Loading...
The EMS Super Store LLC CIQ 11.30.23Cily af Denton PurchasIngal13 Twas St Cbnton. TX 76200DENTONPhan: W)) 34671(X) WWwxJentonpuMasing.corn Substitute we Form The IRS requires all vendas to oompbte a W'9 Form. Ttte information on this form must be filled out, signed and sukxnttted by a vendor representative. All informatIon must be completed before a purchase Older or paWnwlt \MII be issued. Name as shown on your Income tax return:The EMS Super Store LLC Tax IDISodal SecurIty +:824639690 Under penalties of perjury, I aedify that I. The number 8hwn on this form is my cwrwt taxtaxpay© IdenttfiaHon number (or 1 am mlting fa 8 nunt)or to be issu$d to mo), and 2. 1 om not 8ubjoct to backup Wthholdlng beau so (8) 1 am exempt from backup wAtholding, or (b) I have not been notified by the Internal Revenue Servloe (IRS) that I am 6ut4ect to backup u#thholding ITIl Wn:iVo?A ras a result of nlure to report all Interest or,divIdends, or (c) the IRS has naMed me that I am no long6r sut89ct to backup VEl:ljiig£ml atr&el la. PrInted HaIIIng Addns+; Company Name: Contact Name: The EMS Super Store ERniE info@theemssuperstore.mn Tom Sanders WebgtB: ww.th8emssuperstore.com &Id„B, 2800 Canton Rd Suite 1240 Pha„ N,mb,, 770672791 1 Fax Number Marietta, GA 30066 CheGk BppropHat6 box for federal tel g181stncauan Inqulred): Individual/n Sda 1 D C{xWnbm I r-] P8nnershipProprktor Must daslgnaa C or S Limited 18 A:Loon Other El Ple8se specify: aa G SO p== Busbus Type :Red 651818 L] RwUA+n• (A1) Equipment IF RnUkau8 (A'g)D a ReyaHe6 (AQ) NeIIbeIdl se & Sufbu CA,7) U MRlhaVHeath Care (M) Swkn Orgy {A,D 7)D Men:hands+GuIds otty (+7)U bed Fbtn/Anomey (APC) CaIRAnt/Profn Few(+7)Pull:ha&m (S) lmml Real Estate =a Type of CkganizaUon;a a==:Y [] Female Owned [] Non Profit B Histodally UnderuHlbedBusiness ( 'D8finltion afa U.S. Person+or Federal Tax pwpos88, wu are consld8ted a U.S. persul tf you 8r8: (a) an IndIvidual who is a U.S. citizen or U.S. resid#It (b) a p8nnwship, wlxxation, tx)mlnny, or 8$80ci8tk>n ara818d or organized in the UnIta States or under the laws of the UnIted States (c) an estate (other than a foreIgn e$tate), or (d) a donn80c trust (as defIned in Regulations Section 301.7701-7). COD Page 1 9/23/201 1 rIder InformatIon Not Rl Form c.,mw„yN,m, The EMS Super Store LLC c,„b,t Nu„„ Tom Sanders ABA RouW: Ccxttact Name : Md,A„ 2800 Canton RD Bank Account# Bank Name :Suite1 240 Marietta GA 30066 ACH Email : Email, info@thooms superstore.com ACH Email : PMe Numb, 7706727911 Phone Number Fax NunaiecFax Numb8c I jwe) authorIze the CIty r#D•rtttn to depa8ttpaprwtts kIIO the ehecklng •eennt l8t@l. Theauthartty remaIn• in ethel untII the Ctty of Dontwlh•• nulved wrItten rtotlfie•Bon fInn nn of t8tmlrtadon Irt time to 8How rea•onaU• apportwHtyto ast m k, or until the CIty of Denton has sent mewritten naea af t8rmlna6aIr#th• agr&anrenl VHrdor 81gnatun Print Nam•fIlth Date LIU Products and/or $erq£a9 krt8nsted in BIddIng: For htemal Use Only1] N8wVondor n Vendor ChangeE Refund Vendor NamUr Requesting De{nnrnent:Date: Department Represent88w (PHntBd Halle) ! }\ Purchashg Signature:Date: ( I COD Page 2 9/23/2011 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other Doreen doing busIness wIth local governmental e e FMMm This quo$tionnaho b tulng fibd in accordance with Chapter l76, Local Government Code, by a vendor who has a bu8inau relatIonship as donnedby SectIon 176.001(1-a) vHth a kIWI govemmHltal entity and the vendor meets requirunents under S8ctlul 176.