Ron Bush - IL
CITY OF TIGARD,OREGON
PERSONAL SERVICES AGREEMENT
THIS AGREEMENT made and entered into this 24 of November, 2008, by and between the CITY OF
TIGARD, a municipal corporation of the State of Oregon, hereinafter called City, and Ron Bush, P.E., P.L.S.,
hereinafter called Contractor.
RECITALS
City has need for the services of a company with a particular training, ability, knowledge, and experience
possessed by Contractor, and
City has determined that Contractor is qualified and capable of performing the professional services as City
does hereinafter require, under those terms and conditions set forth:
Therefore, the parties agree as follows:
SCOPE OF WORK
Contractor shall initiate services on 24 of November, 2008 upon receipt of City's notice to proceed, together
with an executed copy of this Agreement. Contractor agrees to complete work that is detailed in Exhibit A —
Scope of Work and by this reference made a part hereof.
EFFECTIVE DATE AND DURATION
This Agreement shall become effective upon 1 of December, 2008 and shall expire, unless otherwise terminated
or extended, on 1 of February, 2009. All work under this Agreement shall be completed prior to the expiration
of this Agreement.
COMPENSATION
City agrees to pay Contractor an amount not to exceed four thousand, eight hundred dollars ($4,800) annually
for performance of those services described in this Agreement. Payment will be made based on Contractor's
invoice, subject to the approval of Phil Nachbar, and .not more frequently than monthly. Payment shall be
payable within thirty (30) days from the date of receipt by the City.
CONTACT INFORMATION
All notices, bills, and payments shall be made in writing and may be given by personal delivery, mail, or fax.
Payments may be delivered by personal delivery, mail, or electronic transfer. The following addresses and
contacts shall be used to transmit notices, bills,payments, and other information:
Contact Manager for City: Contact Manager for Contractor:
City of Tigard Company: Ron Bush Surveyor
Attn: Phil Nachbar Attn: Ron Bush
13125 SW Hall Blvd., Tigard, Oregon 97223 Address: 16151 S.E. Bluff Road
Sandy, Oregon 97219
Phone: 503-639-4171 ext. 2557 Phone: (503) 329-8017
Fax: 503-684-7297 Fax: -
Email Address: phil@tigard-or.gov Email Address: ronbush@verizon.net
CONTRACTOR AS INDEPENDENT CONTRACTOR
Contractor acknowledges that for all purposes related to this Agreement, Contractor is and shall be deemed to be an
independent contractor as defined by ORS 670.600 and not an employee of City, shall not be entitled to benefits of
any kind to which an employee of City is entitled and shall be solely responsible for all payments and taxes
required by law. Furthermore, in the event that Contractor is found by a court of law or any administrative agency
to be an employee of City for any purpose, City shall be entitled to offset compensation due, or to demand
repayment of any amounts paid to Contractor under the terms of this Agreement, to the full extent of any benefits
or other remuneration Contractor receives (from City or third party) as a result of said finding and to the full extent
of any payments that City is required to make(to Contractor or to a third party)as a result of said finding.
Contractor acknowledges that for all purposes related to this Agreement, Contractor is not an officer, employee, or
agent of the City as those terms are used in ORS 30.265.
INDEMNIFICATION
City has relied upon the professional ability and training of Contractor as a material inducement to enter into this
Agreement. Contractor warrants that all its work will be performed in accordance with generally accepted
professional practices and standards as well as the requirements of applicable federal, state and local laws, it being
understood that acceptance of a contractor's work by City shall not operate as a waiver or release.
