gov to learn more about
identity theft and how to reduce your risk.
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest,
dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA, or Archer NSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your lax return.
The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and stale agencies to enforce federal
nonlax 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. Payers must generally withhold 28% of taxable interest, dividend, and certain other
payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
11
POUDRE VALLEY
HEALTH SYSTEM
�Olr�IG��c0�1
June 28, 2011
Ms. Lucinda Smith
Natural Resources Department
City of Fort Collins
215 N. Mason
PO Box 580
Fort Collins, CO 80522-0580
Dear Lucinda,
Thank you very much for awarding us a CAIR grant to provide presentations through the
Bicycle and Pedestrian Education Coalition. We are thrilled and grateful for the
opportunity to implement this project!
Enclosed are the signed contract and a W9 form for Poudre Valley Health System
Foundation. Please send a copy of the fully signed and executed contract back to me at
2315 East Harmony Road, Suite 200, Fort Collins, CO 80528. Please note that grants and
donations for Poudre Valley Health System are administered by the PVHS Foundation.
As such, checks should be made payable to PVHS Foundation.
Kim Sharpe will be your primary contact regarding project -related matters, as she
coordinates the PVHS Healthier Communities Coalition and the Bicycle and Pedestrian
Education Coalition. Kim will work with you to calculate greenhouse gas reductions
associated with biking so that uniform information will be provided to the public. She
will also be your contact for filming a video about the project. Kim can be reached at
krs4(a�ovhs.ors and (970) 495-7503.
I will be your primary contact regarding funding and contract -related matters. If you have
questions or need any information, please do not hesitate to contact me at
smw2 a pvhs.org and (970) 237-7404.
Again, thank you for your support!
Sincerely,
At
Susannah right
Grants Coordinator
2315 East Harmony Road, Suite 200 • Fort Collins, Colorado 80528 • Phone: (970) 237-7400 • Fax: (970) 237-7490 • foundation.pvhs,org
11
POUDRE VALLEY
HEALTH SYSTEM
�Olr�IG��c0�1
June 28, 2011
Ms. Lucinda Smith
Natural Resources Department
City of Fort Collins
215 N. Mason
PO Box 580
Fort Collins, CO 80522-0580
Dear Lucinda,
Thank you very much for awarding us a CAIR grant to provide presentations through the
Bicycle and Pedestrian Education Coalition. We are thrilled and grateful for the
opportunity to implement this project!
Enclosed are the signed contract and a W9 form for Poudre Valley Health System
Foundation. Please send a copy of the fully signed and executed contract back to me at
2315 East Harmony Road, Suite 200, Fort Collins, CO 80528. Please note that grants and
donations for Poudre Valley Health System are administered by the PVHS Foundation.
As such, checks should be made payable to PVHS Foundation.
Kim Sharpe will be your primary contact regarding project -related matters, as she
coordinates the PVHS Healthier Communities Coalition and the Bicycle and Pedestrian
Education Coalition. Kim will work with you to calculate greenhouse gas reductions
associated with biking so that uniform information will be provided to the public. She
will also be your contact for filming a video about the project. Kim can be reached at
krs4(a�ovhs.ors and (970) 495-7503.
I will be your primary contact regarding funding and contract -related matters. If you have
questions or need any information, please do not hesitate to contact me at
smw2 a pvhs.org and (970) 237-7404.
Again, thank you for your support!
Sincerely,
At
Susannah right
Grants Coordinator
2315 East Harmony Road, Suite 200 • Fort Collins, Colorado 80528 • Phone: (970) 237-7400 • Fax: (970) 237-7490 • foundation.pvhs,org
7. If the Group fails to meet or fulfill any condition or requirement of this Agreement in the manner and time
specified herein, the Group shall be in breach and the City may terminate the Agreement and withhold any
further payment of funds hereunder. Upon such termination, the Group shall repay to the City all Grant Funds
that have been disbursed to the Group hereunder within thirty (30) days following receipt of the written request
from the City to do so.
8. This Agreement is not assignable without prior written consent of the City, in its sole discretion.
9. If the Project involves activities on a specific site, the Group hereby represents and warrants that it has obtained
the permission of the owner of the site upon which the proposed activities will take place, and further represents
and warrants that it is fully authorized to undertake the activities.
10. The term of this Agreement shall be fromat/ to DPL.31 ?-0 ( (
11. At all times during the performance of this Agreement, the Group shall strictly adhere to all applicable federal,
state and local laws, rules and regulations that have been or may hereafter be established.
12. The signatories maintain that to their knowledge, no City employee has a personal or beneficial interest
whatsoever in the service or property described herein, and no City employee is a party hereto or will receive
payment through the receipt of the Grant Funds provided hereunder.
