HomeMy WebLinkAbout2024-152 AGRMT - NIWA Method, LLC Clear Farm
'` H , `� " I Y 1� Goods and Services Agreement
City Information Contractor Information
City of Ashland Firm Name:NIWA METHOD, LLC
Attn: Parks & Recreation Contact: Francheska V Snyder
C/o Sulaiman Shelton
Address: P.O. Box 14924
Ashland, Oregon 97520 Portland, Oregon 97293
Phone: 541.552.2264 Phone: 505.893.4033
Email: sulaiman.shelton@ashland.or.6 Email: francheska@niwamethod.com
Contract Summary
Procurement Method: Small Procurement
Completion Date: 05/31/2025
Contract Amount: 19075 Nineteen-thousand-seventy-five-dollars
Description of Services: Pine and Maple Pruning, Ashland Japanese Garden
Supporting Documents: Proposal Dated: 08/02/2024
Dated:
Dated:
Dated:
This Goods and Services Agreement (hereinafter "Agreement") is entered into by and between the
City of Ashland, an Oregon municipal corporation (hereinafter"City") and the Contractor listed under
Contractor Information above, (hereinafter "Contractor"), for the services listed under Description of
Services and the Supporting Documents as noted in the Contract Summary above.
This Agreement and the Supporting Documents shall be construed to be mutually complimentary and
supplementary wherever possible. In the event of a conflict which cannot be so resolved, the
provisions of this Agreement itself shall control over any conflicting provisions in any of the Supporting
Documents. In the event of conflict between provisions of the Supporting Documents, the Supporting
Documents shall be given precedence in the order listed above.The Contractor's initials Ff VS ] herein
signify acknowledgment and agreement to this provision, if applicable, or if not sign "N/A".
The goods and services defined and described in the Supporting Documents shall hereinafter be
collectively referred to as "Work."
Pagel of 8: Goods and Services Agreement between the City of Ashland and NIWA METHOD, LLC
1. Term and Termination
1.1. Term. This Agreement shall be effective from the date of execution on behalf of the City as
set forth below (the "Effective Date") and shall continue in full force and effect until the
Completion Date indicated in the Contract Summary on page one of this Agreement unless
sooner terminated as provided in Subsection 1.2.
1.1. Time is of the essence. Time is of the essence for Contractor's performance of
each and every obligation and duty under this Agreement. City, by written notice to
Contractor of default or breach, may at any time terminate the whole or any part of this
Agreement if Contractor fails to provide the Work called for by this Agreement within the
time specified herein or within any extension thereof.
1.2. Termination
1.2.1. The City and Contractor may terminate this Agreement by mutual agreement at any
time.
1.2.2. The City may, upon not less than thirty (30) days' prior written notice, terminate this
Agreement for any reason deemed appropriate in its sole discretion.
1.2.3. Either party may terminate this Agreement, with cause, by not less than fourteen (14)
days' prior written notice if the cause is not cured within that fourteen (14) day period
after written notice. Such termination is in addition to and not in lieu of any other remedy
at law or equity.
2. Compensation
2.1. City shall pay Contractor the sum listed as the "Contract Amount" in the Contract Summary
on page one of this Agreement as provided herein as full compensation for the Work as
specified in the supporting documents.
2.2. In no event shall Contractor's total of all compensation and reimbursement under this
Agreement exceed the "Contract Amount" listed in the Contract Summary without express,
written approval from the appropriate Department Head or City Manager. Contractor
acknowledges that any work delivered, or expenses incurred without authorization as
provided herein is done at Contractor's own risk and as a volunteer without expectation of
compensation or reimbursement.
3. Contractor's Obligations
3.1. Performance. Provide the goods or services as set forth in the Supporting Documents
attached hereto and, by this reference, incorporated herein.
3.2. Nondiscrimination. Contractor agrees that no person shall, on the grounds of race, color,
religion, creed, sex, marital status,familial status or domestic partnership, national origin, age,
mental or physical disability, sexual orientation, gender identity or source of income, suffer
discrimination in the performance of this Agreement when employed by Contractor.
Contractor agrees to comply with all applicable requirements of federal and state civil rights
and rehabilitation statutes, rules and regulations. Further, Contractor agrees not to
discriminate against a disadvantaged business enterprise, minority-owned business, woman-
owned business, a business that a service-disabled veteran owns or an emerging small
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business enterprise certified under ORS 200.055, in awarding subcontracts as required by
ORS 279A.110.
3.3. Subcontractor Notification. In all solicitations either by competitive bidding or negotiation
made by Contractor for work to be performed under a subcontract, including procurements of
materials or leases of equipment, each potential subcontractor or supplier shall be notified by
the Contractors of the Contractor's obligations under this Agreement and Title VI of the Civil
Rights Act of 1964 and other federal nondiscrimination laws.
3.4. Living Wage Requirements. If the amount of this Agreement is $26,429.65 or more,
Contractor is required to comply with Chapter 3.12 of the Ashland Municipal Code by paying
a living wage, as defined in that chapter, to all employees performing Work under this
Agreement and to any Subcontractor who performs 50% or more of the Work under this
Agreement. Contractor is also required to post the notice attached hereto as "Exhibit A"
predominantly in areas where it will be seen by all employees.
4. Contractor's Compliance with Tax Laws
4.1. Contractor represents and warrants to the City that:
4.1.1. Contractor shall, throughout the term of this Agreement, including any extensions
hereof, comply with:
• All tax laws of the State of Oregon, including but not limited to ORS 305.620 and
ORS chapters 316, 317, and 318;
• Any tax provisions imposed by a political subdivision of the State of Oregon
applicable to Contractor; and
• Any rules, regulations, charter provisions, or ordinances that implement or enforce
any of the foregoing tax laws or provisions.
4.1.2. Contractor further certifies that contractor is not in violation of any Oregon tax laws
referenced in ORS 305.380(4).
4.2. Tax Compliance Breach. Contractor's failure to comply with the tax laws of the State of
Oregon and all applicable tax laws of any political subdivision of the State of Oregon shall
constitute a material breach of this Agreement. Further, any violation of Contractor's
warranty, as set forth in this Article 9, shall constitute a material breach of this Agreement.
Any material breach of this Agreement shall entitle the City to terminate this Agreement and
to seek damages and any other relief available under this Agreement, at law, or in equity.
5. Insurance. Contractor shall obtain and maintain during the term of this Agreement and until City's
final acceptance of all Work received hereunder, a policy or policies of liability insurance Each
policy of such insurance shall be on an "occurrence" and not a "claims made" form, and shall
include:
5.1. Commercial general liability -- with a combined single limit, or the equivalent, of not less
than $2,000,000 (two million dollars) per occurrence and $3,000,000 (three million dollars) in
the aggregate for Bodily Injury and Property Damage.