Contractor and City agree to indemnify and defend the other, and the other's officers, agents and employees and
hold them harmless from any and all liability, causes of action, claims, losses, damages,judgments or other costs or
expenses including attorney's fees and witness costs and (at both trial and appeal level, whether or not a trial or
appeal ever takes place) incurred by the party being indemnified resulting from the indemnifying party's acts (or
failure to act when action is appropriate) that may be asserted by any person or entity which in any way arise from
or relate to this Agreement or the performance of obligations under this agreement, except liability arising out of
the sole negligence of the party being indemnified. The indemnification by Contractor of the City shall also cover
claims brought against the City under state or federal worker's compensation laws. If any aspect of this indemnity
shall be found to be illegal or invalid for any reason whatsoever, such illegality or invalidity shall not affect the
Validity of the remainder of this indemnification.
INSURANCE
Contractor shall maintain insurance acceptable to City in full force and effect throughout the term of this contract.
Such insurance shall cover all risks arising directly or indirectly out of Contractor's activities or work hereunder.
The policy or policies of insurance maintained by the Contractor shall provide at least the following limits and
coverages:
a. Commercial General Liability Insurance
Contractor shall obtain, at contractor's expense, and keep in effect during the term of this contract,,
Comprehensive General Liability Insurance covering Bodily Injury and Property Damage on an
"occurrence" form (1996 ISO or equivalent). This coverage shall include Contractual Liability
insurance for the indemnity provided under this contract. The following insurance will be carried:
Coverage Limit
General Aggregate 1,000,000
Products-Completed Operations Aggregate 1,000,000
Personal & Advertising Injury 1,000,000
Each Occurrence 1,000,000
Fire Damage (any one fire) 50,000
Medical Expense (any one person) 5,000
b. Business Automobile Liability Insurance
If Contractor will be delivering the goods, Contractor shall provide City a certificate indicating that
Contractor has business automobile liability coverage for all owned, hired, and non-owned vehicles. The
Combined Single Limit per occurrence shall not be less than$1,000,000. Said insurance shall name City as
an additional insured and shall require written notice to City thirty (30) days in advance of cancellation. If
Contractor hires a carrier to make delivery, Contractor shall ensure that said carrier complies with this
paragraph.
c. Workers' Compensation Insurance
The Contractor and all employers providing work, labor or materials under this Contract that are either
subject employers under the Oregon Workers' Compensation Law and shall comply with ORS 656.017,
which requires them to provide workers' compensation coverage that satisfies Oregon law for all their
subject workers or employers that are exempt under ORS 656.126. Out-of-state employers must provide
Oregon workers' compensation coverage for their workers who work at a single location within Oregon for
more than 30 days in a calendar year. Contractors who perform work without the assistance or labor of any
employee need not obtain such coverage. This shall include Employer's Liability Insurance with coverage
limits of not less than$500,000 each accident.
d. Insurance Carrier Rating
Coverages provided by the Contractor must be underwritten by an insurance company deemed
acceptable by the City. The City reserves the right to reject all or any insurance carrier(s) with an
unacceptable financial rating.
e. Certificates of Insurance
As evidence of the insurance coverage required by the contract, the Contractor shall furnish a Certificate
of Insurance to the City. No contract shall be effected until the required certificates have been received
and approved by the City.
The procuring of such required insurance shall not be construed to limit contractor's liability hereunder.
Notwithstanding said insurance, Contractor shall be obligated for the total amount of any damage, injury, or loss
caused by negligence or neglect connected with this contract.
TERMINATION
The parties agree that any decision by either party to terminate this Agreement before 15t of February, 2009
shall be accompanied by sixty (60) days written notice to the other party prior to the date termination would
take effect. There shall be no penalty for early termination. If City terminates the contract pursuant to this
paragraph, it shall pay Contractor for services rendered prorated to the date of termination.
AGREEMENT MODIFICATIONS
Modifications to this Agreement are valid only if made in writing and signed by all parties.
OWNERSHIP OF WORK PRODUCT
City shall be the owner of and shall be entitled to possession of any and all work products of Contractor which
result from this Agreement, including any computations, plans, correspondence or pertinent data and information
gathered by or computed by Contractor prior to termination of this Agreement by Contractor or upon completion of
the work pursuant to this Agreement.