13. The Group shall indemnify, save and hold harmless the City, its officers, employees and agents against any and
all claims, damages, liability and court awards, including costs, expenses and attorney fees incurred as a result
of any act or omission by the Group, the Coordinator or Alternate Coordinator, or the Group's employees,
agents, subcontractors or assignees pursuant to the terms of this Agreement, or as a result of the performance
of the Grant Project.
14. Additional Program Obligations
A. The Group, the Coordinator, and no person carrying out responsibilities on their behalf in the
provision of services or the operation of any program referred to in this Agreement will
unlawfully discriminate with respect to any program participant or any applicant for
participation on the basis of race, color, national origin, age, sex, religion, handicap, political
affiliation or beliefs, or any other unlawful basis.
B. No services provided under this Agreement shall involve political activities and no funds made
available under this Agreement shall be used for lobbying activities.
C. The Group, the Coordinator, and no person carrying out responsibilities on their behalf in the
provision of the services or the operation of any program referred to in this Agreement will use
his or her position for his or her own private gain or for the gain of any person with whom he or
she has a relationship by blood or marriage or a close business, political or personal
association.
D. The Group must, upon request by the City, make available on a reasonable basis such
information as may be required to ensure or show compliance with local, state and federal
laws.
15. The parties hereby acknowledge and agree that this Agreement is intended to only document the relative rights
and obligations between of the parties to one another, and that no third party beneficiaries are intended. The
Group is solely responsible for any obligations or liabilities in connection with work performed as part of the
Project and any acts or omissions in connection with the same.
16. The undersigned persons each represent and warrant that he or she is authorized to sign this Agreement on
behalf of the party for whom he or she has signed this Agreement, and further represents and warrants that the
signature below establishes this Agreement as a legally binding obligation of said party.
7. If the Group fails to meet or fulfill any condition or requirement of this Agreement in the manner and time
specified herein, the Group shall be in breach and the City may terminate the Agreement and withhold any
further payment of funds hereunder. Upon such termination, the Group shall repay to the City all Grant Funds
that have been disbursed to the Group hereunder within thirty (30) days following receipt of the written request
from the City to do so.
8. This Agreement is not assignable without prior written consent of the City, in its sole discretion.
9. If the Project involves activities on a specific site, the Group hereby represents and warrants that it has obtained
the permission of the owner of the site upon which the proposed activities will take place, and further represents
and warrants that it is fully authorized to undertake the activities.
10. The term of this Agreement shall be fromat/ to DPL.31 ?-0 ( (
11. At all times during the performance of this Agreement, the Group shall strictly adhere to all applicable federal,
state and local laws, rules and regulations that have been or may hereafter be established.
12. The signatories maintain that to their knowledge, no City employee has a personal or beneficial interest
whatsoever in the service or property described herein, and no City employee is a party hereto or will receive
payment through the receipt of the Grant Funds provided hereunder.
13. The Group shall indemnify, save and hold harmless the City, its officers, employees and agents against any and
all claims, damages, liability and court awards, including costs, expenses and attorney fees incurred as a result
of any act or omission by the Group, the Coordinator or Alternate Coordinator, or the Group's employees,
agents, subcontractors or assignees pursuant to the terms of this Agreement, or as a result of the performance
of the Grant Project.
14. Additional Program Obligations
A. The Group, the Coordinator, and no person carrying out responsibilities on their behalf in the
provision of services or the operation of any program referred to in this Agreement will
unlawfully discriminate with respect to any program participant or any applicant for
participation on the basis of race, color, national origin, age, sex, religion, handicap, political
affiliation or beliefs, or any other unlawful basis.
B. No services provided under this Agreement shall involve political activities and no funds made
available under this Agreement shall be used for lobbying activities.
C. The Group, the Coordinator, and no person carrying out responsibilities on their behalf in the
provision of the services or the operation of any program referred to in this Agreement will use
his or her position for his or her own private gain or for the gain of any person with whom he or
she has a relationship by blood or marriage or a close business, political or personal
association.
D. The Group must, upon request by the City, make available on a reasonable basis such
information as may be required to ensure or show compliance with local, state and federal
laws.
15. The parties hereby acknowledge and agree that this Agreement is intended to only document the relative rights
and obligations between of the parties to one another, and that no third party beneficiaries are intended. The
Group is solely responsible for any obligations or liabilities in connection with work performed as part of the
Project and any acts or omissions in connection with the same.
