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IP #928
For the full report on this improvement project, refer to the City Council agenda packets and/or Planning Commission agenda packets. PROJECT NO. 928 Hwy 169 Sound Wall (42nd to 49th) 11.6 11/18/13 Discussion about project and costs 11.1 01/21/14 Discussion with MnDOT reps 03/11/14 Open house 11.2 04/21/14 Discuss open house results Res. 14-75 05/12/14 Resolution supporting construction of a noise wall along TH 169 by the state of Minnesota Department of Transportation (improvement project No. 928) Item 11.3 06/15/15 Discuss 2016 Proposed MnDOT 169 noise wall project (improvement project no. 928) Res. 15-127 08/10/15 Resolution granting temporary right of way access to the Minnesota Department of Transportation for the Trunk Highway No. 169 noise wall construction and storm water site improvements (project no. 928). 2015-189 12/14/15 Resolution approving a cooperative construction agreement between the city of New Hope and the state of Minnesota Department of Transportation that provides for a lump sum payment for construction of a noise wall along TH 169 (improvement project no. 928) COUNCIL Request for Action Originating Department Approved for Agenda Agenda Section Public Works December 14, 2015 Development & Planning Item No. By: Bob Paschke, Director By: Kirk McDonald, City Manager 8.5 Resolution approving a cooperative construction agreement between the city of New Hope and the state of Minnesota Department of Transportation that provides for a lump sum payment for construction of a noise wall along TH 169 (improvement project No. 928). Requested Action Staff requests approval of a resolution approving an agreement between the city of New Hope and the state of Minnesota Department of Transportation (Mn/DOT). The agreement provides for a lump sum payment of $220,201 for the city's share of the construction costs to install a noise wall and storm sewer construction along the east side of TH 169, between 42nd Avenue and 49th Avenue. Background Through an agreement with Mn/DOT, the city took part in construction of a noise wall in 2003 and 2012. Those noise walls were constructed along the east side of TH 169 from approximately Medicine Lake Road to 36th Avenue and 36th to 42nd respectively. The project construction of the noise walls have been contracted and financed by Mn/DOT. In September 2013, Mn/DOT proposed the installation of a noise wall along Highway 169 in New Hope from 42nd Avenue to 49th Avenue. In January 2014, representatives from MNDOT attended a work session to requesting input and support for the project. The New Hope City Council requested Mn/DOT hold an informational open house meeting to discuss the project details with residents as well as send out a survey to allow residents to voice concerns, if any, regarding the project. In May of 2014, the New Hope City Council approved staff to pursue a cooperative construction agreement with Mn/DOT for the construction of a noise wall in 2016. Within the construction agreement it is outlined that the project funding is 90% by the state with a 10% share by the city of New Hope. The state's original total cost estimate was $1,200,000, leaving the city's share at $120,000. Motion by C�71C���7 L Second by J�4wv To: hRMPUBWORKS\2015\928 2016 MNDOT Hwy 169-Soundwall\928 MnDOT noise wall agreement\final-928 Mn -DOT Noise Wall Agreement - resolution.doc Request for Action, Page 2 December 14, 2015 As the project was being developed an opportunity to improve a storm water flooding issue was brought forward and discussed with council. To correct the storm water issue additional construction costs, engineering and additional funding were required, therefore, the project has increased over the original estimate. The city's portion of the updated cost estimate for the noise wall and storm sewer construction is $220,201.00, ($203,890.00, and associated construction engineering $16,311.00). Funding Storm Sewer and Street infrastructure funds Attachment • Resolution Construction Agreement Map exhibit I:\RFA\PUBWORKS\2015\928 2016 MNDOT Hwy 169-Soundwall\928 MnDOT noise wall agreement\final-928 Mn -DOT Noise Wall Agreement - resolution.doc City of New Hope Resolution No. 15 —18 9 Resolution approving a cooperative construction agreement between the city of New Hope and the state of Minnesota Department of Transportation that provides for a lump sum payment for construction of a noise wall along TH 169 (improvement project No. 928) WHEREAS, the state wishes to construct a sound wall within the city limits along Trunk Highway No. 169 between 42nd and 49th Avenues; and, WHEREAS, the state requests the city participate in the costs of the noise wall construction and the city agrees to participate in the cost of said construction with a lump sum amount equal to $220,201 and, WHEREAS, Minnesota statutes authorize the commissioner of transportation to make arrangements with and cooperate with any government authority for the purpose of constructing, maintaining, and improving the trunk highway system. NOW, THEREFORE, BE IT RESOLVED by the City Council of the city of New Hope, Minnesota: That the City of New Hope enter into Mn/DOT Agreement No. 1001525 with the State of Minnesota, Department of Transportation for the following purposes: 2. To provide for payment by the City to the State, of the City's share of the costs of the noise wall and storm sewer construction and other associated construction to be performed upon, along and adjacent to Trunk Highway No. 169 from County State Aid Highway No. 9 - 42nd Avenue North to 49th Avenue North within the corporate City limits under State Project No. 2772-103 (T.H. 169=383). IT IS FURTHER RESOLVED that the Mayor and the City Manager are authorized to execute the Agreement and any amendments to the Agreement. Adopted by the City Council of the city of New Hope, Hennepin County, Minnesota this 14th day of December, 2015. Mayor Attest: City Clerk I:\RFA\PUBW0RKS\2015\928 2016 MNDOT Hwy 169-Soundwall\928 MnDOT noise wall agreement\final-928 Mn -DOT Noise Wall Agreement - resolution.doe 0� December 15, 2015 Ms. Maryanne Kelly-Sonnek MnDOT 395 John Ireland Blvd, MS 682 St. Paul, MN 55155 Subject: State Project 2772-103 (169=383) At its meeting of December 14, 2015, the New Hope City Council approved the cooperative construction agreement with MnDOT for construction of a noise wall along TH 169 between 42-1 Avenue North to 491h Avenue North. The city understands its share of the project cost will be $220,201. Enclosed are two copies of the agreement executed by city officials. I have also included a copy of the city's resolution approving the agreement (Res. No. 2015-189). After the contracts are signed by state officials, please return one fully executed copy to my attention. Please direct questions regarding the project to Bob Paschke, public works director, at 763-592- 6766. Thank you. Sincerely, Valerie Leone, CMC City Clerk Enc. cc: Bob Paschke CITY OF NEW HOPE 4401 Xylon Avenue North • New Hope, Minnesota 55428-4898 • www. ci.new-hope.mn.us City Hall: 763-531-5100 • Police (non -emergency): 763-531-5170 • Public Works: 763-592-6777 City Hall Fax: 763-531-5136 • Police Fax: 763-531-5174 • Public Works Fax: 763-592-6776 D0%VxNRE$oP4 Minnesota Department of Transportation ' 395 John Ireland Boulevard �>oF TRPah¢o Saint Paul, MN 55155 January 11, 2016 Robert Paschke Director of Public Works, City of New Hope 5500 International Parkway New Hope, MN 55428 RE: Coop. Const. Agree. No. 1001525 City of New Hope S.P. 2772-103 (T.H. 169=383) State Funds City lump sum payment for noise wall construction by the State on T.H. 169 Contract Number 150187 Dear Mr. Paschke: (651) 366-4634 Mail Stop 682 Transmitted herewith for the City's use and retention, is a fully executed copy of the subject agreement between the City and this department. The agreement provides for a lump sum payment of $220,201.00 by the City to the State for the noise wall construction on Trunk Highway No. 169. An invoice in the amount of $220,201.00 will be forwarded to the City in a few days, and it is requested that payment be made accordingly. Sincerely, Marya ne Kelly-Sonnek Municipal Agreements Engineer Enclosures An Equal Opportunity Employer 0 0 050' 4-C2� 0 U.4 MnDOT Contract No: 1001525 STATE OF MINNESOTA DEPARTMENT OF TRANSPORTATION State Project Number (S.P.): Trunk Highway Number (T.H.): And