GOVERNING LAW
Contractor shall comply with all applicable federal, state and local laws; and rules and regulations on non-
discrimination in employment because of race, color, ancestry, national origin, religion, sex, marital status, age,
medical condition or disability. The provisions of this Agreement shall be construed in accordance with the
provisions of the laws of the State of Oregon. All provisions required by ORS Chapter 279 to be included in a
contract of this type are incorporated into this Agreement as though fully set forth herein. Any action or suits
involving any question arising under this Agreement must be brought in the appropriate court of the State of
Oregon.
CONDITIONS OF SUPPLYING A PUBLIC AGENCY
Where applicable, Contractor must make payment promptly as due to persons supplying Contractor labor or materials
for the execution of the work provided by this order. Contractor must pay all contributions or amounts due from
Contractor to the Industrial Accident Fund incurred in the performance of this order. Contractor shall not permit any
lien or claim to be filed or prosecuted against Buyer or any subdivision of City on account of any labor or material to be
furnished. Contractor further agrees to pay to the Department of Revenue all sums withheld from employees pursuant
to ORS 316.167.
COMPLETE AGREEMENT
This Agreement and attached exhibit constitutes the entire Agreement between the parties. No waiver, consent,
modification, or change of terms of this Agreement shall bind either party unless in writing and signed by both
parties. Such waiver, consent, modification, or change if made, shall be effective only in specific instances and for
the specific purpose given. There are no understandings, agreements, or representations, oral or written, not
specified herein regarding this Agreement. Contractor, by the signature of its authorized representative, hereby
acknowledges that he/she has read this Agreement, understands it and agrees to be bound by its terms and
conditions.
IN WITNESS WHEREOF, City has caused this Agreement to be executed by its duly authorized undersigned
officer and Contractor has executed this Agreement on the date hereinabove first written.
CITY OF G }CONTRACTOR
��G ! 0"-
By: A thorized City staff y: Authorized Agent of Contractor
Aw �9 �� !� pec
Date Date
sil
Exhibit A
,., Scope of Work
A'i
a
L'
•f
I
.10 _
Ben Johnson October 9, 2008
Walker Macy
I I I SW Oak, Suite 200
Portland, OR 97204
Ronald A. Bush
16151 S.E. Bluff Road
Sandy, Oregon 97219
RE: Proposal-Design Survey-Fanno Creek, City of Tigard
Thank you for providing me with the opportunity to propose on this project. I am acquainted
with the area and have reviewed the information you have provided. I have prepared a proposal
based on that knowledge and information.
Below is a description of the work expected to be performed for the different areas that you have
requested additional information to be included in the base map.
Area A—The diagram shows the area on the westerly side of Fanno Creek just South of Main
Street. The work would include collecting data at the corners of the building in this location as
well as additional ground shots, fence corners, gravel edges, sidewalks, curbs and asphalt to
complete the site drawing for the tax lot. In the written note you also said that you would want
data to the centerline of Main Street and points on the buildings on both sides of the creek. I will
collect that data as well. Field Crew Time—4 hours @ $1501hour=600.00
Area B —An additional 50 feet of the Westerly end of SW Ash Street. I will collect the data you
are requesting between the right-of-way lines including the driveway entering form the
southeast. Field Crew Time— 1 hour @ $150/hour= $150.00
Area C —All data within the boundaries of the Cities Publics Works Yard. This will include all
visible natural and man made features including trees 6" and larger ABH. Field Crew Time— 10
hour @ $150/hour=$1500.00
Area D—All trees that are 6" and larger ABH. Field Crew Time—0 hour @ $1501hour=0
Area E—Your request was to "Survey City Hall Property to Top of Bank". This has been done
and break-lines exist in the surface defining the top of bank. The top of bank location is defined
by a 3-D-Polyline on its own layer within the drawing. I can collect additional data beyond the
top and include that data in the new surface to show the contours extending to the buildings and
beyond if you would like. The cost of that additional area will depend on the limits of what you
would like to have included. Field Crew Time—2 hour @ $150/hour= $300.00
Area F— Survey to the Centerline of Hall Blvd including curb and sidewalk along the eastern
boundary of the project. Field Crew Time—2 hour @ $150/hour= $300.00
Area G—Survey the City owned parcel at the southeast corner of the project. This will include
all above grade manmade and natural features, grade brakes and all trees 6" and larger ABH.