16. The undersigned persons each represent and warrant that he or she is authorized to sign this Agreement on
behalf of the party for whom he or she has signed this Agreement, and further represents and warrants that the
signature below establishes this Agreement as a legally binding obligation of said party.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement this day of , 20
GROUP
Poudre Valley Health System Foundation
(Name of Group)
Name:: Ruth Lytle-Barnaby
Title: Executive Director
Date: in' zS' If
Coordinatof I
Address: PVHS Healthier Communities Coalition
1024 South Lemay Avenue
Fort Collins, CO 80524
Phone: (970)495-7503
And By'
Alternate Coordinator
Address: PVHS Foundation
2315 East Harmony Road, Suite 200
Fort Collins, CO 80528
Phone: (970)237-7404
CITY OF FORT COLLINS
By
J es B. O'Neill II, CPPO
Director of Purc asin and Risk Management
Date:
ATTEST:
City Clerk
APPROVED AS TO LEGAL FORM:
0
Deputy City Attorney
w vvvvvvvvvvvvvvvvv•vvovvvvvvvvvvvvvvvvvvvvvvvvvvvvvv..vvv.v..v..vv...vv.vv...v.vv.•
Alcoholic Beverages Disclaimer
• v
I agree that grant funds will not be used directly or indirectly to purchase alcoholic beverages. e
I further agree that I will assume all responsibility and potential liability associated with the serving of alcoholic :
bever s in connection with any Project activities.
: By. e Lt. C&bze bcc� (Person signing on behalf of Group)
v
:
••vvv vvvuv uv uvvvvvuvvvvvvvvv vvvv svvvvvvvvu vev •vvv vvuvuvv•vvvvvvvvvvvu vvvv vvv
,,.F,.�co�rt` Collins
IN WITNESS WHEREOF, the parties hereto have executed this Agreement this day of , 20
GROUP
Poudre Valley Health System Foundation
(Name of Group)
Name:: Ruth Lytle-Barnaby
Title: Executive Director
Date: in' zS' If
Coordinatof I
Address: PVHS Healthier Communities Coalition
1024 South Lemay Avenue
Fort Collins, CO 80524
Phone: (970)495-7503
And By'
Alternate Coordinator
Address: PVHS Foundation
2315 East Harmony Road, Suite 200
Fort Collins, CO 80528
Phone: (970)237-7404
CITY OF FORT COLLINS
By
J es B. O'Neill II, CPPO
Director of Purc asin and Risk Management
Date:
ATTEST:
City Clerk
APPROVED AS TO LEGAL FORM:
0
Deputy City Attorney
w vvvvvvvvvvvvvvvvv•vvovvvvvvvvvvvvvvvvvvvvvvvvvvvvvv..vvv.v..v..vv...vv.vv...v.vv.•
Alcoholic Beverages Disclaimer
• v
I agree that grant funds will not be used directly or indirectly to purchase alcoholic beverages. e
I further agree that I will assume all responsibility and potential liability associated with the serving of alcoholic :
bever s in connection with any Project activities.
: By. e Lt. C&bze bcc� (Person signing on behalf of Group)
v
:
••vvv vvvuv uv uvvvvvuvvvvvvvvv vvvv svvvvvvvvu vev •vvv vvuvuvv•vvvvvvvvvvvu vvvv vvv
,,.F,.�co�rt` Collins
N(eocqrn
NEW VERSION - UPDATED 514111
LAIR 2011 Grant Application Fort Collin
Project Coordinator Name: Kim She Healthier Communities Coalition Day Phone.(970) 495-7503
Group Name:
Street Address;1024 South Lemay Avenue Fort Collins, CO Zip: 80524
Email Address: 'krs4 aOpvhs.org
Project/Event lProgramTitle: Bicycle and Pedestrian Education Coalition (BPEC)
Amount Applying for: $972. (Requested for CAIR Funding only, excluding value in other contributions)
Group Name: Poudre Valley Health System
1) Project Coordinator Name: Kim Sharpe HCC coordinator, PVHS (same contact info)
2) Project Alternate Coordinator Name: Susannah Wright grants coordinator, PVHS Foundation
Day Phone: (970) 237-7404 Address: 2315 East Harmony Road Suite 200, Fort Collins, CO Zip: 80528
Email: smw2anpyh&org
ProjectlEvent: Description
Federal. Bicycle Commuter Benefit Program.: :
2. Requested CAIR Funding (from Budget worksheet):. 972
Other funding contributions (from Budget worksheet): 1 950
Project Total: M
N(eocqrn
NEW VERSION - UPDATED 514111
LAIR 2011 Grant Application Fort Collin
Project Coordinator Name: Kim She Healthier Communities Coalition Day Phone.(970) 495-7503
Group Name:
Street Address;1024 South Lemay Avenue Fort Collins, CO Zip: 80524
Email Address: 'krs4 aOpvhs.org
Project/Event lProgramTitle: Bicycle and Pedestrian Education Coalition (BPEC)
Amount Applying for: $972. (Requested for CAIR Funding only, excluding value in other contributions)
Group Name: Poudre Valley Health System
1) Project Coordinator Name: Kim Sharpe HCC coordinator, PVHS (same contact info)
2) Project Alternate Coordinator Name: Susannah Wright grants coordinator, PVHS Foundation
Day Phone: (970) 237-7404 Address: 2315 East Harmony Road Suite 200, Fort Collins, CO Zip: 80528
Email: smw2anpyh&org
ProjectlEvent: Description
Federal. Bicycle Commuter Benefit Program.: :
2. Requested CAIR Funding (from Budget worksheet):. 972
Other funding contributions (from Budget worksheet): 1 950
Project Total: M
NEW VERSION - UPDATED 514111
3. Please,describe how the project will contribute to improved air quality. Be as specific as
possible: City staff will use this information to quantify air pollution reduction potential: The Clean
instead of drive on 10% of work days (25 dayslvear) this project will keep 5,625 pounds of pollutants out of
the air. Please note this is a bare minimum estimate based on the direct impact of the spec ific:grant-funded
future as a result of this proiect.