CITY OF NEW HOPE COOPERATIVE CONSTRUCTION 2772-103 169=383 AGREEMENT Estimated Amount Receivable $220,201.00 This Agreement is between the State of Minnesota, acting through its Commissioner of Transportation ("State") and City of New Hope acting through its City Council ("City"). Recitals 1. The State will perform concrete posts, wood planking, noise wall and transportation management system (TMS) construction and other associated construction upon, along and adjacent to Trunk Highway No. 169 from County State Aid Highway No. 9 -42nd avenue north to 49`h avenue north according to State -prepared plans, specifications and special provisions designated by the State as State Project No. 2772-103 (T.H. 169=383)("Project"); and 2. The State requests the City participate in the costs of the noise wall construction and the City is willing to participate in the costs of said construction and associated construction engineering; and 3. The City has requested and granted the State access to install and relocate a drainage pipe to collect and discharge the storm water from the west side of the noise wall to an outlet; and 4. The City agrees to pay for the storm water pipe construction; and 5. Minnesota Statutes § 161.20, subdivision 2 authorizes the Commissioner of Transportation to make arrangements with and cooperate with any governmental authority for the purposes of constructing, maintaining and improving the trunk highway system. Agreement 1. Term of Agreement; Survival of Terms; Plans; Incorporation of Exhibits 1.1. Effective date. This Agreement will be effective on the date the State obtains all signatures required by Minnesota Statutes § 16C.05, subdivision 2. 1.2. Expiration date. This Agreement will expire when all obligations have been satisfactorily fulfilled. 1.3. Survival of terms. All clauses which impose obligations continuing in their nature and which must survive in order to give effect to their meaning will survive the expiration or termination of this Agreement, including, without limitation, the following clauses: 3. Maintenance by the City and State; 7. Liability; Worker Compensation Claims; 9. State Audits; 10. Government Data Practices; 11. Governing Law; Jurisdiction; Venue; and 13. Force Majeure. 1.4. Plans, Specifications, Special Provisions. Plans, specifications and special provisions designated by the State as State Project No. 2772-103 (T.H. 169=383) are on file in the office of the Commissioner of Transportation at St. Paul, Minnesota, and incorporated into this Agreement by reference. ("Project Plans") 1.5. Exhibits. Exhibit A is attached and incorporated into this agreement by reference. 2. Construction by the State 2.1. Contract Award. The State will advertise for bids and award a construction contract to the lowest responsible bidder according to the Project Plans. -1- Receivable Lump Sum (Municipal Agreements) MnDOT Contract No: 1001525 2.2. Direction, Supervision and Inspection of Construction. A. Supervision and Inspection by the State. The State will direct and supervise all construction activities performed under the construction contract, and perform all construction engineering and inspection functions in connection with the contract construction. All contract construction will be performed according to the Project Plans. B. Inspection by the City. The City participation construction covered under this Agreement will be open to inspection by the City. If the City believes the City participation construction covered under this Agreement has not been properly performed or that the construction is defective, the City will inform the State District Engineer's authorized representative in writing of those defects. Any recommendations made by the City are not binding on the State. The State will have the exclusive right to determine whether the State's contractor has satisfactorily performed the City participation construction covered under this Agreement. 2.3. Plan Changes, Additional Construction, Etc. A. The State will make changes in the Project Plans and contract construction, which may include the City participation construction covered under this Agreement, and will enter into any necessary addenda, change orders and supplemental agreements with the State's contractor that are necessary to cause the contract construction to be performed and completed in a satisfactory manner. B. The City may request additional work or changes to the work in the plans as part of the construction contract. Such request will be made by an exchange of letter(s) with the State. If the State determines that the requested additional work or plan changes are necessary or desirable and can be accommodated without undue disruption to the project, the State will cause the additional work or plan changes to be made. C. The State reserves the right to invoice the City for the cost of any additional City requested work and plan changes, including associated construction engineering, before the completion of the contract construction. 2.4. Satisfactory Completion of Contract. The State will perform all other acts and functions necessary to cause the construction contract to be completed in a satisfactory manner. Acceptance by the State of the completed contract construction will be final, binding and conclusive upon the City as to the satisfactory completion of the contract construction. 2.5. Replacement of Castings. Adjustments to certain City -owned facilities, including but not limited to, valve boxes and frame and ring castings, may be performed by the State's contractor under the construction contract. The City will furnish the contractor with new units and/or parts for those in place City -owned facilities when replacements are required and not covered by a contract pay item, without cost or expense to the State or the contractor, except for replacement of units and/or parts broken or damaged by the contractor. 3. Maintenance by the City and the State. Upon completion of the project, the maintenance will be as follows: 3.1. Storm Sewers. The State will be the lead agency responsible for ownership, maintenance (excluding sediment removal from sump structures 5003 and 5004), and operation of the storm sewer system, including all pipe and the following structures: 5011, 5012, 5001, 5002, 5003, and 5004. See Exhibit A depicting the storm sewer pipe structure locations. The City of New Hope will be responsible for sediment removal, at no cost or expense to the State, from sump structure number 5003, and for sediment removal at flared -end section structure number 5004. The City of New Hope will be responsible for ownership and maintenance of structure number 5100. -2- Receivable Lump Sum (Municipal Agreements) MnDOT Contract No: 1001525 The State will provide for all routine maintenance and operation of the system. Routine maintenance will include system inspection, debris, litter, vegetation, ice and sediment removal from structures: 5011, 5012, 5001, 5002 along with repair of drainage structures and pipes of the entire system. The State will inform the City in advance of any pipe flushing to ensure the sump in Structure 5003 is cleaned to catch sediment prior to water discharging to the wetland. If the State inspects structures 5003 and 5004 and deems that it is in need of sediment removal, the State will inform the City of the need. If the City fails to provide the sediment removal, the State reserves the right to provide that maintenance and invoice the City for the labor and equipment needed for the sediment removal. 3.2. Noise Walls. The City is responsible for the maintenance of the non -highway side of the noise wall. This includes vegetation control, graffiti removal on the non -highway side and any other maintenance activities necessary to perpetuate the walls in a safe, usable and aesthetically acceptable condition. The State is responsible for all other maintenance of the noise walls. 3.3. Additional Drainage. Neither party to this Agreement will drain any additional drainage volume into the storm sewer facilities constructed under the construction contract that was not included in the drainage for which the storm sewer facilities were designed, without first obtaining written permission to do so from the other party. The drainage areas served by the storm sewer facilities constructed under the construction contract are shown in a drainage area map, EXHIBIT "Drainage Area", which is on file in the office of the State's District Hydraulics Unit at Roseville and is incorporated into this Agreement by reference. 