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5.2. Commercial Automobile Liability -- with a combined single limit, or the equivalent of not
less than $2,000,000 (two million dollars) for each accident for Bodily Injury and
Property Damage, including coverage for owned, hired and non-owned vehicles.
5.3. Additional forms: (See Attached)
5.4. Worker's Compensation. Contractor shall, at its own expense, maintain Worker's
Compensation Insurance in compliance with ORS 656.017,which requires subject employers
to provide workers' compensation coverage for all of its subject workers. As evidence of the
insurance required by this Agreement, the Contractor shall furnish an acceptable insurance
certificate prior to commencing any Work with limits not less than $500,000.
5.4.1. Workers' Compensation Exemption: If applicable, Contractor affirms and certifies that
it is exempt from providing Workers' Compensation per ORS 656.027.
Exemption criteria:Sole Proprietor
`Contractor initials if exempt: � � Date: 9/12/24
6. Additional Insured/Certificates of Insurance. The Contractor shall name the City of Ashland,
Oregon, along with its elected officials, officers, and employees, as Additional Insureds on all
insurance policies (excluding Professional Liability and Workers' Compensation) necessary for
this Agreement. This inclusion applies solely to the services provided by the Contractor under this
Agreement. The Contractor's insurance must be primary and non-contributory. Before
commencing work, the Contractor must provide acceptable insurance certificates as proof of the
required coverage. These certificates must specify all parties included as additional Insureds,
treating each named and additional named insured as if they were covered under separate
policies, without increasing policy limits. Insuring companies or entities must be accepted by the
City. Upon request, the Contractor must provide complete copies of insurance policies and trust
agreements to the City.Additionally,the Contractor must provide an endorsement naming the City,
its officers, employees, and agents as additional insureds by the Effective Date of this Agreement,
accompanied by approved certificate(s) of insurance.
7. Indemnity. Contractor shall defend, save, hold harmless and indemnify the City and its officers,
employees and agents from and against any and all claims, suits, actions, losses, damages,
liabilities, costs, and expenses of any nature resulting from, arising out of, or relating to the
activities of Contractor or its officers, employees, contractors, or agents under this Agreement.
8. Notice
Whenever notice is required or permitted to be given under this Agreement, such notice shall be
given in writing to the other party by personal delivery, by sending via a reputable commercial
overnight courier, or by mailing using registered or certified United States mail, return receipt
requested, postage prepaid, to the addresses set forth above with a copy to:
City of Ashland — Legal Department
20 E. Main Street
Ashland, Oregon 97520
Phone: (541) 488-5350
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6. Remedies
6.1. In the event Contractor is in default of this Agreement, City may, at its option, pursue any or
all of the remedies available to it under this Agreement and at law or in equity, including, but
not limited to:
6.1.1. Termination of this Agreement.
6.1.2. Withholding all monies due for the Work that Contractor has failed to deliver within any
scheduled completion dates or any Work that have been delivered inadequately or
defectively.
6.1.3. Initiation of an action or proceeding for damages, specific performance, or declaratory
or injunctive relief.
6.1.4. These remedies are cumulative to the extent the remedies are not inconsistent, and
City may pursue any remedy or remedies singly, collectively, successively or in any order
whatsoever.
6.2. Default: The Contractor shall be in default of this Agreement if Contractor: commits any
material breach or default of any covenant, warranty, certification, or obligation under the
Agreement; institutes an action for relief in bankruptcy or has instituted against it an action
for insolvency; makes a general assignment for the benefit of creditors; or ceases doing
business on a regular basis of the type identified in its obligations under the Agreement; or,
without written authorization by the City, attempts to assign rights in, or delegate duties
under, this Agreement.
6.3. Liability Limitation. In no event shall City be liable to Contractor for any expenses related to
termination of this Agreement or for anticipated profits. If previous amounts paid to Contractor
exceed the amount due, Contractor shall pay immediately any excess to City upon written
demand provided.
7. General Provisions
7.1. Non-exclusive Agreement. City is not obligated to procure any specific amount of Work
from Contractor and is free to procure similar types of goods and services from other
Contractors in its sole discretion.
7.2. Independent Contractor Status. Contractor is an independent contractor and not an
employee or agent of the City for any purpose.
7.3. Statutory Requirements. The following laws of the State of Oregon are hereby incorporated
by reference into this Agreement: ORS 279B.220, 27913.230 and 27913.235
7.4. Assignment. Contractor shall not assign this Agreement or subcontract any portion of the
Work to be provided hereunder without the prior written consent of the City. Any attempted
assignment or subcontract without written consent of the City shall be void. Contractor shall
be fully responsible for the acts or omissions of any assigns or subcontractors and of all
persons employed by them, and the approval by the City of any assignment or subcontract
shall not create any contractual relation between the assignee or subcontractor and the City.
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7.5. Force Majeure. Neither party to this Agreement shall hold the other responsible for damages
or delay in performance caused by acts of God, strikes, lockouts, accidents, or other events
beyond the control of the other or the other's officers, employees or agents.
7.6. Deliveries F.O.B destination. Contractor shall pay all transportation and handling charges
for the Goods. Contractor is responsible and liable for loss or damage until final inspection
and acceptance of the Goods by the City. Contractor remains liable for latent defects, fraud,
and warranties.
7.7. Goods Rejection. The City may reject non-conforming Goods and require Contractor to
correct them without charge or deliver them at a reduced price, as negotiated. If Contractor
does not cure any defects within a reasonable time, the City may reject the Goods and cancel
this Agreement in whole or in part. This paragraph does not affect or limit the City's rights,
including its rights under the Uniform Commercial Code, ORS Chapter 72 (UCC).
7.8. Goods Warranty Representation. Contractor represents and warrants that the Goods are
new, current, and fully warranted by the manufacturer. Delivered Goods will comply with
Supporting Documents and be free from defects in labor, material and manufacture.
Contractor shall transfer all warranties to the City.
7.9. Waiver of Breach. One or more waivers or failures to object by either party to the other's
breach of any provision, term, condition, or covenant contained in this Agreement shall not
be construed as a waiver of any subsequent breach, whether or not of the same nature.
7.10. Jurisdiction. This Agreement shall be governed by the laws of the State of Oregon without
regard to conflict of laws principles. Exclusive venue for litigation of any action arising under
this Agreement shall be in the Circuit Court of the State of Oregon for Jackson County unless
exclusive jurisdiction is in federal court, in which case exclusive venue shall be in the federal
district court for the district of Oregon. Each party expressly waives any and all rights to
maintain an action under this Agreement in any other venue, and expressly consents that,
upon motion of the other party, any case may be dismissed or its venue transferred, as
appropriate, so as to effectuate this choice of venue.
