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Haney, Brenda CIQ 12.16.2024Docusign Envelope ID: 3477DBD6-2799-4BFC-8EBE-306868E9D6291/17/20251/20/2025 Docusign Envelope ID: 3477DBD6-2799-4BFC-8EBE-306868E9D629 Tax ID/Social Security #: Individual/ Sole Proprietor Partnership Limited Liability Corporation Other Please specify: Exempt Payee Business Type :Equipment Rental/Lease (A-9)Royalties (A-2) Medical/Health Care (A-6) Merchandise- Goods Only (A-7) Merchandise & Services (A-7)Legal Firm/Attorney (A-C) Proceeds from Real Estate Purchases (S) Type of Organization:Female Owned Non Profit Historically Underutilized Business City of Denton Purchasing 901-B Texas St. Denton, TX 76209 Phone: (940) 349-7100 Fax: (940) 349-7302 www.dentonpurchasing.com Authorized Signature:____________________________ Printed Name:_______________________________________ Mailing Address: Consultant/Prof Fees (A-7) Company Name: Real Estate Rental/Lease (A1) Check appropriate box for federal tax classification (required): 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 page*. *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). C Corporation Minority Owned Name as shown on your income tax return: 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. Services Only (A- 7) Contact Name: Address: Phone Number: Fax Number: S Must designate C or S Email: Website: COD Page 1 9/23/2011 Brenda A Haney 454538614 Brenda A. Haney 4519 13th St Lubbock, TX 79416 X 4. I unsderstand that I must disclose any conflict of interest in accordance with Section 176.006 (a-1) of the Local Government Code. Remit Address (if different from above) Email: List Products and/or Services Interested in Bidding: For Internal Use Only Requesting Department: Date: Purchasing Signature: Date: ACH Information-Voluntary 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. Bank Name : ABA Routing#: Contact Name : Bank Account# Vendor Number Company Name: Contact Name: Address: ACH Email : Phone Number: Phone Number: Fax Number: Fax Number: Vendor Change Refund New Vendor Vendor Signature __________________________ Print Name/Title ____________________________ Date _____________________________________ Department Representative (Printed Name) ________________________________________________________ ACH Email : Vendor Information Not Required for W-9 Form COD Page 2 9/23/2011 111000614 373373783 Chase Docusign Envelope ID: 3477DBD6-2799-4BFC-8EBE-306868E9D629 Docusign Envelope ID: 3477DBD6-2799-4BFC-8EBE-306868E9D629 Imagery ©2024 TerraMetrics, Map data ©2024 Google, INEGI 50 mi Explore new places along this route Add suggested stops 4 hr 53 min 304 miles via US-82 E Fastest route now due to trac conditions  4 hr 57 min 302 miles via US-82 E and TX-114 5 hr 10 min 329 miles via US-82 E and US-82 E Drive 304 miles, 4 hr 53 min4519 13th St, Lubbock, TX 79416 to 1527 S Mayhill Rd, Denton, TX 76208 12/17/24, 9:26 AM 4519 13th St, Lubbock, TX 79416 to 1527 S Mayhill Rd, Denton, TX 76208 - Google Maps https://www.google.com/maps/dir/4519+13th+St,+Lubbock,+TX+79416/1527+S+Mayhill+Rd,+Denton,+TX+76208/@33.5006539,-102.1372719,10003…1/1 Docusign Envelope ID: 3477DBD6-2799-4BFC-8EBE-306868E9D629 Certificate Of Completion Envelope Id: 3477DBD6-2799-4BFC-8EBE-306868E9D629 Status: Completed Subject: Complete with Docusign: Expense Report_BrendaHaney.pdf Source Envelope: Document Pages: 6 Signatures: 2 Envelope Originator: Certificate Pages: 5 Initials: 0 Kendra Williams AutoNav: Enabled EnvelopeId Stamping: Enabled Time Zone: (UTC-06:00) Central Time (US & Canada) 901B Texas Street Denton, TX 76209 kendra.williams@cityofdenton.com IP Address: 198.49.140.104 Record Tracking Status: Original 1/17/2025 12:59:46 PM Holder: Kendra Williams kendra.williams@cityofdenton.com Location: DocuSign Signer Events Signature Timestamp Brian Boerner Brian.Boerner@cityofdenton.com Director of Solid Waste SWR Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.10 Sent: 1/17/2025 1:04:19 PM Viewed: 1/17/2025 1:23:37 PM Signed: 1/17/2025 1:24:01 PM Electronic Record and Signature Disclosure: Accepted: 1/17/2025 1:23:37 PM ID: 06bb51c5-d12a-4138-8df6-038063defa28 Megan Gilbreath Megan.Gilbreath@cityofdenton.com HR Director City of Denton - Human Resources Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 209.55.117.179 Sent: 1/17/2025 1:24:02 PM Viewed: 1/20/2025 2:16:34 PM Signed: 1/20/2025 2:16:39 PM Electronic Record and Signature Disclosure: Not Offered via DocuSign In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 1/17/2025 1:04:19 PM Certified Delivered Security Checked 1/20/2025 2:16:34 PM Signing Complete Security Checked 1/20/2025 2:16:39 PM Envelope Summary Events Status Timestamps Completed Security Checked 1/20/2025 2:16:39 PM Payment Events Status Timestamps Electronic Record and Signature Disclosure ELECTRONIC RECORD AND SIGNATURE DISCLOSURE From time to time, City of Denton (we, us or Company) may be required by law to provide to you certain written notices or disclosures. 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Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from us. Electronic Record and Signature Disclosure created on: 7/21/2017 3:59:03 PM Parties agreed to: Brian Boerner How to contact City of Denton: You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows: To contact us by email send messages to: purchasing@cityofdenton.com To advise City of Denton of your new e-mail address To let us know of a change in your e-mail address where we should send notices and disclosures electronically to you, you must send an email message to us at melissa.kraft@cityofdenton.com and in the body of such request you must state: your previous e-mail address, your new e-mail address. 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