4. City Cost and Payment by the City 4.1. City Cost. $220,201.00 is the City's full and complete lump sum cost for the noise wall and storm sewer construction ($203,890.00), and associated construction engineering ($16,311.00). 4.2. Conditions of Payment. The City will pay the State the full and complete lump sum amount after the following conditions have been met: A. Execution of this Agreement and transmittal to the City. B. The City's receipt of a written request from the State for the advancement of funds. 5. Authorized Representatives Each party's Authorized Representative is responsible for administering this Agreement and is authorized to give and receive any notice or demand required or permitted by this Agreement. 5.1. The State's Authorized Representative will be: Name/Title: Maryanne Kelly-Sonnek, Municipal Agreements Engineer (or successor) Address: 395 John Ireland Boulevard, Mailstop 682, St. Paul, MN 55155 Telephone: (651) 366-4634 E -Mail: maryanne.kellysonnek@state.mn.us 5.2. The City's Authorized Representative will be: Name/Title: Robert Paschke, Director of Public Works, City of New Hope (or successor) Address: 5500 International Parkway, New Hope, MN 55428 Telephone: (763) 592-6777 E -Mail: bpaschke@ci.new-hope.mn.us 6. Assignment; Amendments; Waiver; Contract Complete 6.1. Assignment. Neither party may assignor transfer any rights or obligations under this Agreement without the prior consent of the other party and a written assignment agreement, executed and approved by the same parties who executed and approved this Agreement, or their successors in office. -3- Receivable 3- Receivable Lump Sum (Municipal Agreements) MnDOT Contract No: 1001525 6.2. Amendments. Any amendment to this Agreement must be in writing and will not be effective until it has been executed and approved by the same parties who executed and approved the original Agreement, or their successors in office. 6.3. Waiver. If a party fails to enforce any provision of this Agreement, that failure does not waive the provision or the party's right to subsequently enforce it. 6.4. Contract Complete. This Agreement contains all prior negotiations and agreements between the State and the City. No other understanding regarding this Agreement, whether written or oral, may be used to bind either party. 7. Liability; Worker Compensation Claims 7.1. Each party is responsible for its own acts, omissions and the results thereof to the extent authorized by law and will not be responsible for the acts and omissions of others and the results thereof. Minnesota Statutes § 3.736 and other applicable law govern liability of the State. Minnesota Statutes Chapter 466 and other applicable law govern liability of the City. 7.2. Each party is responsible for its own employees for any claims arising under the Workers Compensation Act. 7.3. The City will hold the State harmless from any liability due to the City's maintenance and operation of the storm sewer system or failure to maintain the system as stated in 3.1 above. Nothing in the Agreement constitutes a waiver by the City of any statutory or common law defenses, immunities or limits on liability. S. Nondiscrimination Provisions of Minnesota Statutes § 181.59 and of any applicable law relating to civil rights and discrimination are considered part of this Agreement. 9. State Audits Under Minnesota Statutes § 16C.05, subdivision 5, the City's books, records, documents, and accounting procedures and practices relevant to this Agreement are subject to examination by the State and the State Auditor or Legislative Auditor, as appropriate, for a minimum of six years from the end of this Agreement. 10. Government Data Practices The City and State must comply with the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13, as it applies to all data provided under this Agreement, and as it applies to all data created, collected, received, stored, used, maintained, or disseminated by the City under this Agreement. The civil remedies of Minnesota Statutes § 13.08 apply to the release of the data referred to in this clause by either the City or the State. 11. Governing Law; Jurisdiction; Venue Minnesota law governs the validity, interpretation and enforcement of this Agreement. Venue for all legal proceedings arising out of this Agreement, or its breach, must be in the appropriate state or federal court with competent jurisdiction in Ramsey County, Minnesota. 12. Termination; Suspension 12.1. By Mutual Agreement. This Agreement may be terminated by mutual agreement of the parties. 12.2. Termination for Insufficient Funding. The State may immediately terminate this Agreement if it does not obtain funding from the Minnesota Legislature, or other funding source; or if funding cannot be continued at a level sufficient to allow for the performance of contract construction under the Project. Termination must be by written or fax notice to the City. -4- Receivable Lump Sum (Municipal Agreements) MnDOT Contract No: 1001525 12.3. Suspension. In the event of a total or partial government shutdown, the State may suspend this Agreement and all work, activities and performance of work authorized through this Agreement. 13. Force Majeure Neither party will be responsible to the other for a failure to perform under this Agreement (or a delay in performance), if such failure or delay is due to a force majeure event. A force majeure event is an event beyond a party's reasonable control, including but not limited to, unusually severe weather, fire, floods, other acts of God, labor disputes, acts of war or terrorism, or public health emergencies. [The remainder of this page has been intentionally left blank] -5- Receivable Lump Sum (Municipal Agreements) CITY OF NEW HOPE The undersigned certify that they have lawfully executed this contract on behalf of the Governmental Unit as required by applicable charter provisions, resolutions or ordinances. By'e,c Ile ��' MnDOT Contract No: 1001525 DEPARTMENT OF TRANSPORTATION Recommended for Approval: By: A-0114 / (District Engineer) Date: 12-116115 Title: Mayor Approved: Date: 12/14/15 By: l By: � Date: (Sty Title: City Manager Date: 12/14/15 Engineer) I2/18/Zo1S COMMISSIONER OF ADMINISTRATION By: L'✓ (With delegated authority) Date: 0/ 4 INCLUDE COPY OF RESOLUTION APPROVING THE AGREEMENT AND AUTHORIZING ITS EXECUTION. In Receivable Lump Sum (Municipal Agreements) W E Q City of New Hope Resolution No. 15 —189 Resolution approving a cooperative construction agreement between the city of New Hope and the state of Minnesota Department of Transportation that provides for a lump sum payment for construction of a noise wall along TH 169 (improvement project No. 928) WHEREAS, the state wishes to construct a sound wall within the city limits along Trunk Highway No. 169 between 42nd and 49th Avenues; and, WHEREAS, the state requests the city participate in the costs of the noise wall construction and the city agrees to participate in the cost of said construction with a lump sum amount equal to $220,201 and, WHEREAS, Minnesota statutes authorize the commissioner of transportation to make arrangements with and cooperate with any government authority for the purpose of constructing, maintaining, and improving the trunk highway system. NOW, THEREFORE, BE IT RESOLVED by the City Council of the city of New Hope, Minnesota: 1. That the City of New Hope enter into Mn/DOT Agreement No. 1001525 with the State of Minnesota, Department of Transportation for the following purposes: 2. To provide for payment by the City to the State, of the City's share of the costs of the noise wall and storm sewer construction and other associated construction to be performed upon, along and adjacent to Trunk Highway No. 169 from County State Aid Highway No. 9 - 42nd Avenue North to 49th Avenue North within the corporate City limits under State Project No. 2772-103 (T.H. 169=383). IT IS FURTHER RESOLVED that the Mayor and the City Manager are authorized to execute the Agreement and any amendments to the Agreement. Adopted by the City Council of the city of New Hope, Hennepin County, Minnesota this 14th day of December, 2015. Mayor Attest: City Clerk I:\RFA\PUBW0RKS\2015\928 2016 MNDOT Hwy 169-Soundwall\928 MnDOT noise wall agreement\final-928 Mn -DOT Noise Wall Agreement - resolution.doc