7.11. Severance. If any provision of this Agreement is found by a court of competent jurisdiction
to be unenforceable, such provision shall not affect the other provisions, but such
unenforceable provision shall be deemed modified to the extent necessary to render it
enforceable, preserving to the fullest extent permitted the intent of Contractor and the City set
forth in this Agreement.
8. Merger. This agreement and the attached exhibits constitute the entire understanding and
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 the specific instance and for
the specific purpose given. There are no understandings, agreements, or representations, oral or
written, not specified herein regarding this agreement. Contractor, by 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.
Page 6 of 8: Goods and Services Agreement between the City of Ashland and NIWA METHOD, LLC
WITNESS WHEREOF, the parties have executed this Agreement in their respective names by their
duly authorized representatives as of the dates indicated below. This Agreement may be executed in
two counterparts, each of which shall be deemed an original,with equal force and effect as if executed
in a single document.
CITY OF ASHLAND: NIWA METHOD, LLC(CONTRACTOR):
Digitally signed by Rocky Houston
Rocky Houston Date:2024.10.14 09:15:59-07'00'
By: By:
Signature
Rocky Houston, Director Signature
Francheska Snyder
Printed Name
Printed Name
Date Owner/Operator
Title
09/12/24
Date
Purchase Order No.
(W-9 is to be submitted with this signed Agreement)
APPROVED AS TO FORM:
City Attorney
Page 7 of 8: Goods and Services Agreement between the City of Ashland and NIWA METHOD, LLC
CITY OF OREGON
City of Ashland
LIVING
. WAGE
per hour, effective June 30, 2024.
i ' The Living Wage is adjusted annually every
June 30 by the Consumer Price Index.
• - - portion of the business of of health care, retirement,
their employer, if the 401 K, and IRS eligible
employer has ten or more cafeteria plans (including
employees, and has received childcare) benefits to the
➢ For all hours worked under a financial assistance for the employee's amount of wages.
service contract between their project or business from the
employer and the City of City of Ashland over ➢ Note: For temporary and
Ashland if the contract $26,429.65; part-time employees, the
exceeds$26,429.65 or more. Living Wage does not apply
➢ If their employer is the City of to the first 1040 hours worked
➢ For all hours worked in a Ashland, including the Parks in any calendar year. For
month, if the employee and Recreation Department. more details, please see
o Ashland Municipal Code
spends 50/o or more of the ➢employee's time in that month In calculating the living wage, Section 3.12.020.
working on a project or employers may add the value
For additional information:
Call the Ashland City Manager's office at 541-488-6002 or write to the City Manager,
City Hall, 20 East Main Street, Ashland, OR 97520, or visit the City's website at www.ashlan .or.us.
Notice to Employers: This notice must be posted in areas where it can be seen by all employees.
Niwa Method LLC P.O. Box 14924, Portland, Oregon 97293
Japanese Garden Craft 505.893.4033 francheska@niwamethod.com
LIC#9825
PROPOSAL
Date: August 2, 2024
To: Sulaiman Shelton For: Pine and Maple Pruning
Ashland Japanese Garden
Ashland Parks and Recreation Commission
20 East Main Street
Ashland,OR 97520
Ph: 541-552-2264(c): 541-499-8798
DESCRIPTION
The primary focus of work will be to prune the pine and maple trees in the Ashland Japanese Garden in Lithia Park. These pruning sessions
in the Japanese Garden will be during fall and spring, planning for an ongoing yearly basis.
Pine Trees:
Pine trees have two seasons of pruning. During the fall/winter pine trees receive their branch thinning and removal of old needles. During
the spring (May/June), the new growth,"candies"are pruned to control and direct the season's structure.
Maple Trees:
Maple pruning season falls between mid-May and early January. Large structural changes to a maple tree should be performed during the
latter part of the pruning window from leaf drop to January. Basic branch thinning of limbs less than 2"in diameter can be performed at
any time within the pruning window. Because of the intense heat and drought conditions during the summer months, maple pruning shall
be directed towards the beginning of the maple pruning season. The larger more mature maples
The pine pruning shall be five days of work for a two person team in November. The maple pruning paired with pine candling shall be five
days of work for a one-oerson team in late May. The team size may increase or decrease in subsequent years as duties shift to Ashland
Park staff and/or scope of work changes. Additional garden needs will be assessed during these visits and scheduled with Ashland Park staff
and advisors as appropriate.
Onsite rates for a two-person team: Onsite rates for a one-person team:
Full Day: $1300 Full Day: $1000
Half Day: $700 Half Day: $550
Minimum: $300 Minimum: $200
Additional Helpers can join the workday at the rate of$300/day.
Travel days will be part travel and part onsite work if time allows.
Travel days will be billed as a full or half day depending if timing of travel also allows for work.
Any additional offsite design, consultation, or plant/material sourcing will be billed as time and materials at the rate of$90/hr.
Additional charges will be $375 per person for travel and $60/day per person for incidentals.
The cost or provision of two rooms for lodging will also be required when working as a two or more person team.
The difference in insurance premium cost will be billed annually. Currently set at$1800.
Sulaiman Shelton, Client/APRC Date
8/02/2024
Francheska Snyder, Gardener Date
We look forward to working with you. THANK YOU!
Page 1/2
Niwa Method LLC P.O. Box 14924, Portland, Oregon 97293
Japanese Garden Craft 505.893.4033 francheska@niwamethod.com
LIC#9825
PROPOSAL
Date: August 2, 2024
To: For: Pine and Maple Pruning
Sulaiman Shelton
Ashland Japanese Garden
Ashland Parks and Recreation Commission
20 East Main Street
Ashland,OR 97520
Ph: 541-552-2264(c): 541-499-8798
DESCRIPTION cont.
The proposed dates to complete this round of work with a two person and one person team respectively are:
Stage I Pine Pruning Stage II Maple Pruning and Pine Candling
December 2-6, 2024 May 19-22, 2025
12/01 -arrive 5/18 arrive
12/02 -work full day 5/19 work full day
12/03 -work full day 5/20 work full day
12/04-work full day 5/21 work full day
12/05 -work full day 5/22 work full day
12/06-work full day
Additional work hours can be added at the discretion of Ashland Japanese Garden for additional training or consulting
opportunities.