For this site I will also call the one-call number and have utilities located. The utilities on the site
may not be located because of ownership change at the property line to private in most cases. I
am not sure how the private "on-site"utilities will be located but will tie all features such as
meters, cleanouts and exposed pipes/conduits to assist in the location of the facilities. Field
Crew Time—8 hour @ $150/hour=$1200.00
MAP PREPARATION—To modify the base map the entire surface will be effected. Additional
point data and break-lines will be included. The base map will be amended and submitted for
your review. I will make modifications as called for to meet the intent of the proposal.
Technician Time— 10 hour @ $75/hour= $750.00
Proposed Cost to perform work—$4,800.00
If you have any questions please call me at(cell) (503) 329-8017, (home/office) (503) 668-8265,
(fax) (503) 668-0528. My e-mail address is ronbush@verizon.net. I appreciate this opportunity to
provide this proposal to you and look forward to working with you on this project.
RONALD A. BUSH, P.E., P.L.S.
Job Number 08-59
From:Dana Gamble At:Western Slates Insurance Agency FaxlD:Western States Insur To:Ron Bush Date:12/1162M 09:20 AM Page:2 of 3
DATE(MM7DDMhY)
ACORD_ CERTIFICATE OF LIABILITY INSURANCE OP ID DIA
RONBDA 12/08/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Western States - Cottage Grove HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
339 Pacific Highway South ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Cottage Grove OR 97424
Phone:S41-942-0555 Fax:541-942-9860 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A- The Hartford Insurance
INSURER B: American States of Texas
Ron Bush Engineering and INSURER C. Continental Casualty Co.
Surveying P
16151 Blu#f Rd INSURER D
Sandy OR 97055
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED HN&D ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
MN U1. POLICY EFFECTIVE POLICY EXPLKATK)
LIR SRC TYPE OF INSURANCE POLICY NUMBER DATE(MMATDIYY) DATE(MMATDIYY) LIM
GENERAL LIABILRY EACH OCCURRENCE s2,000,000
A X COMMERCIAL GENERAL LIABILITY 52SBALU9245 08/11/08 08/11/09 PREMISES(Eev�wa>ce) $300,000
CLAIMS MADE NJ OCCUR MED EXP(Any one person) $10,000
PERSONAL 8 ADV INJURY s2,000,000
GENERAL AGGREGATE s4,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000
Xj POLICY M PER& LOC
AUTOMOBLE LIABILITY
COMBINED SINGLE LIMIT $1,000,000
B ANY AUTO 04CC2203361 12/10/08 12/10/09 (Eaeccldert)
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per person) ;
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS
(Per acciderd) :
PROPERTY DAMAGE ;
(Per accident)
GARAGE LIABRM AUTO ONLY-EA ACCIDENT ;
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG S
EXCESSI MBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
s
DEDUCTIBLE t
RETENTION t $
WORKERS COMPENSATION AND X TORY LIMBS ER
EMPLOYERS•LWBam
A ANY PROPRIETORIPARTNEWE:CECUTIVE 52WECPQ3769 07/27/08 07/27/09 E.L.EACH ACCIDENT 1500,000
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000
If yes,describe under
SPECIAL PROVISIONS bei E.L.DISEASE-POLICY LIMIT [$500,000
OTHER
C Professional SM88275674 09/25/07 09/25/10 Per Claim 1,000,000
Liability r ate 2,000,000
DESCRFnON OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS
Engineers & Engineering Services/Scheduled Autos: 2004 Chev 1500 PU VIN#
1GCEK19T04E200582 & 2003 Chev Venture VIN#lG1?DX03E23D190568
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRA71ON
DATE THEREOF,THE ISSUING INSURER WLL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FALURE TO DO SO SHALL
City of Tigard IMPOSE NO OBLIGATION OR LIABLTTY OF ANY KIND UPON THE MURER ITS AGENTS OR
13125 SW Hall Blvd REPRESENTATIVES
Tigard OR 97223 SAnvl,,,,
ACORD 25(2001108) 0 ACORD CORPORATION 1988
From:Dana Gamble At:Weestern States Insurance Agency FaxIDr Western States Insur To:Ron Bush Date:12(81200a 09:20 AM Page:3 of 3
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer; and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25(2001108)
Ben Johnson October 9, 2008
Walker Macy
111 SW Oak, Suite 200
Portland, OR 97204
Ronald A. Bush
16151 S.E. Bluff Road
Sandy, Oregon 97219
RE: Proposal-Design Survey-Fanno Creek, City of Tigard
Thank you for providing me with the opportunity to propose on this project. I am acquainted
with the area and have reviewed the information you have provided. I have prepared a proposal
based on that knowledge and information.