4 :Please describe how the project will serve to increase citizen awareness. about air quality.issues,
City goals, andlor and actions that improve air quality: According to the Bureau of Transportation
Statistics Amedcans are increasingly concerned about the impact of transportation choices on quality of
life and are increasingly willing to consider bicycling as part of the solution Half of all Americans believe
presentations which will reach an additional 300 people annually. This proiect will also reacn spamsn-
speakinq community members The BPEC recently received a grant from the CSU Colorado Iniury Control
Research Center to provide bicycle safety presentations in Spanish in partnership with the Vida Sana
® [ill) agree 4D paa-i; c`t;?Pk 'i„ r-cPhtq video Co/- n1i
-t, in ; n M r-v� CAT TZ Zird i e6f,
NEW VERSION - UPDATED 514111
3. Please,describe how the project will contribute to improved air quality. Be as specific as
possible: City staff will use this information to quantify air pollution reduction potential: The Clean
instead of drive on 10% of work days (25 dayslvear) this project will keep 5,625 pounds of pollutants out of
the air. Please note this is a bare minimum estimate based on the direct impact of the spec ific:grant-funded
future as a result of this proiect.
4 :Please describe how the project will serve to increase citizen awareness. about air quality.issues,
City goals, andlor and actions that improve air quality: According to the Bureau of Transportation
Statistics Amedcans are increasingly concerned about the impact of transportation choices on quality of
life and are increasingly willing to consider bicycling as part of the solution Half of all Americans believe
presentations which will reach an additional 300 people annually. This proiect will also reacn spamsn-
speakinq community members The BPEC recently received a grant from the CSU Colorado Iniury Control
Research Center to provide bicycle safety presentations in Spanish in partnership with the Vida Sana
® [ill) agree 4D paa-i; c`t;?Pk 'i„ r-cPhtq video Co/- n1i
-t, in ; n M r-v� CAT TZ Zird i e6f,
NEW VERSION' UPDATED 514111
5. Please briell . describe any other environmental, social or economic impacts of the project: The
6. Estimated number of citizensihouseholds who benefit from proposal: ILO citizens 150 Househc
Please describe the assumption'.you made in these estimates: Me will reach approAknateiy 150
-- - - . „1---- -
7. How many people will be involved in the planning and implementation of the projectlevent?6_8
people (HCC coordinator, 5-7 volunteer BPEC oresenters)
8. Please describe the -timetable and plans for implementing, completing; and evaluating the event:
of December.
9. Is there any on -going maintenance required for this projectlevent? . No _X Yes
If ves please describe: One of BPEC's primary activities is to provide educational presentations abo
air pollution through bicycle riding Currently there are 16 certified League uvciing instructors in t-or[
Collins plus dozens of additional community members who have been trained by BPEC to deliver
10. Will the projectiprogram be held on private property? X No _Yes.
Property Owner Signature
Applicant Street Address _
Date
Zip _
Please complete the budget sheet on the following page.
NEW VERSION' UPDATED 514111
5. Please briell . describe any other environmental, social or economic impacts of the project: The
6. Estimated number of citizensihouseholds who benefit from proposal: ILO citizens 150 Househc
Please describe the assumption'.you made in these estimates: Me will reach approAknateiy 150
-- - - . „1---- -
7. How many people will be involved in the planning and implementation of the projectlevent?6_8
people (HCC coordinator, 5-7 volunteer BPEC oresenters)
8. Please describe the -timetable and plans for implementing, completing; and evaluating the event:
of December.