Total Costs for Stage I Total Costs for Stage II
Onsite work rate $7200 Onsite work rate $4550
Travel and Incidental $1350 Travel and Incidental $ 615
Lodging Estimate(x2) $2445 Lodging Estimate(xi) $1115
Insurance Premium $1800 $6280
$12,795
Sulaiman Shelton, Client/APRC Date
8/02/2024
Francheska Snyder, Gardener Date
We look forward to working with you. THANK YOU!
Page 2/2
Form Request for Taxpayer Give Form to the
(Rev.October2018) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service ►Go to wwwJrs.gov/FormW9 for instructions and the latest information.
1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank.
Francheska V Snyder
2 Business name/disregarded entity name,if different from above
Niwa Method, LLC
M 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions codes apply only to
� P Y P ( PP Y Y
following seven boxes. certain entities,not individuals;see
a instructions on page 3):
p ✓❑ Individual/sole proprietor or ElC Corporation ElS Corporation ElPartnership ElTrust/estate
w single-member LLC Exempt payee code(if any)
ai c
a o
v ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)►
p r Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting
w LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is de(if any)
another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that co
IL v is disregarded from the owner should check the appropriate box for the tax classification of its owner.
y ❑ Other(see instructions)► (Applies to accounts maintained outside the U.S.)
y5 Address(number,street,and apt.or suite no.)See instructions. Requester's name and address(optional)
a P.O. Box 14924
W
6 City,state,and ZIP code
Portland, Oregon 97293
7 List account number(s)here(optional)
RiUM 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 generally your social security number(S However,for a TU —
resident alien,sole proprietor,or disregarded entity,see the instructions for Part I, later. For other
entities,it is your employer identification number(EIN). If you do not have a number,see How to get a
TIN, later. or
Note:If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
M84 - 2 4 2 9 7 7 9
Certification
Under penalties of perjury, I certify that:
1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2. I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3. I am a U.S.citizen or other U.S. person(defined below);and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments
other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions for Part ll,later.
Signature of
Sign —
Here U.S.person 0- Date► 09/12/24
General Instructions • Form 1099-DIV(dividends, including those from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise . Form 1099-MISC(various types of income, prizes,awards,or gross
noted. proceeds)
Future developments. For the latest information about developments . Form 1099-B(stock or mutual fund sales and certain other
related to Form W-9 and its instructions,such as legislation enacted transactions by brokers)
after they were published,go to www.irs.gov/FormW9.
• Form 1099-S(proceeds from real estate transactions)
Purpose of Form • Form 1099-K(merchant card and third party network transactions)
An individual or entity(Form W-9 requester)who is required to file an • Form 1098(home mortgage interest), 1098-E(student loan interest),
information return with the IRS must obtain your correct taxpayer 1098-T(tuition)
identification number(TIN)which may be your social security number • Form 1099-C(canceled debt)
(SSN),individual taxpayer identification number(ITIN),adoption .Form 1099-A(acquisition or abandonment of secured property)
taxpayer identification number(ATIN),or employer identification number
(EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S. person(including a resident
amount reportable on an information return. Examples of information alien),to provide your correct TIN.
returns include, but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might
• Form 1099-INT(interest earned or paid) be subject to backup withholding. See What is backup withholding,
later.
Cat.No.10231X Form W-9(Rev.10-2018)
Form W-9(Rev.10-2018) Page 2
By signing the filled-out form,you: Example.Article 20 of the U.S.-China income tax treaty allows an
1.Certify that the TIN you are giving is correct(or you are waiting for a exemption from tax for scholarship income received by a Chinese
number to be issued), student temporarily present in the United States. Under U.S.law,this
student will become a resident alien for tax purposes if his or her stay in
2.Certify that you are not subject to backup withholding,or the United States exceeds 5 calendar years. However, paragraph 2 of
3.Claim exemption from backup withholding if you are a U.S.exempt the first Protocol to the U.S.-China treaty(dated April 30, 1984)allows
payee. If applicable,you are also certifying that as a U.S.person,your the provisions of Article 20 to continue to apply even after the Chinese
allocable share of any partnership income from a U.S.trade or business student becomes a resident alien of the United States.A Chinese
is not subject to the withholding tax on foreign partners'share of student who qualifies for this exception(under paragraph 2 of the first
effectively connected income,and protocol)and is relying on this exception to claim an exemption from tax
4.Certify that FATCA code(s)entered on this form(if any)indicating on his or her scholarship or fellowship income would attach to Form
that you are exempt from the FATCA reporting,is correct.See What is W-9 a statement that includes the information described above to
FATCA reporting, later,for further information. support that exemption.
Note:If you are a U.S.person and a requester gives you a form other If you are a nonresident alien or a foreign entity,give the requester the
than Form W-9 to request your TIN,you must use the requester's form if appropriate completed Form W-8 or Form 8233.
it is substantially similar to this Form W-9. Backup Withholding
Definition of a U.S.person. For federal tax purposes,you are
considered a U.S. person if you are: What is backup withholding?Persons making certain payments to you
•An individual who is a U.S.citizen or U.S.resident alien; must under certain conditions withhold and pay to the IRS 24%of such
payments.This is called"backup withholding." Payments that may be
•A partnership,corporation,company,or association created or subject to backup withholding include interest,tax-exempt interest,
organized in the United States or under the laws of the United States; dividends,broker and barter exchange transactions, rents, royalties,
•An estate(other than a foreign estate);or nonemployee pay,payments made in settlement of payment card and
•A domestic trust(as defined in Regulations section 301.7701-7). third party network transactions,and certain payments from fishing boat
operators. Real estate transactions are not subject to backup
Special rules for partnerships.Partnerships that conduct a trade or withholding.
business in the United States are generally required to pay a withholding You will not be subject to backup withholding on payments you
tax under section 1446 on any foreign partners'share of effectively receive if you give the requester your correct TIN,make the proper
connected taxable income from such business. Further, in certain cases certifications,and report all your taxable interest and dividends on your
where a Form W-9 has not been received,the rules under section 1446 tax return.
require a partnership to presume that a partner is a foreign person,and
pay the section 1446 withholding tax.Therefore,if you are a U.S.person payments you receive will be subject to backup withholding if:
that is a partner in a partnership conducting a trade or business in the 1.You do not furnish your TIN to the requester,
United States,provide Form W-9 to the partnership to establish your 2.You do not certify your TIN when required(see the instructions for
U.S.status and avoid section 1446 withholding on your share of Part II for details),
partnership income.