Below is a description of the work expected to be performed for the different areas that you have
requested additional information to be included in the base map.
Area A—The diagram shows the area on the westerly side of Fanno Creek just South of Main
Street. The work would include Collecting data at the corners of the building in this location as
well as additional ground shots, fence corners, gravel edges, sidewalks, curbs and asphalt to
complete the site drawing for the tax lot. In the written note you also said that you would want
data to the centerline of Main Street and points on the buildings on both sides of the creek. I will
collect that data as well. Field Crew Time—4 hours @ $150/hour= 600.00
Area B —An additional 50 feet of the Westerly end of SW Ash Street. I will collect the data you
are requesting between the right-of-way lines including the driveway entering form the
southeast. Field Crew Time— 1 hour @ $150/hour= $150.00
Area C—All data within the boundaries of the Cities Publics Works Yard. This will include all
visible natural and man made features including trees 6" and larger ABH. Field Crew Time— 10
hour @ $150/hour= $1500.00
Area D—All trees that are 6"and larger ABH. Field Crew Time—0 hour @ $150/hour=0
Area E—Your request was to "Survey City Hall Property to Top of Bank". This has been done
and break-lines exist in the surface defining the top of bank. The top of bank location is defined
by a 3-D-Polyline on its own layer within the drawing. I can collect additional data beyond the
top and include that data in the new surface to show the contours extending to the buildings and
beyond if you would like. The cost of that additional area will depend on the limits of what you
would like to have included. Field Crew Time—2 hour @ $150/hour= $300.00
Area F— Survey to the Centerline of Hall Blvd including curb and sidewalk along the eastern
boundary of the project. Field Crew Time—2 hour @ $150/hour= $300.00
Area G— Survey the City owned parcel at the southeast corner of the project. This will include
all above grade manmade and natural features, grade brakes and all trees 6" and larger ABH.
For this site I will also call the one-call number and have utilities located. The utilities on the site
may not be located because of ownership change at the property line to private in most cases. I
am not sure how the private "on-site"utilities will be located but will tie all features such as
meters, cleanouts and exposed pipes/conduits to assist in the location of the facilities. Field
Crew Time—8 hour @ $150/hour= $1200.00
MAP PREPARATION—To modify the base map the entire surface will be effected. Additional
point data and break-lines will be included. The base map will be amended and submitted for
your review. I will make modifications as called for to meet the intent of the proposal.
Technician Time— 10 hour @ $75/hour= $750.00
Proposed Cost to perform work—$4,800.00
If you have any questions please call me at (cell) (503) 329-8017, (home/office) (503) 668-8265,
(fax) (503) 668-0528. My e-mail address is ronbush@verizon.net. I appreciate this opportunity to
provide this proposal to you and look forward to working with you on this project.
RONALD A. BUSH, P.E., P.L.S.