9. Is there any on -going maintenance required for this projectlevent? . No _X Yes
If ves please describe: One of BPEC's primary activities is to provide educational presentations abo
air pollution through bicycle riding Currently there are 16 certified League uvciing instructors in t-or[
Collins plus dozens of additional community members who have been trained by BPEC to deliver
10. Will the projectiprogram be held on private property? X No _Yes.
Property Owner Signature
Applicant Street Address _
Date
Zip _
Please complete the budget sheet on the following page.
NEW VERSION - UPDATED 5/4111
EventlProject Budget Qtypf
Please complete this budget sheet Include a detailed description and cost of FlirtCollins
each item. If the cost is recouped in a donation, please indicate that and name / N,
the donor. If:.you are receiving In. kind or actual monetary donations please
indirafp which itamc will ho dnnntpd and their estimated vAup. in the 9`riaht-hand columns -
- CAIRFUND
Donation:
Donation:
Value i
From whom
Bost To
(including items,
Item Description Purchase
s ace, and cash)
Presenter Stipends - $50 per presenter x 12
presentations to honor volunteer commitment to
training, preparation, travel, and presentation time. I $6110
$0
Materials/Supplies - incentive items to support and
u
encourage presentation attendees to ride bicycles, i.e.
bike lights, reflective stickers _ $150
_$500 1
BPEC members
Presenter Training -compensation for trainer t0
I
prepare, travel, and train presenters in air quality
issues and how biking can reduce air pollution $150
_ $0 ±0
Project Coordinator- Kim Sharpe will spend approx. t__
25 hours x $30 per hour to oversee and implement
project track results, and report to City of Fort Collins L, $0,
- . $750 PVHS
Printing/Copying - PVHS will pay for all needed
printing and copying $D
_ __._ $100
PVHS
Presentation Space - host sites will provide space for _
presentations free of charge, estimated value of room I
rental is $50 per presentation x 12 presentations j $0
$600
Host sites
I Subtotal $900
_.:_ $f,950
--- --
-
PVHSF Indirect Costs 8%$72
$0
j
i TOTALS' $972
$1;950
;
TOTAL GRANT AMOUNT: s972 requested from CAIR FUND + $1950 Donation Value = $2 922 Prolect Cost
Volunteers
6 Estimated Number of Volunteers
8 Average number of hours each volunteer contributes
48 TOTALVOLUNTEER HOURS
An evaluation form and return envelope will be mailed to you after your event. Please return the evaluation and any
associated receipts within two weeks of receiving the evaluation.
Office use 0
Air Pollution Reduction -
Awareness Raising
Other Environmental, social and/or economic benefits
Matching donations & volunteer hours contributed to event
Likelihood of completion
-innovation
Comments
1 2-345
1 2 3.4 5
1 2 3 4 5
1'2345
1 2 3 4 5
1 2 3 4 5
NEW VERSION - UPDATED 5/4111
EventlProject Budget Qtypf
Please complete this budget sheet Include a detailed description and cost of FlirtCollins
each item. If the cost is recouped in a donation, please indicate that and name / N,
the donor. If:.you are receiving In. kind or actual monetary donations please
indirafp which itamc will ho dnnntpd and their estimated vAup. in the 9`riaht-hand columns -
- CAIRFUND
Donation:
Donation:
Value i
From whom
Bost To
(including items,
Item Description Purchase
s ace, and cash)
Presenter Stipends - $50 per presenter x 12
presentations to honor volunteer commitment to
training, preparation, travel, and presentation time. I $6110
$0
Materials/Supplies - incentive items to support and
u
encourage presentation attendees to ride bicycles, i.e.
bike lights, reflective stickers _ $150
_$500 1
BPEC members
Presenter Training -compensation for trainer t0
I
prepare, travel, and train presenters in air quality
issues and how biking can reduce air pollution $150
_ $0 ±0
Project Coordinator- Kim Sharpe will spend approx. t__
25 hours x $30 per hour to oversee and implement
project track results, and report to City of Fort Collins L, $0,
- . $750 PVHS
Printing/Copying - PVHS will pay for all needed
printing and copying $D
_ __._ $100
PVHS
Presentation Space - host sites will provide space for _
presentations free of charge, estimated value of room I
rental is $50 per presentation x 12 presentations j $0
$600
Host sites
I Subtotal $900
_.:_ $f,950
--- --
-
PVHSF Indirect Costs 8%$72
$0
j
i TOTALS' $972
$1;950
;
TOTAL GRANT AMOUNT: s972 requested from CAIR FUND + $1950 Donation Value = $2 922 Prolect Cost
Volunteers
6 Estimated Number of Volunteers
8 Average number of hours each volunteer contributes
48 TOTALVOLUNTEER HOURS
An evaluation form and return envelope will be mailed to you after your event. Please return the evaluation and any
associated receipts within two weeks of receiving the evaluation.