In the cases below,the following person must give Form W-9 to the 3.The IRS tells the requester that you furnished an incorrect TIN,
partnership for purposes of establishing its U.S.status and avoiding 4.The IRS tells you that you are subject to backup withholding
withholding on its allocable share of net income from the partnership because you did not report all your interest and dividends on your tax
conducting a trade or business in the United States. return(for reportable interest and dividends only),or
• In the case of a disregarded entity with a U.S.owner,the U.S.owner 5.You do not certify to the requester that you are not subject to
of the disregarded entity and not the entity; backup withholding under 4 above(for reportable interest and dividend
• In the case of a grantor trust with a U.S.grantor or other U.S.owner, accounts opened after 1983 only).
generally,the U.S.grantor or other U.S.owner of the grantor trust and Certain payees and payments are exempt from backup withholding.
not the trust;and See Exempt payee code, later,and the separate Instructions for the
• In the case of a U.S.trust(other than a grantor trust),the U.S.trust Requester of Form W-9 for more information.
(other than a grantor trust)and not the beneficiaries of the trust. Also see Special rules for partnerships, earlier.
Foreign person.If you are a foreign person or the U.S. branch of a What is FATCA Reporting?
foreign bank that has elected to be treated as a U.S. person,do not use
Form W-9. Instead,use the appropriate Form W-8 or Form 8233(see The Foreign Account Tax Compliance Act(FATCA)requires a
Pub.515,Withholding of Tax on Nonresident Aliens and Foreign participating foreign financial institution to report all United States
Entities). account holders that are specified United States persons.Certain
Nonresident alien who becomes a resident alien.Generally,only a payees are exempt from FATCA reporting.See Exemption from FATCA
nonresident alien individual may use the terms of a tax treaty to reduce reporting code, later,and the Instructions for the Requester of Form
or eliminate U.S.tax on certain types of income. However, most tax W-9 for more information.
treaties contain a provision known as a"saving clause." Exceptions Updating Your Information
specified in the saving clause may permit an exemption from tax to
continue for certain types of income even after the payee has otherwise You must provide updated information to any person to whom you
become a U.S. resident alien for tax purposes. claimed to be an exempt payee if you are no longer an exempt payee
If you are a U.S.resident alien who is relying on an exception and anticipate receiving reportable payments in the future from this
contained in the saving clause of a tax treaty to claim an exemption person. For example,you may need to provide updated information if
from U.S.tax on certain types of income,you must attach a statement you are a C corporation that elects to be an S corporation,or if you no
to Form W-9 that specifies the following five items. longer are tax exempt. In addition,you must furnish a new Form W-9 if
1.The treaty country. Generally,this must be the same treaty under the name or TIN changes for the account;for example, if the grantor of a
which you claimed exemption from tax as a nonresident alien. grantor trust dies.
2.The treaty article addressing the income. Penalties
3.The article number(or location)in the tax treaty that contains the
saving clause and its exceptions. Failure to furnish TIN.If you fail to furnish your correct TIN to a
4.The type and amount of income that qualifies for the exemption requester,you are subject to a penalty of$50 for each such failure
from tax. unless your failure is due to reasonable cause and not to willful neglect.
5.Sufficient facts to justify the exemption from tax under the terms of Civil penalty for false information with respect to withholding.If you
the treaty article. make a false statement with no reasonable basis that results in no
backup withholding,you are subject to a$500 penalty.
Form W-9(Rev.10-2018) Page 3
Criminal penalty for falsifying information.Willfully falsifying IF the entity/person on line 1 is THEN check the box for...
certifications or affirmations may subject you to criminal penalties a(n)...
including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of • Corporation Corporation
federal law,the requester may be subject to civil and criminal penalties. • Individual Individual/sole proprietor or single-
* Sole proprietorship,or member LLC
Specific Instructions • Single-member limited liability
company(LLC)owned by an
Line 1 individual and disregarded for U.S.
You must enter one of the following on this line;do not leave this line federal tax purposes.
blank.The name should match the name on your tax return. . LLC treated as a partnership for Limited liability company and enter
If this Form W-9 is for a joint account(other than an account U.S.federal tax purposes, the appropriate tax classification.
maintained by a foreign financial institution(FFI)), list first,and then . LLC that has filed Form 8832 or (P= Partnership;C=C corporation;
circle,the name of the person or entity whose number you entered in 2553 to be taxed as a corporation, or S=S corporation)
Part I of Form W-9. If you are providing Form W-9 to an FFI to document or
a joint account,each holder of the account that is a U.S. person must . LLC that is disregarded as an
provide a Form W-9.
entity separate from its owner but
a. Individual.Generally,enter the name shown on your tax return. If the owner is another LLC that is
you have changed your last name without informing the Social Security not disregarded for U.S.federal tax
Administration(SSA)of the name change,enter your first name,the last purposes.
name as shown on your social security card,and your new last name.
Note:ITIN applicant: Enter your individual name as it was entered on • Partnership Partnership
your Form W-7 application, line 1 a.This should also be the same as the le Trust/estate Trust/estate
name you entered on the Form 1040/1040A/1040EZ you filed with your Line 4, Exemptions
application.
b. Sole proprietor or single-member LLC. Enter your individual If you are exempt from backup withholding and/or FATCA reporting,
name as shown on your 1040/1040A/1040EZ on line 1.You may enter enter in the appropriate space on line 4 any code(s)that may apply to
your business,trade,or"doing business as"(DBA)name on line 2. you.
c. Partnership,LLC that is not a single-member LLC,C Exempt payee code.
corporation,or S corporation.Enter the entity's name as shown on the • Generally, individuals(including sole proprietors)are not exempt from
entity's tax return on line 1 and any business,trade,or DBA name on backup withholding.
line 2. • Except as provided below,corporations are exempt from backup
d. Other entities.Enter your name as shown on required U.S.federal withholding for certain payments, including interest and dividends.
tax documents on line 1.This name should match the name shown on the . Corporations are not exempt from backup withholding for payments
charter or other legal document creating the entity.You may enter any made in settlement of payment card or third party network transactions.
business,trade,or DBA name on line 2.