Job Number 08-59
t W l
r
co
r tl«k
o l
wY V AsSs0.4
wjT�
brjond park t
wr ��bl« lhlor�s hard TerrcS
raft,ears,
- �; l� L��+ $F} w �.n\,�• ei}�u- side,
•, , �� �.� f. / � a� c bank
��. Mdse � ,„P,r•�,CA
(0 09 sF.01
wr N a ll BtvA ib
�`�. �'' Corr► - N '[tees ovor 6
�� � �`�^•��': `�_ - =. Spot-Sb1�5� �uGtlK
tj
Loww
Nd m
Jerree Lewis December 6, 2008
City of Tigard
13125 SW Hall Blvd
Tigard, OR 97223
Ron Bush Engineering and Surveying, PC
Attn: Ron Bush
16151 SE Bluff Road
Sandy, OR 97055
RE: Contract for Surveying Services, Fanno Creek
Enclosed are the documents you sent me to be filled out and signed. They include:
Contract
W-9
Business License Form
I have also included a copy of my Certificate of Insurance. My insurance company is also
mailing you the Certificate.
If you have any questions please call me at(503) 329-8017 (cell) or office at(503) 668-
8265. My e-mail address is ronbush@verizon.net.
Ron Bush, P.E.,P.L.S.
Job no. 08-59
Form -9 Request for Taxpayer Give form to the
{Rev.October 200 i Identification Number and Certification requester. Do not
oenartm_at of the T;easury send to the IRS.
Internal Re-janye Sen+ce
Name lasstx v.n on yo income tax return)
Z o ti•."tj �Le S L
CL Business name,if different from above
o [ I�—cS1\ L�C I S °�Pyr t 1 lel Sllnf U g
C
p_r i Check appropriate box: ❑ Individuaole proprietor y� Cor o El Partnership r
mExempt
� Limited:: l; Corporation
ability copany.Enter the tax classification!0=disrenarded entity. ion• =parnersp)► ------_
C=corporatPthi
� i payee
= �J Ot`er jsee i:^striciio^s Ii
t
c mAddress;number,street;and apt.or suite no.
ae }) Requester's name and address iopt:onal)
10 S U R1 fL Fr- ,zed B City of Tigard
City.state:and ZIP code 13125 SW Hail Blvd
rn S 0157 0� 9 7 d� S Tigard OR 97223
Lst account number(s)here ioptional)
CD
Taxpayer Identification Number (TIN)
Enter your TIN in the approcriate box.The TI`' provided must match the na =e given on !!na ? to avoid i 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. I Q,�r
FMM Certification C�
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a)I am exempt from backup withholding, or(b)I have not been notified by the Internal
Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has
notified me that I am no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S. person(defined below).
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions,item 2 does not apply.
For mortgage interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement
arrangement(IRF), 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 CR—( Q
Here U.S.person 0, Date ► 6 D/ ,16U U
General Instructions Definition of a U.S. person. For federal tax purposes, you are
Section references are to the Internal Revenue Code unless considered a U.S. person if you are:
otherwise noted. • An individual who is a U.S.citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
Purpose of Form organized in the United States or under the laws of the United
A person who is required to file an information return with the States,
IRS must obtain your correct taxpayer identification number(TIN) • An estate(other than a foreign estate), or
to report, for example, income paid to you, real estate s A domestic trust(as defined in Regulations section
transactions, mortgage interest you paid,acquisition or 301,7701-7).
abandonment of secured property, cancellation of debt,or
contributions you made to an IRA. Special rules for partnerships. Partnerships that conduct a
trade or business in the United States are generally required to
Use Form W-9 only if you are a U.S.person(including a pay a:withholding tax on any foreign partners' share of income
resident alien), to provide your correct TIN to the person from such business. Further, in certain cases where a Form W-9
requesting it(the requester)and, when applicable,to: has not been received, a partnership is required to presume that
1. Certify that the TIN you are giving is correct(or you are a partner is a foreign person, and pay the withholding tax.
waiting for a number to be issued), Therefore, if you are a U.S. person that is a part,-ter in a
2.Certify that you are not subject to backup withhoidirtg, or partnership conducting a trade or business in the United States.
provide Form W-9 to the partnership to establish your U.S.