Office use 0
Air Pollution Reduction -
Awareness Raising
Other Environmental, social and/or economic benefits
Matching donations & volunteer hours contributed to event
Likelihood of completion
-innovation
Comments
1 2-345
1 2 3.4 5
1 2 3 4 5
1'2345
1 2 3 4 5
1 2 3 4 5
=orm W-9
Request for Taxpayer
Give form to the
Rev. October 2007)
Identification Number and Certification
requester. Do not
>partment of the Treasury
SeDd t0 the IRS.
nternal Revenue Service
Name (as shown on your income tax return)
m
Poudre Valley Health System Foundation
Business name, if different from above
a
dba Medical Center of the Rockies Foundation dba Poudre Valley Hospital Foundation
0
nc
Check appropriate box: ❑ Individual/3ole proprietor ® Corporation ❑ Partnership
Exempt
B`.20
❑ Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) ►-------
payee
`p
❑ Other (see instructions) ►
c
Address (number, street, and apt. or suite no.)
Requester's name and address (optional)
i o
2315 East Harmony Road, Suite 200
City, state, and ZIP code
rn
Fort Collins, CO 80528
m
List account number(s) here (optional)
N
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid
Social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
or
Note. If the account is In more than one name, see the chart on page 4 for guidelines on whose
Employer identification number
number to enter.
74 I 1894581
Under penalties of perjury, I certify that:
t. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. See the instructions on page 4.
Sign Signature of
Here I U.S. person ► Date P. 4/12/11
General Instructions
Section references are to the Internal Revenue Code unless
otherwise noted.
Purpose of Form
A person who is required to file an information return with the
IRS must obtain your correct taxpayer identification number (TIN)
to report, for example, income paid to you, real estate
transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a
resident alien), to provide your correct TIN to the person
requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S.
exempt payee. If applicable, you are also certifying that as a
U.S. person, your allocable share of any partnership income from
a U.S. trade or business is not subject to the withholding tax on
foreign partners' share of effectively connected income.
Note. If a requester gives you a form other than Form W-9 to
request your TIN, you must use the requester's form if it is
substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United
States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section
301.7701-7).
Special rules for partnerships. Partnerships that conduct a
trade or business in the United States are generally required to
pay a withholding tax on any foreign partners' share of income
from such business. Further, in certain cases where a Form W-9
has not been received, a partnership is required to presume that
a partner is a foreign person, and pay the withholding tax.
Therefore, if you are a U.S. person that is a partner in a
partnership conducting a trade or business in the United States,
provide Form W-9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership
income.
The person who gives Form W-9 to the partnership for
purposes of establishing its U.S. status and avoiding withholding
on its allocable share of net income from the partnership
conducting a trade or business in the United States is in the
following cases:
• The U.S. owner of a disregarded entity and not the entity,
Cal. No. 10231x Form W-9 (Rev. 10-2007)
=orm W-9
Request for Taxpayer
Give form to the
Rev. October 2007)
Identification Number and Certification
requester. Do not
>partment of the Treasury
SeDd t0 the IRS.
nternal Revenue Service
Name (as shown on your income tax return)
m
Poudre Valley Health System Foundation
Business name, if different from above
a
dba Medical Center of the Rockies Foundation dba Poudre Valley Hospital Foundation
0
nc
Check appropriate box: ❑ Individual/3ole proprietor ® Corporation ❑ Partnership
Exempt
B`.20
❑ Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) ►-------
payee
`p
❑ Other (see instructions) ►
c
Address (number, street, and apt. or suite no.)
Requester's name and address (optional)
i o
2315 East Harmony Road, Suite 200
City, state, and ZIP code
rn
Fort Collins, CO 80528
m
List account number(s) here (optional)
N
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid
Social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
or
Note. If the account is In more than one name, see the chart on page 4 for guidelines on whose
Employer identification number
number to enter.
74 I 1894581
Under penalties of perjury, I certify that:
t. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. See the instructions on page 4.
Sign Signature of
Here I U.S. person ► Date P. 4/12/11
General Instructions
Section references are to the Internal Revenue Code unless
otherwise noted.