• Corporations are not exempt from backup withholding with respect to
e. Disregarded entity.For U.S.federal tax purposes,an entity that is attorneys'fees or gross proceeds paid to attorneys,and corporations
disregarded as an entity separate from its owner is treated as a that provide medical or health care services are not exempt with respect
"disregarded entity." See Regulations section 301.7701-2(c)(2)(iii). Enter to payments reportable on Form 1099-MISC.
the owner's name on line 1.The name of the entity entered on line 1
should never be a disregarded entity.The name on line 1 should be the The following codes identify payees that are exempt from backup
name shown on the income tax return on which the income should be withholding. Enter the appropriate code in the space in line 4.
reported. For example,if a foreign LLC that is treated as a disregarded 1—An organization exempt from tax under section 501(a),any IRA,or
entity for U.S.federal tax purposes has a single owner that is a U.S. a custodial account under section 403(b)(7)if the account satisfies the
person,the U.S.owner's name is required to be provided on line 1. If requirements of section 401(0(2)
the direct owner of the entity is also a disregarded entity,enter the first 2—The United States or any of its agencies or instrumentalities
owner that is not disregarded for federal tax purposes. Enter the
disregarded entity's name on line 2, "Business name/disregarded entity 3—A state,the District of Columbia,a U.S.commonwealth or
name." If the owner of the disregarded entity is a foreign person,the possession,or any of their political subdivisions or instrumentalities
owner must complete an appropriate Form W-8 instead of a Form W-9. 4—A foreign government or any of its political subdivisions,agencies,
This is the case even if the foreign person has a U.S.TIN. or instrumentalities
Line 2 5—A corporation
If you have a business name,trade name, DBA name,or disregarded 6—A dealer in securities or commodities required to register in the
entity name,you may enter it on line 2. United States,the District of Columbia,or a U.S.commonwealth or
possession
Line 3 7—A futures commission merchant registered with the Commodity
Check the appropriate box on line 3 for the U.S.federal tax Futures Trading Commission
classification of the person whose name is entered on line 1.Check only 8—A real estate investment trust
one box on line 3. 9—An entity registered at all times during the tax year under the
Investment Company Act of 1940
10—A common trust fund operated by a bank under section 584(a)
11—A financial institution
12—A middleman known in the investment community as a nominee or
custodian
13—A trust exempt from tax under section 664 or described in section
4947
Form W-9(Rev.10-2018) Page 4
The following chart shows types of payments that may be exempt M—A tax exempt trust under a section 403(b)plan or section 457(g)
from backup withholding.The chart applies to the exempt payees listed plan
above, 1 through 13. Note:You may wish to consult with the financial institution requesting
IF the payment is for... THEN the payment is exempt this form to determine whether the FATCA code and/or exempt payee
for... code should be completed.
Interest and dividend payments All exempt payees except Line 5
for 7 Enter your address(number,street,and apartment or suite number).
Broker transactions Exempt payees 1 through 4 and 6 This is where the requester of this Form W-9 will mail your information
through 11 and all C corporations. returns. If this address differs from the one the requester already has on
S corporations must not enter an file,write NEW at the top. If a new address is provided,there is still a
exempt payee code because they chance the old address will be used until the payor changes your
are exempt only for sales of address in their records.
noncovered securities acquired Line 6
prior to 2012.
Barter exchange transactions and Exempt payees 1 through 4 Enter your city,state,and ZIP code.
patronage dividends Part I. Taxpayer Identification Number (TIN)
Payments over$600 required to be Generally,exempt payees Enter your TIN in the appropriate box. If you are a resident alien and
reported and direct sales over 1 through 52 you do not have and are not eligible to get an SSN,your TIN is your IRS
$5,000' 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
Payments made in settlement of Exempt payees 1 through 4 below.
payment card or third party network If you are a sole proprietor and you have an EIN,you may enter either
transactions your SSN or EIN.
' See Form 1099-MISC, Miscellaneous Income,and its instructions. If you are a single-member LLC that is disregarded as an entity
separate from its owner,enter the owner's SSN(or EIN, if the owner has
2 However,the following payments made to a corporation and one). Do not enter the disregarded entity's EIN. If the LLC is classified as
reportable on Form 1099-MISC are not exempt from backup a corporation or partnership,enter the entity's EIN.
withholding: medical and health care payments,attorneys'fees,gross Note:See What Name and Number To Give the Requester, later,for
proceeds paid to an attorney reportable under section 6045(f),and
payments for services paid by a federal executive agency. further clarification of name and TIN combinations.
Exemption from FATCA reporting code.The following codes identify How to get a TIN.If you do not have a TIN,apply for one immediately.
payees that are exempt from reporting under FATCA.These codes To apply for an SSN,get Form SS-5,Application for a Social Security
apply to persons submitting this form for accounts maintained outside Card,from your local SSA office or get this form online at
of the United States by certain foreign financial institutions.Therefore,if www.SSA.gov.You may also get this form by calling 1-800-772-1213.
you are only submitting this form for an account you hold in the United Use Form W-7,Application for IRS Individual Taxpayer Identification
States,you may leave this field blank. Consult with the person Number,to apply for an ITIN,or Form SS-4,Application for Employer
requesting this form if you are uncertain if the financial institution is Identification Number,to apply for an EIN.You can apply for an EIN
subject to these requirements.A requester may indicate that a code is online by accessing the IRS website at www.irs.gov/Businesses and
not required by providing you with a Form W-9 with"Not Applicable"(or clicking on Employer Identification Number(EIN)under Starting a
any similar indication)written or printed on the line for a FATCA Business. Go to www.irs.gov/Forms to view,download,or print Form
exemption code. W-7 and/or Form SS-4. Or,you can go to www.irs.gov/OrderForms to
place an order and have Form W-7 and/or SS-4 mailed to you within 10
A—An organization exempt from tax under section 501(a)or any business days.
individual retirement plan as defined in section 7701(a)(37)
If you are asked to complete Form W-9 but do not have a TIN,apply
B—The United States or any of its agencies or instrumentalities for a TIN and write"Applied For"in the space for the TIN,sign and date
C—A state,the District of Columbia,a U.S.commonwealth or the form,and give it to the requester. For interest and dividend
possession,or any of their political subdivisions or instrumentalities payments,and certain payments made with respect to readily tradable
D—A corporation the stock of which is regularly traded on one or instruments,generally you will have 60 days to get a TIN and give it to
more established securities markets,as described in Regulations the requester before you are subject to backup withholding on
section 1.1472-1(c)(1)(i) 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
E—A corporation that is a member of the same expanded affiliated you provide your TIN to the requester.
group as a corporation described in Regulations section 1.1472-1(c)(1)(i)
Note: Entering"Applied For"means that you have already applied for a
F—A dealer in securities,commodities,or derivative financial TIN or that you intend to apply for one soon.
instruments(including notional principal contracts,futures,forwards,
and options)that is registered as such under the laws of the United Caution:A disregarded U.S.entity that has a foreign owner must use
States or any state the appropriate Form W-8.
G—A real estate investment trust Part 11. Certification
H—A regulated investment company as defined in section 851 or an To establish to the withholding agent that you are a U.S. person,or
entity registered at all times during the tax year under the Investment resident alien,sign Form W-9.You may be requested to sign by the
Company Act of 1940 withholding agent even if item 1,4,or 5 below indicates otherwise.