3. Claim exemption from backup withholding if you are a U.S. status and avoid withholding on your share of partnership
exempt payee. If applicable, you are also certifying that as a income.
U.S. person,your allocable share of any partnership income from The person who gives Form W-9 to the partnership for
a U.S- trade or business is not subject to the withholding tax on purposes of establishing its U.S- status and avoiding withholding
foreign partners' share of effectively connected income. on its allocable share of net income from the partnership
Note. If a requester gives you a form other than Form W-9 to conducting a trade or business in the United States is in the
request your TIN, you must use the requester's form if it is following cases:
substantially similar to this Form W-9. • The U.S. owner of a disregarded entity and not the entity,
Cat.No.10231X Form W-9 (Rev.10-2007)
Form l•'1-9(Rev. 10-200) Page 2
s The U.S. grantor or other owner of a grantor trust and not the 4. I Ile, IRS tells you that you are subject to backup
trust, and withholding because you did not report all your interest and
• The U.S. trust(other than a grantor trust)and not the dividends on your tax return (for reportable interest and
beneficiaries of the trust. dividends only), or
Foreign person. If you are a foreign person, do not use Form 5. You do not certify to the requester that you are not subject
W-9. Instead, use the appropriate Form lid-8(see Publication to backup withholding under 4 above (for reportable interest and
515, Withholding of Tax on Nonresident Aliens and Foreign dividend accounts opened after 1983 only).
Entities). Certain payees and payments are exempt from backup
Nonresident alien who becomes a resident alien.Generally, withholding. See the instructions below and the separate
m {
only a nonresident alien individual
may use the terms of a tax Instructions ,or the Requester of Form W-9.
treaty to reduce or eliminate U.S. tax on certain types of income. Also see Special rules for partnerships on page 1.
However, most tax treaties contain a provision known as a Penalties
clause." Exceptions specified in the saving clause may
permit an exemption from tax to continue for certain types of Failure to furnish TIN. If you fail to furnish your correct TIN to a
income even after the payee has otherwise become a U.S. requester, you are subject to a penalty of$50 for each such
resident alien for tax purposes, failure unless your failure is due to reasonable cause and not to
If you are a U.S. resident alien who is relying on an exception willful neglect.
contained in the saving clause of a tax treaty to claim an Civil penalty for false information with respect to
exemption from U.S. tax on certain types of income, you trust withholding. If you make a false statement with no reasonable
attach a statement to Form W-9 that specifies the following five basis that results in no backup withholding, you are subject to a
items: $500 penalty.
1.The treaty countrv. Generally, this must be the same treaty Criminal penalty for falsifying information.Willfully fa!sifyinq
under which you claimed exemption from tax as a nonresident certifications or affirmations may subject you to criminal
alien• penalties including fines and/or imprisonment.
2_The treaty article addressing the income. Misuse of TINS. if the requester discloses or uses TINS in
3.The article number(or location) in the tax treaty that violation of federal law, the requester may be subject to civil and
contains the saving clause and its exceptions. criminal penalties.
4.The type and amount of income that qualifies for the
exemption from tax. Specific Instructions
5. Sufficient facts to justify the exemption from tax under the Name
terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows If you are an individual, you must generally enter the name
an exemption from tax for scholarship income received by a shown on your income tax return. However, if you have changed
Chinese student temporarily present in the United States. Under your last name,for instance. due to marriage without informing
U.S. law, this student will become a resident alien for tax the Social Security Administration of the name change, enter
purposes if his or her stay in the United States exceeds 5 your first name,the last name shown on your social security
calendar years. However, paragraph 2 of the first Protocol to the card, and your new last name.
