Buehler Transfer & Storage of Texas CIQ 7.24.23City of Denton Purchasing
901-B Texas St. Denton, TX 76209
Phone: (940) 349-7100 Fax: (940) 349-7302
www.dentonpurchasing.com
Substitute W-9 Form
The IRS requires all vendors to complete a W-9 Form. The information on this form must be filled out, signed and submitted by a
vendor representative. All information must be completed before a purchase order or payment will be issued.
Name as shown on your income tax return:
Tax ID/Social Security#:
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9' 3 -II 11 l 7 ·1
Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxtaxpayer 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 witholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding
as a result of 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 US citizen or other U.S. person-for fededral tax purposes as defined at the bottom of this paQe*. 4. I unsderstand that I must disclose any conflict of interest in accordance with Sedion 176.006 (a-1) of he local Government'l:ode.
Authorized Signature: C(d d ---Printed Name: , acl r
Check appropriate box for federal tax classification (required):
D
D
Individual/
Sole
Proprietor
Exempt
Payee
Business Type :
Type of Organization:
Corporation
Must designate C or S
~ c
0 s
Real Estate
D Rental/Lease (A1)
Services Only (A-
7)
Consultani/Prof
0 Fees (A-7)
D Minority
Owned
D Partnership
Equipment
D Rental/Lease (A-9)
Merchandise-
D Goods Only (A-7)
Proceeds from
Real Estate
0 Purchases (S)
D Female Owned
Fax Number:
Limited
0 Liability
Corporation
D Royalties (A-2)
Merchandise &
0 Services (A-7)
D Non Profit
-------------------------
Other
D Please specify:
0 Medical/Health Care (A-6)
0 Legal Firm/Attorney (A-C)
D Historically Underutilized
Business
*Definition of a U.S. Person-For Federal Tax purposes, you are considered a U.S. person if you are: (a) an individual who is a U.S. citizen or
U.S. resident (b) a partnership, corporation, company, or association created or organized in the United States or under the laws of the United
States (c) an estate (other than a foreign estate), or (d) a domestic trust (as defined in Regulations Section 301.7701-7).
COD Page 1 9/23/2011
Vendor Information Not Required for W-9 Form
Remit Address (if different from above)
Company Name:---------------------------
Contact Name: ----,T.--r-1/i....-i'e.~-------
Address: ----~,L-u _________ _
Email: --------------
Phone Number: --------------
Fax Number: --------------
For Internal Use Only
0 New Vendor
D Vendor Change
D Refund
Requesting Department: ------------------------
Vendor Number
ACH Information-Voluntary
ABA Routing#:------------------------
Contact Name : --------------
Bank Account# --------------
Bank Name : --------------
ACH Email : --------------
ACH Email : -------------
Phone Number: ---------------
Fax Number:--------------
I (we) authorize the City of Denton to deposit
payments into the checking account listed. The
authority remains in effect until the City of Denton
has received written notification from me of
termination in time to allow reasonable opportunity
to act on it, or until the City of Denton has sent me
written notice of termination of the agreement.
Vendor Signature-----------
Print Name/Title------------
Date _______________ _
Date:
Department Representative (Printed Name)--------------------------
Purchasing Signature: Date:
COD Page 2 9/23/2011
CONFLICT OF INTEREST QUESTIONNAIRE -FORM CIQ
For vendor or other person doing business with local governmental entity
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined
by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Secti on 176.006(a) and by City of Denton
Ethics Code, Ordinance 18-757.
By law this questionnaire must be filed with the records administrator of the local government entity not later than the 7th business day after the
date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1 ), Local Government Code.
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a
misdemeanor.
1 Name of vendor who has a business relationship with local governmental entity.
r-B vch / ~ r Tr-~" sl'cr qf'J ~~ora?,..e of /e ;cq_s
2
1--D Check this box if you are filing an update to a previously filed questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 71h business day
after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) W Name of local government officer about whom the inform ation in this section is being disclosed.
Name of Officer
Describe each employment or other business relationship with the local government officer, or a family member of the offi cer, as described by Section
176.003(a)(2)(A). Also describe any family relations hip with the local government officer. This section, (item 3 including subparts A, B, C & D), must be
completed for each officer with whom the vendor has an employment or other business relationship as defined by Section 176.00 I ( 1-a), Local Government Code.
Attach additional pages to this Fonn CIQ as necessary.
A. Is the local government officer named in this section receiving or likely to receive tax able income, other than investment income, from the vendor?
D Yes ~No
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer nan1ed in
this section AND the taxable income is not received from the local governmental entity?
D Yes )KJ No
C. Is the filer of this questi01maire employed by a corporation or other business entity with respect to which the local government officer serves as an officer
or director, or holds an ownership of one percent or more?
D Yes ~No
D. Describe each employment or business and fan1ily relationship wiU1 the local govenunent officer named in this section.
4
5
1--
p I have no Conflict of Interest to disclose.
Signature of vendor doing business with the governmental entity
7-J-tf-~o)J
Date
Form W-9 Request for Taxpayer Give Form to the
(Rev. October 2018) Identification Number and Certification requester. Do not
send to the IRS. Department of the Treasury Internal Revenue Service .,.. Go to www.irs.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.
Buehler Transfer and Storage of Texas
2 Business name/disregarded entity name, if different from above
<'i
ell 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
Ol following seven boxes. certain entities, not individuals; see Ol a. instructions on page 3):
c D Individual/sole proprietor or 0 C Corporation 0 S Corporation D Partnership D TrusVestate 0 . "' single-member LLC Exempt payee code Of any) ell c Q.O ~:g D Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ~>-
.... :I 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 0 .... 1:t:) ·-c:
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is code Of any) another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that .... -0. 0 I;: is disregarded from the owner should check the appropriate box for the tax classification of its owner.
'(3 D Other (see instructions) "" (Apptia~ lo accounts maintained oul$ido tho U.S.} ell a. 5 Address (number, street, and apt. or suite no.) See instructions. Requester's name and address (optional) (/)
ell 633 Many Street ell If)
6 City, state, and ZIP code
Fort Worth, Texas 76102-1705
7 list account number(s) here (optionaQ
.:f.Ti ll. Taxpayer Identification Number (TIN)
Enter you~ TIN in, the app;opri.ate box. ~h~ TIN provided must. match the name given on line 1 to ayoLd
backup wtthholdlng. For mdtVlduals, thts 1s generally your soc1al security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
I Social security number I ITIJ -ITJ -1 I I I I
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
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 1 am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form [If any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement {IRA), and generally, payments
other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign
Here Signature of
U.S. person~>-
General Instructions
Sestien references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number {A TIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1 099-INT (interest earned or paid)
Cat. No. 10231X
Date~>-0
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1 099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1 099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1 099-S (proceeds from real estate transactions)
• Form 1 099-K (merchant card and third party networik transactions)
• Form 1098 (home mortgage interest), 1 098-E (student loan interest),
1098-T (tuition)
• Form 1 099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Form W-9 (Rev. 10-2018)