I—A common trust fund as defined in section 584(a) For a joint account,only the person whose TIN is shown in Part I
J—A bank as defined in section 581 should sign(when required). In the case of a disregarded entity,the
K—A broker person identified on line 1 must sign. Exempt payees,see Exempt payee
L—A trust exempt from tax under section 664 or described in section code,earlier.
4947(a)(1) Signature requirements.Complete the certification as indicated in
items 1 through 5 below.
Form W-9(Rev.10-2018) Page rJ
1.Interest,dividend,and barter exchange accounts opened For this type of account: Give name and EIN of:
before 1984 and broker accounts considered active during 1983.
You must give your correct TIN,but you do not have to sign the 14.Account with the Department of The public entity
certification. Agriculture in the name of a public
entity(such as a state or local
2.Interest,dividend,broker,and barter exchange accounts government,school district,or
opened after 1983 and broker accounts considered inactive during prison)that receives agricultural
1983.You must sign the certification or backup withholding will apply. If program payments
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 15.Grantor trust filing under the Form The trust
certification before signing the form. 1041 Filing Method or the Optional
3.Real estate transactions.You must sign the certification.You may Form 1099 Filing Method 2(see
cross out item 2 of the certification. Regulations section 1.671-4(1b)(2)(i)(B))
4.Other payments.You must give your correct TIN,but you do not List first and circle the name of the person whose number you furnish.
have to sign the certification unless you have been notified that you If only one person on a joint account has an SSN,that person's number
have previously given an incorrect TIN."Other payments"include must be furnished.
payments made in the course of the requester's trade or business for 2 Circle the minor's name and furnish the minor's SSN.
rents,royalties,goods(other than bills for merchandise),medical and
health care services(including payments to corporations),payments to 3 You must show your individual name and you may also enter your
a nonemployee for services, payments made in settlement of payment business or DBA name on the"Business name/disregarded entity"
card and third party network transactions,payments to certain fishing name line.You may use either your SSN or EIN (if you have one),but the
boat crew members and fishermen,and gross proceeds paid to IRS encourages you to use your SSN.
attorneys(including payments to corporations). 4 List first and circle the name of the trust,estate,or pension trust. (Do
5.Mortgage interest paid by you,acquisition or abandonment of not furnish the TIN of the personal representative or trustee unless the
secured property,cancellation of debt,qualified tuition program legal entity itself is not designated in the account title.)Also see Special
payments(under section 529),ABLE accounts(under section 529A), rules for partnerships,earlier.
IRA,Coverdell ESA,Archer MSA or HSA contributions or *Note:The grantor also must provide a Form W-9 to trustee of trust.
distributions,and pension distributions.You must give your correct Note:If no name is circled when more than one name is listed,the
TIN,but you do not have to sign the certification. number will be considered to be that of the first name listed.
What Name and Number To Give the Requester Secure Your Tax Records From Identity Theft
For this type of account: Give name and SSN of: Identity theft occurs when someone uses your personal information
1.Individual The individual such as your name,SSN,or other identifying information,without your
2.Two or more individuals Qoint The actual owner of the account or,if permission,to commit fraud or other crimes.An identity thief may use
account)other than an account combined funds,the first individual on your SSN to get a job or may file a tax return using your SSN to receive
maintained by an FFI the account' a refund.
3.Two or more U.S.persons Each holder of the account To reduce your risk:
(joint account maintained by an FFI) • Protect your SSN,
4.Custodial account of a minor The minor • Ensure your employer is protecting your SSN,and
(Uniform Gift to Minors Act) • Be careful when choosing a tax preparer.
5.a.The usual revocable savings trust The grantor-trustee' If your tax records are affected by identity theft and you receive a
(grantor is also trustee) notice from the IRS,respond right away to the name and phone number
b.So-called trust account that is not The actual owner printed on the IRS notice or letter.
a legal or valid trust under state law
If your tax records are not currently affected by identity theft but you
6.Sole proprietorship or disregarded The owner3 think you are at risk due to a lost or stolen purse or wallet,questionable
entity owned by an individual credit card activity or credit report,contact the IRS Identity Theft Hotline
7.Grantor trust filing under Optional The grantor* at 1-800-908-4490 or submit Form 14039.
Form 1099 Filing Method 1 (see For more information,see Pub.5027, Identity Theft Information for
Regulations section 1.6714(b)(2)(i) Taxpayers.
(A)) Victims of identity theft who are experiencing economic harm or a
For this type of account: Give name and EIN of: systemic problem,or are seeking help in resolving tax problems that
8.Disregarded entity not owned by an The owner have not been resolved through normal channels,may be eligible for
individual Taxpayer Advocate Service(TAS)assistance.You can reach TAS by
9.A valid trust,estate,or pension trust Legal entity4 calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD
1-800-829-4059.
10.Corporation or LLC electing The corporation Protect yourself from suspicious emails or phishing schemes.
corporate status on Form 8832 or Phishing is the creation and use of email and websites designed to
Form 2553 mimic legitimate business emails and websites.The most common act
11.Association,club,religious, The organization is sending an email to a user falsely claiming to be an established
charitable,educational,or other tax- legitimate enterprise in an attempt to scam the user into surrendering
exempt organization private information that will be used for identity theft.
12.Partnership or multi-member LLC The partnership
13.A broker or registered nominee The broker or nominee
Form W-9(Rev.10-2018) Page 6
The IRS does not initiate contacts with taxpayers via emails.Also,the privacy Act Notice
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers, passwords,or similar secret access Section 6109 of the Internal Revenue Code requires you to provide your
information for their credit card,bank,or other financial accounts. correct TIN to persons(including federal agencies)who are required to
If you receive an unsolicited email claiming to be from the IRS, file information returns with the IRS to report interest,dividends,or
certain other income paid to you;mortgage interest you paid;the
forward this message to phishing@irs.gov.You may also report misuse
of the IRS name,logo,or other IRS property to the Treasury Inspector acquisition tr abandonment d secured property;the cancellation of
General for Tax Administration(TIGTA)at 1-800-366-4484.You can debt;n contributions you made to in IRA,Archer the for to
The
forward suspicious emails to the Federal Trade Commission at person collecting this form uses the information o the form to file
spam@uce.gov or report them at www.ftc.gov/complaint. You can information returns with the IRS, reporting the above information.
contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT(877-438-4338). Routine uses of this information include giving it to the Department of
If you have been the victim of identity theft,see www.ldentityTheft.gov Justice for civil and criminal litigation and to cities,states,the District of
and Pub.5027. Columbia,and U.S.commonwealths and possessions for use in
administering their laws.The information also may be disclosed to other
Visit www.irs.gov//dentityTheft to learn more about identity theft and countries under a treaty,to federal and state agencies to enforce civil
how to reduce your risk. and criminal laws,or to federal law enforcement and intelligence
agencies to combat terrorism.You must provide your TIN whether or
not you are required to file a tax return. Under section 3406, payers
must generally withhold a percentage of taxable interest,dividend,and
certain other payments to a payee who does not give a TIN to the payer.