(m(8) and by City of DentonEthics Code, Ordin8nce IB-757. By law thIs questionnaire must be fibd with the reaxrb admlnisVabIr of the laal govnnment entity not later than the 7th buslne® day after th,date tha vendor tntx>mos aware of facts that require the statement to be ebd. Sae Sectbn 176.006{8.1 }, Local Gowmmont Code. A vudor canmit3 an agerm if the verxlor knowIngly violates SecOul 176.(X)6, Local GovernmuR CaI8. An offense undH this section b ami8domaanor.a 'Tk 2 U Check thIs box if you are fiIIng •n update to a pwlotnty flbd tpmHwlrnlr& (The bw nquiru that yar nb an updated mmpletBd questionn8im wIth the 8pprwrbtB fIIng authority not lator than the 7" busIness day3Rer the date on which you tncame 8wn that the originally fibd qJestknnairo was hmvMta n InamlratB.) d N8ne of bed goveranat onk:u aUnt when the laf8rma&m b &II ncdea b bdaB MInd. -Top-tn-by had ev ifName of Offioer Describe each arrployman or ahn busia6ss nlaaardtip with the local gwcnmrwt eaten, or a family number of the ofEic% as dacdbcd tv Section 176.tX13(8X2XA). At&r cbscritn arv family nlation$ hip with the local Bo\uwnau oaicu. This 8u6m, (itnn 3 including £ubparts A, B, C & D). mud becompleted for each affiwr with whom the vendor has an cmploymau or other txrsinu£ nl4aaaship ag dctirHd by Snlioa 176.CH 1( 14), LInd Gowrnment CodeAttach wklnimal pgn to this Form CIQ as annsar$ A. Is the laul Buvcrwrurt oaiaer named in this 6esBon receiving or likely to rush'e taxable home, other than iwc atanK income, awar Un veutMaYesNo B. k the wachx rwcivinB nr likely to receive taxable iacuru, other than investrrRnt iawne, from ur at ale diKctitn uf the luul government officer named in this section AND the taxable incorn jg lwt naivsd from the local gowrnmmhJ entity?n Yes ml C.k the filu of this or£xdoturaire CIIployed by a crxporatiur w other business waV with respur to which the local govcmment officer sewn as an afb£w or dir%nr, or holds an awrnt£hip aTonement or more? LJ Yes UZJ No r)thscribe adr arploymcnt or businus and family HIUinn£hip with the local gwnnmcnt officer mEnaI in this section. 4 I have no ColdIct a brterwt to dIsclose. 5 iGiurc oE Ms==;;iiiieW;tlriii;FaR Fnm \11 n 9 Request for TaxpayerIdentIfIcatIon Number and CertIfIcatIon Gtv• Form to th• WIV. adobe 2018)[Hiztnent gf tt8Teagr#ykTtWnd Revnw Uvb - roqtrostor. Do notsend to the IRS. I s Urn dark > Go to www+&awfFumWB far tn8tnndorn and ere lateet hIfonnatkn. The EMS SWr Store LLCa : W&Rmilate box Im hdua1 tax dasslflc,aIm of the parse@MmmmI-ne 1. CMMmEH9l1 talbwhgwvnbons.dI [] bwahwsobpqHdau B : +gb+wmtw LIE !8: ] 1 [] ah+bwhdnRgon}>8c ] 12800 Canton RD SuIte 1240 i 4 Exemptk>ns (codes app:y oriy tocertdn •fTtRIU. not hdlvHu&; 8n insbuctbns on page :3):D C Capaatim [/]SC,upuatbn a PartnHst+[] TamASale [d] Umaed lawty company. ErRB the tax cbsst6cadon W, eorporatbr\ bS eapentk>n, bP#In#shU pJ HaIn Cteak tIn anprupriat6 box h the In8 above for tIn tax eb•st6calim of the •Inql+memtw aw\n th not che::k £urJ:LIt:: WIn:£jtoT;::113 :It;SIrITIS Emm:;HE:=IT !t8£hl cade A any)Is diwegaded from tIn cwu #wtd check tIe qVr4#gte lux in itn tax chul fk:dIon d Its ownw. Exenpt lnya8 ccxta (tWIg) Exnnpllur