U.S.-China treaty(dated April 30, 1984)allows the provisions of If the account is in joint names, list first, and then circle, the
Article 20 to continue to apply even after the Chinese student name of the person or entity whose number you entered in Part I
becomes a resident alien of the United States. A Chinese of the form,
student who qualifies for this exception (under paragraph 2 of Sole proprietor. Enter your individual name as shown on your
the first protocol)and is relying on this exception to claim an income tax return on the"Name" line. You may enter your
exemption from tax on his or her scholarship or fellowship business, trade, or"doing business as(DBA)" name on the
income would attach to Form W-9 a statement that includes the "Business name" line.
information described above to support that exemption.
Limited liability company (LLC).Check the "Limited liability
If you are a nonresident alien or a foreign entity not subject to company" box only and enter the appropriate code for the tax
backup withholding, give the requester the appropriate classification ("D"for disregarded entity, "C"for corporation, "P"
completed Form W-8, for partnership)in the space provided.
What is backup withholding?Persons making certain payments For a single-member LLC(including a foreign LLC with a
to you must under certain conditions withhold and pay to the domestic owner)that is disregarded as an entity separate from
IRS 28% of such payments. This is called "backup withholding." its owner under Regulations section 301.7701-3, enter the
Payments that may be subject to backup withholding include owner's name on the "Name" line. Enter the LLC's name on the
interest, tax-exempt interest, dividends, broker and barter "Business name" line.
exchange transactions, rents, royalties, nonemployee pay, and
certain payments from fishing boat operators. Real estate For an LLC classified as a partnership or a corporation, enter
transactions are not subject to backup withholding. the LLC's name on the "Name" line and any business, trade, or
You will not be subject to backup withholding on payments DBA name on the"Business name" line.
you receive if you give the requester your correct TIN, make the Other entities. Enter your business name as shown on required
proper certifications, and report all your taxable interest and federal tax documents on the "Name" line. This name should
dividends on vour tax return. match the name shown on the charter or other legal document
creating the entity. You may enter any business, trade, or DBA
Payments you receive will be subject to backup name on the"3usrless narne" line.
withholding if: Note. You are requested to check the appropriate box for your
1. You do not furnish your TIN to the requester, status(individual/sole proprietor. corporation, etc.).
2. You do not certify your TIN when required (see the Part II Exempt Payee
instructions on page 3 for details),
3.The IRS tells the requester that you furnished an incorrect If you are exempt from backup withholding, enter your name as
TIN, described above and check the appropriate box for your status,
then check the"Exempt payee" box in the line following the
business narne, sign and date the form.
a
CITY OF TIGARD
CONTRACT SUMMARY FORM
(THIS MUST ACCOMPANYEACH CONTRACT BEFOREAUTHORIZATION SIGNATURE CAN BEACQUIRED)
Tide of Contract:Design Survey- Fanno Creek Contract#: (Assigned after execution
Contractor:Ron Bush Engineering and Surveying Total: $4800
Brief Overview: Design survey-Fanno Creek
Changes Made To
Boilerplate Contract.
Type of Contract: ❑ Purchase Agreement X Personal Service ❑ Construction ❑ Other
Start Date: 12/1/08 1 End Date: 2/1/09 LCRB Award Date: n/a
Contract Manager: Phil Nachbar Extension: 2556 Department: CD
Quotes/Bids/Proposals: COMPANY AMOUNT/ SCORE
Ron Bush Engineering and Surveying $4800
Department Comments:
Department Signature X0001/ Date:
Purchasing Comments:
Purchasing Signa Date: On
D
i IF
Administration: Date:
Certificate of Insurance Received? X Yes ❑ No ❑ Self-Insured (Form Received
Business Tax Current? ❑Yes ❑ No Contractor License Current? ❑ Yes ❑ No n/a
Federal TIN/1099 #: 20-2126087 Bonds Required: ❑Yes ❑ No n/a
Accounting String: Fund Division Account Total
100 2290 601000 $4,800.00