Certain penalties may also apply for providing false or fraudulent
information.
Phone: (541)522-2259 Fax: (541)488-5314
DATE(MMIDD/YYYY)
ACORU® CERTIFICATE OF LIABILITY INSURANCE F
10109/2024
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
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).
PRODUCER CONTACT
NAME: Tatiana POstoronca
AIC Insurance Agency LLC PHOA/C"No Ext: 503-513-4453 FAX No: 503-513-5929
14000 SE Johnson Rd Ste 210 E-MAIL
ADDRESS: tpostoronca@aicinsagency.com
Milwaukie, OR 97267 INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA: Main Street America Insurance Group 27138M
INSURED INSURER B: Artisan &Truckers Casualty Company 10194
NIWA Method LLC INSURER : Austin Mutual Insurance Company
2329 N Bryant St INSURER D
Portland, OR 97217 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 00055339-240958 REVISION NUMBER: 4
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER MMIDD/YYYY MMIDD/YYYY
A X COMMERCIAL GENERAL LIABILITY Y CP00032133 09/18/2024 09/18/2025 EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE F�vl DAMAGE J OCCUR PREM SESOERENTED
a occurrence) $ 100,000
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
�( POLICY D PRO-
JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
MBIB AUTOMOBILE LIABILITY 971592172 07/19/2024 07/19/2025 EOa a.,deDtsINGLE LIMIT $ 1 000 000
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY X AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
C X UMBRELLA LAB X OCCUR C000004801 10/09/2024 10/09/2025 EACH OCCURRENCE $ 2,000,000
EXCESS LAB CLAIMS-MADE AGGREGATE $ 2,000,000
DED RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS.
20 East Main Street
Ashland, OR AUTHORIZED REPRESENTATIVE
WIe� A�4 TAP
@ 1988-201 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by TAP on 10/09/2024 at 12:11 PM
AMENDMENT NO. 1
to
GOODS & SERVICES AGREEMENT
between
THE CITY OF ASHLAND,
an Oregon municipal corporation,
�f1 Lityll)
and
NIWA METHOD, LLC,
a (corporation/company),
("Provider")
for
PO#20250153: Pine & Maple Pruning,Ashland Japanese Garden
RECITALS
A. The City and Provider previously entered into a Goods and Services Agreement effective October
23, 2024 (the"Agreement"), for pruning services at the Ashland Japanese Garden.
B. The City and Provider now wish to amend the Agreement to decrease the amount of
compensation to be paid to Provider.
AGREEMENT
NOW THEREFORE, in consideration of the mutual benefits and obligations set forth
herein, the parties agree as follows:
1. Amend Section 2 of the Agreement as follows, with strikeout wording deleted and
underscored wording added:
2.1 City shall pay Provider the sum of $17,405.79 ($'° �) as provided herein as full
compensation for the Work as specified in the SUPPORTING DOCUMENTS.
2.2 In no event shall Provider's total of all compensation and reimbursement under this
Agreement exceed the sum of $17,405.79 ($ °�0) without the express, written
approval from the City official whose signature appears below, or such official's
successor in office. Provider expressly acknowledges that no other person has authority
to order or authorize additional Work which would cause this maximum sum to be
exceeded and that any authorization from the responsible official must be in writing.
Provider further acknowledges that any Work delivered, or expenses incurred without
authorization as provided herein is done at Provider's own risk and as a volunteer without
expectation of compensation or reimbursement.
2. This Amendment No. 1 is effective upon being signed by both parties.
3. Except as specifically modified by this Amendment No. 1, the terms and conditions of the
Agreement remain in full force and effect.
Page 1 of 2: Amendment No. 1 to Goods& Services Agreement between the City of Ashland and Niwa Method,LLC
IN WITNESS WHEREf F the parties have caused this Amendment No. 1 to be signed in their
respective names by t y authorized representatives as of the dates set forth below:
CITY ASHL REGON NIWA METHOD,LLC
By: By:
koc1414ouston, Director Francheska Snyder
Printed Name:
Date: j f C22 h o2 Title: Owner/Operator
Date: 11/21/24
Page 2 of 2: Amendment No. 1 to Goods& Services Agreement between the City of Ashland and Niwa Method,LLC
Brandon Terry
From: Francheska Snyder <niwamethod@gmail.com>
Sent: Wednesday, November 20, 2024 9:04 AM
To: Sulaiman Shelton; Brandon Terry
Subject: Re: Updated Plan for December Visit
[EXTERNAL SENDER]
Hello Sulaiman,
The one day reduction for maintenance of the pine trees from our proposal is fine. We'll plan on working
December 2nd-5th.
The corresponding savings for this one day reduction is$1669.21.
This includes the pruning daily rate, per diem, and one night hotel stay for two rooms.
Thank you and I look forward to seeing you in December.
My Best,
Francheska
On Tue, Nov 19, 2024 at 10:40 AM Francheska Snyder<niwa method(@gmail.com>wrote:
Sorry for the delay. I will get back to you tomorrow.
Francheska Snyder
Niwa Method, LLC
Japanese Garden Craft
LIC.#9825
c: 503-893-4033
P.O. Box#14924
Portland, Oregon 97293
On Tue, Nov 12, 2024, 12:54 Sulaiman Shelton <sulaiman.shelton(@ashland.or.us>wrote:
Hi Francheska,
spoke with Pete and Noelle today, and we all agreed that shifting your time here to 4 days in
December would be the best idea considering the condition of two of the pines.
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Thank you for your flexibility!We will plan on December 2"d-5cn
If you could please respond to this email with an acknowledgement of the one day reduction, and
provide the corresponding savings based on that reduction that would be appreciated.
Let me know if you have any questions or concerns.
Kindly,
Sulaiman Shelton
Volunteer& Event Manager
Ashland Parks & Recreation Commission
1195 E Main St. Ashland, OR 97520
541-552-2264 Office 541-499-8798 Cell
sulaiman.sheltonPashland.or.us
This email transmission is official business of the City of Ashland,and it is subject to Oregon Public Records Law for
disclosure and retention. If you have received this message in error,please contact me at(541)552-2264.
Francheska Snyder
Niwa Method, LLC
Japanese Garden Craft
LIC.#9825
c: 503-893-4033
IP.O. IBox#14924
IFoirtland, Oregon 97293
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