City of New Hope Resolution No. 15 —189 Resolution approving a cooperative construction agreement between the city of New Hope and the state of Minnesota Department of Transportation that provides for a lump sum payment for construction of a noise wall along TH 169 (improvement project No. 928) WHEREAS, the state wishes to construct a sound wall within the city limits along Trunk Highway No. 169 between 42nd and 49th Avenues; and, WHEREAS, the state requests the city participate in the costs of the noise wall construction and the city agrees to participate in the cost of said construction with a lump sum amount equal to $220,201 and, WHEREAS, Minnesota statutes authorize the commissioner of transportation to make arrangements with and cooperate with any government authority for the purpose of constructing, maintaining, and improving the trunk highway system. NOW, THEREFORE, BE IT RESOLVED by the City Council of the city of New Hope, Minnesota: That the City of New Hope enter into Mn/DOT Agreement No. 1001525 with the State of Minnesota, Department of Transportation for the following purposes: 2. To provide for payment by the City to the State, of the City's share of the costs of the noise wall and storm sewer construction and other associated construction to be performed upon, along and adjacent to Trunk Highway No. 169 from County State Aid Highway No. 9 - 42nd Avenue North to 49th Avenue North within the corporate City limits under State Project No. 2772-103 (T.H. 169=383). IT IS FURTHER RESOLVED that the Mayor and the City Manager are authorized to execute the Agreement and any amendments to the Agreement. Adopted by the City Council of the city of New Hope, Hennepin County, Minnesota this 14th day of December, 2015. Mayor Attest: City Clerk hRMPUBWORKS\2015\928 2016 MNDOT Hwy 169-Soundwall\928 MnDOT noise wall agreement\final-928 Mn -DOT Noise Wall Agreement - resolution.doc December 7, 2015 Mr. Rod Byholm MnDOT 1500 West County Road B2 Roseville, MN 55113 Subject: S.P. 2771-103RW CS: 2772 (169=5;383) 511 Job TRW225243 Address: 9401 49� Avenue North Enclosed please find two executed copies of the following: • Offer to Sell and Memorandum of Conditions • Drainage Easement I have also enclosed resolution no. 15-127 granting temporary right-of-way access and resolution no. 14-75 in support of the project. Sincerely, q9 IC /Zl6ye� Valerie Leone, CMC City Clerk Enc. cc: Bob Paschke, Director of Public Works (project 928) CITY OF NEW HOPE 4401 Xylon Avenue North • New Hope, Minnesota 55428-4898 • www. ci.new-hope.mn.us City Hall: 763-531-5100 • Police (non -emergency): 763-531-5170 • Public Works: 763-592-6777 City Hall Fax: 763-531-5136 • Police Fax: 763-531-5174 • Public Works Fax: 763-592-6776 Office of Land Management (2-98) STATE OF MINNESOTAI RECOMMENDED FOR APPROVAL DEPARTMENT OF TRANSPORTATION Supervisor of Direct Purchase APPROVED OFFER TO SELL AND MEMORANDUM OF CONDITIONS B C.S.: 2772 (169=5;383) 511 Parcel: 233 County: Hennepin Owners and addresses: City of New Hope, 4401 Xylon Ave. N., New Hope, Minnesota, 55428; For a valuable consideration, on this "1 day of, �� , 2-01 S the undersigned owners hereby offer to sell and convey to the State of Minnesota an easement in the real estate or an interest therein situated in Hennepin County, Minnesota, described in the copy of the instrument of conveyance hereto attached. The undersigned parties have this day executed an instrument for the conveyance of the aforesaid real estate or an interest therein to the State of Minnesota, and have conditionally delivered the same to the State of Minnesota, which instrument shall have no effect until and unless this offer to sell and convey is accepted in' writing by the Office of Land Management of the Minnesota Department of Transportation within ninety (90) days from the date of this offer. Such notice of acceptance shall be by certified mail directed to the address appearing after our signatures hereto. If this offer is not so accepted within the time limited herein such conveyance shall be of no effect, and said instrument shall forthwith be returned to the undersigned owners. If this offer is accepted it is mutually agreed by and between the owners and the State as follows: (1) Possession of the real estate shall transfer to the State on the date of acceptance. The owners shall have the right to continue to occupy the property or to rent same to the present occupants or others until the date of transfer of possession. Any change in occupancy shall be subject to approval and concurrence by the State. On or before the date for transfer or possession the owners will vacate the real estate and the improvements (if any) located thereon, or cause same to be vacated, remove all personal effects therefrom and have all utilities (if any) shut off by the supplier of same. No buildings appurtenances or other non -personal items or fixtures will be removed from the premises by the owners or renters, including plumbing and heating fixtures, etc. The owners shall notify the Department of Transportation as soon as the improvements are vacated. The owners will maintain the improvements during their period of occupancy and will make all necessary repairs at their own expense. The State's prospective bidders for the purchase or demolition of the improvements on the property shall have the right of entry for inspection purposes during the last 10 days of possession by the owners. (2) Title to said easement interest shall pass to the State of Minnesota as of the date of said acceptance subject to conditions hereinafter stated. OWNERS CITY OF NEW H PE By ;� Its GLwY �4�- And Its �:tpmm- (Address of Owner where acceptance is to be mailed.) 4401 Xylon Avenue North New Hope, MN 55428 DRAINAGE EASEMENT Date: / I5 C.S. 2772 (169=5;383) 511 Parcel 233 County of Hennepin For valuable consideration, City of New Hope, a municipal corporation under the laws of the state of Minnesota, Grantors, (whether one or more), hereby convey and warrant to the State of Minnesota, Grantee, a drainage easement in perpetuity for the construction and maintenance of a drainage system, together with the unrestricted right to improve the same, free and clear of all encumbrances on the following described premises in Hennepin County, Minnesota: All of the following: An easement in perpetuity for drainage purposes on that part of Outlot A, PLUFKA FIRST ADDITION, shown as Parcel 233 on Minnesota Department of Transportation Right of Way Plat Numbered 27-228 as the same is on file and of record in the office of the Registrar of Titles in and for Hennepin County, Minnesota; the title thereto being registered as evidenced by Certificate of Title No. 669222. Grantors are the owners of the above described premises and have the lawful right and authority to convey and grant the easement herein granted. Grantee shall have the right of ingress to and egress from the hereinbefore described property for the purpose of maintaining and repairing said drainage system. The said Grantors do hereby release the State of Minnesota from any claims for damages to the fair market value of the above-described area covered by the drainage easement and for their use, or any claims for damages to the fair market value of the remaining property of Grantors caused by the use of the drainage easement, including grading and removal of materials from said easement area for highway purposes. Notwithstanding the foregoing, Grantors do not release any claims Grantors may have as a result of the negligence of the Grantee, its agents or contractors, in conducting any of the above activities. Page 1 of 2 CITY OF NEW VORE By 41,L _ ff�a Its T And 1 Its STATE OF MINNESOTA ) )SS. COUNTY OF HENNEPIN ) Th,Q foregoing instrument was acknowledged before me this day of A615 by 16U11i and k r-rK x"1'1/�C�� _ la( , the _ 1LLL/m and r��A-4 of City of Ne Hope, a municipal corporation under the laws of the state of Mi nesota, on behalf of the municipal corporation. NOTARY PUBLIC My commission expires: %-3 /- VALERIE LEONE This instrument was drafted by the yC affiSonRY uc•MJNNEsoTa My Cpmrttission Expires Jan. 3t, 2020 State of Minnesota, Department of Transportation, Metro Right of Way, 1500 W. County Road B2 Roseville, MN 55113 Page 2 of 2 RESOLUTION NO. 15 12 7 RESOLUTION GRANTING TEMPORARY RIGHT OF WAY ACCESS TO THE MINNESOTA DEPARTMENT OF TRANSPORTATION FOR THE CONSTRUCTION OF TRUNK HIGHWAY NO. 169 