frOm FATCA newSnO &Alxlb8 b HOtXJB mOd+Hd adda Itu aBI I s MarIetta GA 3CXi66Ta===iniiFiaTE;atMl ii a Fammppropriate kxlx. The nN provided must match the name given m Uno I to avoidknckup wtttfrokling. For ind}vidtrab, this b gwlardy your social smurity numbR {SSN). However, hr are$idmt allen, sole lnprtetu, or di$regeded entIty, soe the ktgruatkxls for Part I, later. Fu athnen&ties, it is your employer identification nt#nEar (EIN). If you do Int have a nutT#>w, sw How to get aTIN. later -=[H Note: if tIn acaoult is in more that one nnrte, su the Instructluls for line 1. Also sse What Name and Nurrdnr To Give tIn Rat}uast6r far guiddlna6 on whose number to mtar. aRm e 1. The nrEnb& shawl on thIs tum b my ctxrBct taxpayer identification numtw (Or I am waIting for a numlw to be i=ued to me); and2. 1 am not suM to backup wtthhokBIIg bnal,lse: (a) I am exempt from bukup wKhhaldlng, or b) I have ncR been notIfied by the Int&rnal R8vnknSevic8 ORS) that I am subject to backup wIthholdIng as a ruult af a faillro to nfxxt all krtarest or cfvidoRi6, or (c) the FIS has notIfied me that I am no longer 8ubjoct to backup wFthhdding; and Under per8ltlw of perJury, I certify that: 3. 1 8rn a U.S. citIzen or oBrw U.S. persm Wlned bak>wI; and C•rtt$cgUon Ingbrx:tkn•. You must aus out IBm 2 above if you tuva ben nc>UtM by the IRS that wn are currontb 6ubJotit to backup witHtokJhg<:IIons, ltwn 2 does nat HPV. Fa mortgage Intwast pdd\II trrtwast an} dMd6rd8 Ulwa tax rdum. For real 66l8l8yw have fallwl ta n IH„-,t <nA>. arxi g„tHa% WWtsof 8ewred property, cancdatim of ddR 10acqddtion u dIvidends, you are See the instructiu6 Ia Part II, lat©9quirod tQ 'i$1ttnco'Whatkx1' tHt Wother th#1 intent 4. The FATGA wHo{8) enterul m tHs tum (if any) Indicating thgt I am exemF# fran FATGA rapcxting is correct. aHere glgrurtrn ofU£p•naII b General II ons and the htemal Revenue Code unless othBwiseSet;tim reflnoted. ======2funds) • Form 109bMISC {various types of income, prizes, awardsIXQeoedb)Futrze dw8loptnerrt& For the latest Ink>rm8Uon atnut devebpmentsrdatuJ to Form W-9 and Its instructions, such as legislatIon enacted aftu they wwe published, go to www.inawfFormW9. • nm ICHbB (stock or mutual fund sales utd certain alher transwtlwn by tXt$tOrs) Purpose of Form • Fwm 109bS brocaods from real ®tat8 transactions) ' Fern 10MK {merchant aard and thIrd party natwork tran&actkxr6) An hdMdual or &Why (Form wa rBquosta} who is nqutmd ta Hb anInf©matlu r6trzn wtth the IRS mLBt obtdn your carrotit taxpayorIdutlflcatton number (TIN) whIch may be your wcial security number (SW), indivklual taxpayer IdenttHrntiRt numb+ OTIN), adoptIontaxpayer Idmttfication number (ATIN), or WTvioye Iden$ficatkn number{EIN), to report on an Information return the amount paId to you, or atheamount nportaUo on an Information return. Examples of Infotmatiwlrgtwns Include, but are not limit# to, the folknMng. • Fwm 1098 (home mortgago inte®t), 10984 (student loan interest),109&T Mtion) • Fern 1099-C (cancded debt) Use Fun W-9 only if wu are a U. S. pewin Oncluding a r%idwttalien), to provIde your wrecK TIN. • Farm 1 CUbA (a£xluisHo or abandonmwt of sectxed property) • nm 1(MINT Interest earned or paid) If yurI do mt return Form W'9 to the rwlester with a TIN, pu mightbe subJect to ba#up wtthholcRng. Sw VWlat b backup witt#dding,hter Cal. No. 1a231x R