Purpose of Form
A person who is required to file an information return with the
IRS must obtain your correct taxpayer identification number (TIN)
to report, for example, income paid to you, real estate
transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or
contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a
resident alien), to provide your correct TIN to the person
requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S.
exempt payee. If applicable, you are also certifying that as a
U.S. person, your allocable share of any partnership income from
a U.S. trade or business is not subject to the withholding tax on
foreign partners' share of effectively connected income.
Note. If a requester gives you a form other than Form W-9 to
request your TIN, you must use the requester's form if it is
substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United
States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section
301.7701-7).
Special rules for partnerships. Partnerships that conduct a
trade or business in the United States are generally required to
pay a withholding tax on any foreign partners' share of income
from such business. Further, in certain cases where a Form W-9
has not been received, a partnership is required to presume that
a partner is a foreign person, and pay the withholding tax.
Therefore, if you are a U.S. person that is a partner in a
partnership conducting a trade or business in the United States,
provide Form W-9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership
income.
The person who gives Form W-9 to the partnership for
purposes of establishing its U.S. status and avoiding withholding
on its allocable share of net income from the partnership
conducting a trade or business in the United States is in the
following cases:
• The U.S. owner of a disregarded entity and not the entity,
Cal. No. 10231x Form W-9 (Rev. 10-2007)
Form W-9 (Rev. 10-2007)
• The U.S. grantor or other owner of a grantor trust and not the
trust, and
• The U.S. trust (other than a grantor trust) and not the
beneficiaries of the trust.
Foreign person. If you are a foreign person, do not use Form
W-9. Instead, use the appropriate Form W-8 (see Publication
515, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
Nonresident alien who becomes a resident alien. Generally,
only a nonresident alien individual may use the terms of a tax
treaty to reduce or eliminate U.S. tax on certain types of income.
However, most tax treaties contain a provision known as a
"saving clause." Exceptions specified in the saving clause may
permit an exemption from tax to continue for certain types of
income even after the payee has otherwise become a U.S.
resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an
exemption from U.S. tax on certain types of income, you must
attach a statement to Form W-9 that specifies the following five
items:
1. The treaty country. Generally, this must be the same treaty
under which you claimed exemption from tax as a nonresident
alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax under the
terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows
an exemption from tax for scholarship income received by a
Chinese student temporarily present in the United States. Under
U.S. law, this student will become a resident alien for tax
purposes if his or her stay in the United States exceeds 5
calendar years. However, paragraph 2 of the first Protocol to the
U.S.-China treaty (dated April 30, 1984) allows the provisions of
Article 20 to continue to apply even after the Chinese student
becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of
the first protocol) and is relying on this exception to claim an
exemption from tax on his or her scholarship or fellowship
income would attach to Form W-9 a statement that includes the
information described above to support that exemption.
If you are a nonresident alien or a foreign entity not subject to
backup withholding, give the requester the appropriate
completed Form W-8.
What is backup withholding? Persons making certain payments
to you must under certain conditions withhold and pay to the
IRS 28% of such payments. This is called "backup withholding."
Payments that may be subject to backup withholding include
interest, tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay, and
certain payments from fishing boat operators. Real estate
transactions are not subject to backup withholding.
You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make the
proper certifications, and report all your taxable interest and
dividends on your tax return.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part II
instructions on page 3 for details),
3. The IRS tells the requester that you furnished an incorrect
TIN.
4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or
S. You do not certify to the requester that you are not subject
to backup withholding under 4 above (for reportable interest and
dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Instructions for the Requester of Form W-9.
Also see Special rules for partnerships on page 1.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such
failure unless your failure is due to reasonable cause and not to
willful neglect.
Civil penalty for false information with respect to
withholding. If you make a false statement with no reasonable
basis that results in no backup withholding, you are subject to a
$500 penalty.
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
Name
If you are an individual, you must generally enter the name
shown on your income tax return. However, if you have changed
your last name, for instance, due to marriage without informing
the Social Security Administration of the name change, enter
your first name, the last name shown on your social security
card, and your new last name.
If the account is in joint names, list first, and then circle, the
name of the person or entity whose number you entered in Part 1
of the form.
Sole proprietor. Enter your individual name as shown on your
income tax return on the "Name" line. You may enter your
business, trade, or "doing business as (DBA)" name on the
"Business name" line.
Limited liability company (LLC). Check the "Limited liability
company" box only and enter the appropriate code for the tax
classification ("D" for disregarded entity, "C" for corporation, "P"
for partnership) in the space provided.
For a single -member LLC (including a foreign LLC with a
domestic owner) that is disregarded as an entity separate from
its owner under Regulations section 301.7701-3, enter the
owner's name on the "Name" line. Enter the LLC's name on the
"Business name" line.