NOISE WALL (PROJECT 928) BE IT RESOLVED by the City Council of the City of New Hope as follows: WHEREAS, the Minnesota Department Of Transportation has required a temporary right of way access to complete the 2016 Trunk Highway No. 169 sound wall project; and WHEREAS, the City of New Hope will grant the Minnesota Department of Transportation a temporary right of way access to Outlot A, Plufka First Addition, Hennepin County, Minnesota, per the attached Zero Dollar Permit to Construct and Exhibit A which are incorporated herein by this reference; and WHEREAS, it would be in the best interests of the City and its people to authorize the temporary right of way access NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of New Hope as follows: That the temporary right of way access is hereby granted. Adopted by the New Hope City Council on August 10, 2015. Kathi Hemken, Mayor Attest: Valerie Leone, City Clerk I: RFA \ Pubworks \ 2015 \ NINDOT 169 Noise Wall temp access ZERO DOLLAR PERMIT TO CONSTRUCT C.S. 2772 (169=5;383) 511 Parcel 233 Dated: June 25, 2015 County of Hennepin The State of Minnesota has by its Commissioner of Transportation established and designated the route of Trunk Highway No. 169 in Hennepin County, Minnesota. It is necessary that the State of Minnesota use for highway purposes real property situated in Hennepin County, Minnesota, as shown on "EXHIBIT A": The undersigned, having an interest in the above described real property, understand that they are not required to surrender possession of real property without just compensation and are not required to surrender lawfully occupied real property without at least 90 days notice. For a valuable consideration, the undersigned hereby waive these rights and give the State of Minnesota an immediate right of entry and permit to Construct. This Permit will expire when construction is completed. T -Id-� Sign re �XM �Att4fy Date Signature Pic MeA Date Signature Date Signature Date City of New Hope Resolution No. 14 - 75 Resolution supporting construction of a noise wall along TH 169 by the state of Minnesota Department of Transportation (improvement project No. 928) WHEREAS, the state proposes noise wall construction within the city lints along Trunk Highway No. 169; and, WHEREAS, the state requests the city participate in the costs of the noise wall construction and the city agrees to participate in the cost of said construction with a sum amount equal to ten percent; and, WHEREAS, Minnesota statutes authorize the commissioner of transportation to make arrangements with and cooperate with any government authority for the purpose of constructing, maintaining, and improving the trunk highway system. NOW, THEREFORE, BE IT RESOLVED by the City Council of the city of New Hope, Minnesota: 1. New Hope supports construction of a 2016 noise wall project by the state of Minnesota Department of Transportation; Project MnDot SP 2772-103. 2. The city will assist in construction of a noise wall, by providing ten percent of the cost, as the city's share. 3. The noise wall is proposed along and adjacent to Trunk Highway No. 169, from 42nd Avenue to 49th Avenue within the corporate city limits. 4. The mayor and city manager are authorized and directed to sign the same on behalf of the city: Adopted by the City Council of the city of New Hope, Hennepin County, Minnesota this' 12th day of May, 2014. Mayor Attest: City Clerk bO�,r1NESp)gy0 Minnesota Department of Transportation 1500 County Road B2 �y� Roseville, MN 55113 OFTRP Date: City of New Hope 4401 Xylon Ave. N. New Hope, MN 55428 In reply refer to: S.P.: 2772-103RW C.S.: 2772 (169=5;383) 511 Job: TRW225243 County: Hennepin Parcel: 233 - City of New Hope Property Address: 9401 49th Ave N, New Hope, MN 55428 The State of Minnesota, through the Department of Transportation (MnDOT), is acquiring part of your property for the improvement of Trunk Highway 169. The person delivering this letter is a real estate specialist representing MnDOT. This individual will explain the procedures involved in the acquisition process. The State's valuation report is included with this letter. The monetary damage to your property due to this acquisition is for valuable consideration, this being the State's certified offer. Please be advised that lawful owners and/or occupants of the property on the date of this offer may be entitled to relocation assistance/benefits in accordance with Federal and State laws. It is important that you read the information provided in the purchase packet. It will help you to understand your rights during the acquisition process and also to assist you in making sound decisions. 14ESGT4t Rod Byholm Real Estate Representative OF TaP`' Metro District 1500 West County Road B2 Roseville, MN 55113 Office: (651) 234-7556 Cell : (763) 614-8835 Fax: (651) 234-7549 E-mail: rod.byholm@state.mn.us An Equal unity Employer E) 0 00- © - o As the acquisition of your property proceeds, you will undoubtedly have additional questions. Please direct them to the MnDOT representative who submitted this offer. Sincerely, �11 �/� Tom O'Keefe, P.E., Director Metro District Program Delivery Package Contents: "Guide for Property Owners" Booklet Legal Description describing acquisition Offer to Sell and Memorandum of Conditions (reference copy if applicable) Conveyance Instrument (reference copy if applicable) "Relocation Assistance" Booklet (if applicable) Acquisition Incidental Claim form Plat map (if applicable) Parcel sketch Receipt of Valuation Report: Date: Owner: DRAINAGE EASEMENT Date: C.S. 2772 (169=5;383) 511 Parcel 233 County of Hennepin For valuable consideration, City of New Hope, a municipal corporation under the laws of the state of Minnesota, Grantors, (whether one or more), hereby convey and warrant to the State of Minnesota, Grantee, a drainage easement in perpetuity for the construction and maintenance of a drainage system, together with the unrestricted right to improve the same, free and clear of all encumbrances on the following described premises in Hennepin County, Minnesota: All of the following: An easement in perpetuity for drainage purposes on that part of Outlot A, PLUFKA FIRST ADDITION, shown as Parcel 233 on Minnesota Department of Transportation Right of Way Plat Numbered 27-228 as the same is on file and of record in the office of the Registrar of Titles in and for Hennepin County, Minnesota; the title thereto being registered as evidenced by Certificate of Title No. 669222. Grantors are the owners of the above described premises and have the lawful right and authority to convey and grant the easement herein granted. Grantee shall have the right of ingress to and egress from the hereinbefore described property for the purpose of maintaining and repairing said drainage system. The said Grantors do hereby release the State of Minnesota from any claims for damages to the fair market value of the above-described area covered by the drainage easement and for their use, or any claims for damages to the fair market value of the remaining property of Grantors caused by the use of the drainage easement, including grading and removal of materials from said easement area for highway purposes. Notwithstanding the foregoing, Grantors do not release any claims Grantors may have as a result of the negligence of the Grantee, its agents or contractors, in conducting any of the above activities. Page 1 of 2 CITY OF NEW HOPE By Its And Its STATE OF MINNESOTA ) )SS. COUNTY OF HENNEPIN ) The foregoing instrument was acknowledged before me this , by day of and the and of City of New Hope, a municipal corporation under the laws of the state of Minnesota, on behalf of the municipal corporation. NOTARY PUBLIC My commission expires: This instrument was drafted by the State of Minnesota, Department of Transportation, Metro Right of Way, 1500 W. County Road B2 Roseville, MN 55113 Page 2 of 2 N...,Uvl yuw on.vvr WUliluu V Uli' W W Il I!- WW `V� L5 L5W I! VU �` MINNESOTA DEPARTMENT OF TRANSPORTATION �•`�; Topographic Information required: Proposed R/W line & access taking. L® ensi s.�'H>s�wr Shoal north arrow. Outline & location of buildings & Improvements. Streets or highway frontage. C.S. 2772(169=5;383)511 S.P. 2772-103 COUNTY Hennepin PARCEL NO. 233 OWNER City of New Hope ScaIe 1" = 100 ft. N 121T NI1 T QUARTER C - 49TH AVE. N. 'u I S 2 lig W WLIOD' 1 _U I 3 SCALE IN FEET aM s 4 W 1,,W OUTLOT A 5 ~ Z�N6 Z a� � 01 to 7 LL z z �,� P e O PVF N a N /4- W1 411 to -• 12 W 13 OA Z T CL 14 8 6 O • 21 cc 15 0 .. 