For an LLC classified as a partnership or a corporation, enter
the LLC's name on the "Name" line and any business, trade, or
IDEA name on the "Business name" line.
Other entities. Enter your business name as shown on required
federal tax documents on the "Name" line. This name should
match the name shown on the charter or other legal document
creating the entity. You may enter any business, trade, or DBA
name on the "Business name" line.
Note. You are requested to check the appropriate box for your
status (individual/sole proprietor, corporation, etc.).
Exempt Payee
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status,
then check the "Exempt payee" box in the line following the
business name, sign and date the form.
Form W-9 (Rev. 10-2007)
• The U.S. grantor or other owner of a grantor trust and not the
trust, and
• The U.S. trust (other than a grantor trust) and not the
beneficiaries of the trust.
Foreign person. If you are a foreign person, do not use Form
W-9. Instead, use the appropriate Form W-8 (see Publication
515, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
Nonresident alien who becomes a resident alien. Generally,
only a nonresident alien individual may use the terms of a tax
treaty to reduce or eliminate U.S. tax on certain types of income.
However, most tax treaties contain a provision known as a
"saving clause." Exceptions specified in the saving clause may
permit an exemption from tax to continue for certain types of
income even after the payee has otherwise become a U.S.
resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an
exemption from U.S. tax on certain types of income, you must
attach a statement to Form W-9 that specifies the following five
items:
1. The treaty country. Generally, this must be the same treaty
under which you claimed exemption from tax as a nonresident
alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax under the
terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows
an exemption from tax for scholarship income received by a
Chinese student temporarily present in the United States. Under
U.S. law, this student will become a resident alien for tax
purposes if his or her stay in the United States exceeds 5
calendar years. However, paragraph 2 of the first Protocol to the
U.S.-China treaty (dated April 30, 1984) allows the provisions of
Article 20 to continue to apply even after the Chinese student
becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of
the first protocol) and is relying on this exception to claim an
exemption from tax on his or her scholarship or fellowship
income would attach to Form W-9 a statement that includes the
information described above to support that exemption.
If you are a nonresident alien or a foreign entity not subject to
backup withholding, give the requester the appropriate
completed Form W-8.
What is backup withholding? Persons making certain payments
to you must under certain conditions withhold and pay to the
IRS 28% of such payments. This is called "backup withholding."
Payments that may be subject to backup withholding include
interest, tax-exempt interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay, and
certain payments from fishing boat operators. Real estate
transactions are not subject to backup withholding.
You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make the
proper certifications, and report all your taxable interest and
dividends on your tax return.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part II
instructions on page 3 for details),
3. The IRS tells the requester that you furnished an incorrect
TIN.
4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or
S. You do not certify to the requester that you are not subject
to backup withholding under 4 above (for reportable interest and
dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Instructions for the Requester of Form W-9.
Also see Special rules for partnerships on page 1.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such
failure unless your failure is due to reasonable cause and not to
willful neglect.
Civil penalty for false information with respect to
withholding. If you make a false statement with no reasonable
basis that results in no backup withholding, you are subject to a
$500 penalty.
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
Name
If you are an individual, you must generally enter the name
shown on your income tax return. However, if you have changed
your last name, for instance, due to marriage without informing
the Social Security Administration of the name change, enter
your first name, the last name shown on your social security
card, and your new last name.
If the account is in joint names, list first, and then circle, the
name of the person or entity whose number you entered in Part 1
of the form.
Sole proprietor. Enter your individual name as shown on your
income tax return on the "Name" line. You may enter your
business, trade, or "doing business as (DBA)" name on the
"Business name" line.
Limited liability company (LLC). Check the "Limited liability
company" box only and enter the appropriate code for the tax
classification ("D" for disregarded entity, "C" for corporation, "P"
for partnership) in the space provided.
For a single -member LLC (including a foreign LLC with a
domestic owner) that is disregarded as an entity separate from
its owner under Regulations section 301.7701-3, enter the
owner's name on the "Name" line. Enter the LLC's name on the
"Business name" line.
For an LLC classified as a partnership or a corporation, enter
the LLC's name on the "Name" line and any business, trade, or
IDEA name on the "Business name" line.
Other entities. Enter your business name as shown on required
federal tax documents on the "Name" line. This name should
match the name shown on the charter or other legal document
creating the entity. You may enter any business, trade, or DBA
name on the "Business name" line.
Note. You are requested to check the appropriate box for your
status (individual/sole proprietor, corporation, etc.).
Exempt Payee
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status,
then check the "Exempt payee" box in the line following the
business name, sign and date the form.