0 ti � 16 9 5 A` `v 20 17 t{ 1 ` I 19 18 1 p 10 4 NO IT 16 LS 3 NZ 11 I J ID 22 21 I`vA` 23 le 15 12 2 1 — I c 5 5 16 I 20 19 14 13 1 . ail 24 ..vaao �i � � F o Layout sketch by PDP Date 7-10-2015 Parcel No. 233 September 10, 2015 2772-511-233 Parcel 233 C.S. 2772 (169=5;383) 511 S.P. 2772-103RW All of the following: An easement in perpetuity for drainage purposes on that part of Outlot A, PLUFKA FIRST ADDITION, shown as Parcel 233 on Minnesota Department of Transportation Right of Way Plat Numbered 27-228 as the same is on file and of record in the office of the Registrar of Titles in and for Hennepin County, Minnesota; the title thereto being registered as evidenced by Certificate of Title No. 669222. Torrens RW - AC - TE Page 1 of 1 LD1009 9/10/2015 Office of Land Management (2-98) STATE OF MINNESOTAI RECOMMENDED FOR APPROVAL DEPARTMENT OF TRANSPORTATION Supervisor of Direct Purchase APPROVED OFFER TO SELL AND MEMORANDUM OF CONDITIONS B C.S.: 2772 (169=5;383) 511 Parcel: 233 County: Hennepin Owners and addresses: City of New Hope, 4401 Xylon Ave. N., New Hope, Minnesota, 55428; For a valuable consideration, on this day of, , the undersigned owners hereby offer to sell and convey to the State of Minnesota an easement in the real estate or an interest therein situated in Hennepin County, Minnesota, described in the copy of the instrument of conveyance hereto attached. The undersigned parties have this day executed an instrument for the conveyance of the aforesaid real estate or an interest therein to the State of Minnesota, and have conditionally delivered the same to the State of Minnesota, which instrument shall have no effect until and unless this offer to sell and convey is accepted in writing by the Office of Land Management of the Minnesota Department of Transportation within ninety (90) days from the date of this offer. Such notice of acceptance shall be by certified mail directed to the address appearing after our signatures hereto. If this offer is not so accepted within the time limited herein such conveyance shall be of no effect, and said instrument shall forthwith be returned to the undersigned owners. If this offer is accepted it is mutually agreed by and between the owners and the State as follows: (1) Possession of the real estate shall transfer to the State on the date of acceptance. The owners shall have the right to continue to occupy the property or to rent same to the present occupants or others until the date of transfer of possession. Any change in occupancy shall be subject to approval and concurrence by the State. On or before the date for transfer or possession the owners will vacate the real estate and the improvements (if any) located thereon, or cause same to be vacated, remove all personal effects therefrom and have all utilities (if any) shut off by the supplier of same. No buildings appurtenances or other non -personal items or fixtures will be removed from the premises by the owners or renters, including plumbing and heating fixtures, etc. The owners shall notify the Department of Transportation as soon as the improvements are vacated. The owners will maintain the improvements during their period of occupancy and will make all necessary repairs at their own expense. The State's prospective bidders for the purchase or demolition of the improvements on the property shall have the right of entry for inspection purposes during the last 10 days of possession by the owners. (2) Title to said easement interest shall pass to the State of Minnesota as of the date of said acceptance subject to conditions hereinafter stated. (3) Buildings (if any) on said real estate shall be insured by the owners against loss by fire and windstorm in the amount of present coverage or if none in force then in an amount not less than the current market value during the entire period of the owners' occupancy of the buildings on the real estate, such policy or policies of insurance to be endorsed to show the State's interest. (4) If the State of Minnesota is acquiring all or a major portion of the property, mortgages (if any) on the property shall be satisfied in full by the State of Minnesota. The amount paid by the State of Minnesota to satisfy said mortgage(s) shall be deducted from the amount to be paid to the owners under the terms of this agreement. The amount paid by the State of Minnesota to satisfy the mortgage(s) shall include interest on the mortgage(s) to date that payment is made to the mortgage holder. (5) If the State of Minnesota is acquiring only a minor portion of the property, and the property is encumbered by a mortgage, it shall be the responsibility of the owners to furnish a written consent of mortgagee. Any fee charged by the mortgage holder for the written consent of mortgage must be paid for by the owners. (6) The owners will pay all delinquent (if any) and all current real estate taxes, whether deferred or not, which are a lien against the property. Current taxes shall include those payable in the calendar year in which this document is dated. The owners will also pay in full any special assessments, whether deferred or not, which are a lien against the property. The owners will also be responsible for and will pay in full any pending special assessments. The owners' obligation to pay deferred and pending_taxes and assessments shall continue after the sale and shall not merge with the delivery and acceptance of the deed. (7) If encumbrances, mechanics liens or other items intervene before the date the instrument of conveyance is presented for recording and same are not satisfied or acknowledged by the owners as to validity and amount and payment thereof authorized by the owners, said instrument of conveyance shall be returned to the owners. (8) Payment to the owners shall be made :in the due course of the State's business after payment of taxes, assessments, mortgages and all other liens or encumbrances against said real estate. The owners will not be required to vacate the property until the owners have received payment. (9) No payments shall be made of any part of the consideration for said sale until marketable title is found to be in the owners and until said instrument of conveyance has been recorded. (10) The owners hereby acknowledge receipt of a copy of the instrument of conveyance executed by them on this date, and a copy of this offer and memorandum. (11) It is understood that unless otherwise hereinafter stated the State acquires all appurtenances belonging to the premises including: Vacant property. OWNERS CITY OF NEW HOPE By Its And Its (Address of Owner where acceptance is to be mailed.) 4401 Xylon Avenue North New Hope, MN 55428 (3/2014) Minnesota Department of Transportation ACQUISITION INCIDENTAL CLAIM FOR OFFICIAL USE ONLY Name (Payee) City of N Address 4401 Xylon , Dist. DM - Metro - V S.P. 2772-103RW Parcel 233 C.S. 2772 (169=5:3 C.ID. 0 Fed No. State Func County Hennepin Prop. Owner City of Parcel Address 94 City/State/Zip New Hor . N. 511 r (< U Advance Claim LJ Partial Claim LJ Final Claim FOR OFFICIAL USE ONLY Approved Amount Approved By Approved By OLM Authorization Date Application Approved Mail Check to: Name Address City/State/Zip FOR OFFICIAL USE ONLY Vendor Number: A. Service fee charged by Mortgage for Partial Release of Mortgage $ B. Pre -payment penalty charged by Mortgagee $ C. Abstract costs (Optional - see explanation on back of form) $ D. Court costs $ TOTAL PAYMENT $ Residency Certification: I attest, under penalty of perjury, that myself and my family, are lawful citizens of the United States, or aliens lawfully admitted for residence in the United States; OR, I attest, under penalty of perjury, that myself and/or members of this partnership, association or corporation are lawfully citizens of United States or aliens lawfully admitted for residency and authorized to conduct business in the United States. I, the undersigned, do hereby certify that the above information is correct, and that any receipts or statements attached hereto accurately represent the expenses incurred. I further certify that I have not submitted any other claim for reimbursement of, or have received compensation or reimbursement for, any expense in connection with this claim. I understand that any falsification of any portion of this claim will result in its denial. MAIL CLAIM TO: Date Telephone Name (print) Signature Incidental Claim DP1023 11/23/2015 (see over for instructions on filling a claim) BEFORE YOU MAIL THIS CLAIM, PLEASE READ BELOW Have you enclosed proper receipts where the need for such receipt is indicated in the instructions? Have you signed this claim form and indicated the address to which you wish the reimbursement check mailed? INSTRUCTIONS FOR FILING OF CLAIM A. ❑ SERVICE FEES CHARGED BY MORTGAGEE FOR A PARTIAL RELEASE OF MORTGAGE Mortgage Partial Release fees may, if requested by the Owner, be paid directly to the Mortgagee by the Agency, or be reimbursed if paid directly to the Mortgagee by the Owner. (See instructions below.) B. ❑ PRE -PAYMENT PENALTY CHARGED BY MORTGAGEE Mortgage Pre -Payment Penalties may, if requested by the Owner, be paid directly to the Mortgagee by the Agency, or be reimbursed if paid directly to the Mortgagee by the Owner. (See instructions below.) Instructions for Filing Claims for Items A. or B. above: • If requesting direct payment by the Agency to a Mortgagee, submit this completed claim form, along with: ❑ a letter from the Owner to the Agency, requesting direct payment be made to the Mortgagee; and ❑ a copy of the Mortgagee's fee statement or letter indicating the amount due • If requesting reimbursement of fees paid directly to the Mortgagee, then submit this claim form, along with evidence of fees receipted and processed by the Mortgagee. Such evidence must, at a minimum, include: ❑ a copy of the Mortgagee's fee statement or letter indicating the amount due; and at least one of the following: ❑ a copy of a receipt of payment from the Mortgagee; or ❑ the original cancelled check paid to the Mortgagee; or ❑ other evidence that payment has been received and processed by the Mortgagee; or ❑ in the case of a Partial Release, a copy of the executed Partial Release document. C. ❑ ABSTRACT COSTS (Optional) We emphasize that this particular item is entirely optional. It is not required by the state that you incur any expenses whatsoever. It is only if you wish to have your property abstract up -dated to show the state's acquisition that these instructions apply. o You are eligible to be reimbursed for only that cost of an abstract continuation which is attributable to the State's acquisition. o You cannot be reimbursed by the State for: (1) the entry on your abstract of any transfer which took place before or after the transfer to the State; (2) Abstractor's Certificate; (3) Tax Certificates; (4) Lien or Judgment searches. o It is likely that the abstract cost reimbursement will be considerable less than the total cost that you will incur. o Special Instructions: To qualify for this reimbursement, you must take or send your property abstract to a Registered Abstractor or to the Office of the Register of Deeds in the County where the affected property is located. The property abstract may then be brought up to date by the Abstractor or Register of Deeds. When the Abstractor or the Register of Deeds has been paid for his services, the claimant should ask for a receipt which includes a completely itemized breakdown of the total fee charged. The breakdown must indicate what portion of the fee is attributable of those entries which deal with only the State's acquisition. If you decide to forego the up -dating of the abstract, and thereby waive your eligibility to reimbursement for this item, please indicate by writing in ink the word "none" and your initials in the blank opposite item "C" on the claim form. Such a waiver will have no effect whatever on your eligibility to be reimbursed for other expenses you may have incurred, if any. D. ❑ COURT COSTS You are eligible to be reimbursed (upon presentation of an itemized receipted bill) for expenses incurred, including reasonable attorney's fees, for obtaining a court -approved agreement for a guardian or conservator to sell to the state under M.S. '525.67 and the guardian's or conservator's deed. Incidental Claim DP1023 11/23/2015 Schedule of Appraisal Fees Be especially aware that if you decide to get your own appraisal and you have a property other than a single or two family dwelling and the offer amount is less than $10,000.00, a minimum damage acquisition (MDA), you are only eligible for a $1500.00 reimbursement. The appraiser must be licensed at the appropriate level for the type of appraisal required. The following fees apply: Residential Properties Single and two family dwellings $1,500.00 (No matter how much is offered up to and including the entire property) Commercial and all other types of Properties Other than single or two family dwellings Where the amount offered for the acquisition including any and all damages is less than $10,000.00 (See MDA)* $1,500.00 If the amount offered is $10,000.00 or greater (for properties other than single or two family dwellings) the owner may be entitled to an appraisal reimbursement up to; $5,000.00 However, before proceeding — Check with the Real Estate Representative who tendered this Offer. *MDA (Minimum Damage Acquisitions) An Offer Amount of $10,000.00 or less On all types properties — Residential — Multi -Family — Vacant Land — Commercial/Industrial Zoned $1,500.00 Verbal Appraisal All appraisals must be in writing —There is NO reimbursement for a verbal appraisal report. 11/22/2013 Form W-9 Request for Taxpayer Give Form to the (Rev. December 2014)Identification Number and Certification requester. Do not Department of the Treasury Send to the IRS. Internal Revenue Service 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. Business name/disregarded entity name, if different from above N2 N m Ca °- 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to ° ❑Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate certain entities, not individuals; see instructions on page 3): MC Z:. .2 single -member LLC ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ► Exempt payee code (f any) p i Note. For a single -member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for Exemption from FATCA reporting a the tax classification of the single -member owner. code (if any) n` V ❑ Other (see instructions) 10 -(Applies to accounts maintained outside the U.S.) 5 Address (number, street, and apt. or suite no.) Requester's name and address (optional) a� CLv y City, state, and ZIP code W U) 7 List account number(s) here (optional) 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 (SSN). However, fora resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other _ m _ entities. it is vour emolover identification number ON). If you do not have a number, see How to pet a TIN on page 3. or Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for I Employer identification number guidelines on whose number to enter. F -T-1 KUTMI" 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. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); 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 on page 3. Sign Signature of Here I U.S. person ► Date Do - General General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9. 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 (ATIN), 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 1099 -INT (interest earned or paid) • Form 1099 -DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-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? on page 2. By signing the filled -out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information. Cat. No. 10231X Form W-9 (Rev. 12-2014) Form W-9 (Rev. 12-2014) Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien; • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; • An estate (other than a foreign estate); or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners' share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 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 that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income. In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States: • In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity; • In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and • In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust. Foreign person. If you are a foreign person or the U.S. branch of a 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 Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. If you are a U.S, resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items: 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese 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 the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233. Backup Withholding What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. This is called "backup withholding." Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if 1. You do not furnish your TIN to the requester, 2. You do not certify your TIN when required (see the Part II instructions on page 3 for details), Page 2 3. The IRS tells the requester that you furnished an incorrect TIN, 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See Exempt payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information. Also see Special rules for partnerships above. What is FATCA reporting? The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information. Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties. Specific Instructions Line 1 You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return. If this Form W-9 is for a joint account, list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name. Note. [TIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1 a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application. b. Sole proprietor or single -member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or "doing business as" (DBA) name on line 2. c. Partnership, LLC that is not a single -member LLC, C Corporation, or S Corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2. d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2. e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a "disregarded entity." See Regulations section 301.7701-2(c)(2)(iii). Enter 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 name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, "Business name/disregarded entity name." If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN. Form W-9 (Rev. 12-2014) Page 3 Line 2 If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2. Line 3 Check the appropriate box in line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box in line 3. Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a partnership for U.S. federal tax purposes, check the "Limited Liability Company" box and enter "P" in the space provided. If the LLC has filed Form 8832 or 2553 to be taxed as a corporation, check the "Limited Liability Company" box and in the space provided enter "C" for C corporation or "S" for S corporation. If it is a single -member LLC that is a disregarded entity, do not check the "Limited Liability Company" box; instead check the first box in line 3 "Individual/sole proprietor or single -member LLC." Line 4, Exemptions If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space in line 4 any code(s) that may apply to you. Exempt payee code. • Generally, individuals (including sole proprietors) are not exempt from backup withholding. • Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends. • Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions. • Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC. The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4. 1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(%2) 2—The United States or any of its agencies or instrumentalities 3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities 4—A foreign government or any of its political subdivisions, agencies, or instrumentalities 5—A corporation 6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession 7—A futures commission merchant registered with the Commodity Futures Trading Commission 8—A real estate investment trust 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 The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13. IF the payment is for ... THEN the payment Is exempt for ... Interest and dividend payments All exempt payees except for 7 Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012. Barter exchange transactions and Exempt payees 1 through 4 patronage dividends Payments over $600 required to be Generally, exempt payees reported and direct sales over $5,000' 1 through 52 Payments made in settlement of Exempt payees 1 through 4 payment card or third party network transactions See Form 1099-MISC, Miscellaneous Income, and its instructions. 2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045 ft and payments for services paid by a federal executive agency. Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with "Not Applicable" (or any similar indication) written or printed on the line for a FATCA exemption code. A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37) B—The United States or any of its agencies or instrumentalities C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i) E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(1) F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state G—A real estate investment trust H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940 —A common trust fund as defined in section 584(a) J—A bank as defined in section 581 K—A broker L—A trust exempt from tax under section 664 or described in section 4947(a)(1) M—A tax exempt trust under a section 403(b) plan or section 457(g) plan Note. You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed. Line 5 Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns. Line 6 Enter your city, state, and ZIP code. Part I. Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS 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 below. If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN. If you are a single -member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on this page), enter the owner's SSN (or EIN, if the owner has one). Do not enter the disregarded entity's EIN. If the LLC is classified as a corporation or partnership, enter the entity's EIN. Note. See the chart on page 4 for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS -5, Application for a Social Security Card, from your local SSA office or get this form online at www.ssa.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS -4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS -4 from the IRS by visiting IRS.gov or by calling 1 -800 -TAX -FORM (1-800-829-3676). If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write "Applied For" in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on 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 you provide your TIN to the requester. Note. Entering "Applied For" means that you have already applied for a TIN or that you intend to apply for one soon. Caution: A disregarded U.S_ entity that has a foreign owner must use the appropriate Form W-8. Form W-9 (Rev. 12-2014) Page 4 Part II. Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 4, or 5 below indicate otherwise. For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code earlier. Signature requirements. Complete the certification as indicated in items 1 through 5 below. 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If 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 certification before signing the form. 3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification. 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. "Other payments" include payments made in the course of the requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations). S. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. What Name and Number To Give the Requester For this type of account: Give name and SSN of: 1. Individual The individual 2. Two or more individuals Qoint The actual owner of the account or, account) if combined funds, the first individual on the account 3. Custodian account of a minor The minor' (Uniform Gift to Minors Act) 4. a. The usual revocable savings The grantor -trustee' trust (grantor is also trustee) b. So-called trust account that is The actual owner' not a legal or valid trust under state law 5. Sole proprietorship or disregarded The owner entity owned by an individual 6. Grantor trust filing under Optional The grantor* Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i) (A)) For this type of account: Give name and EIN of: 7. Disregarded entity not owned by an The owner individual 8. A valid trust, estate, or pension trust Legal entity' 9. Corporation or LLC electing The corporation corporate status on Form 8832 or Form 2553 10. Association, club, religious, The organization charitable, educational, or other tax- exempt organization 11. Partnership or multi -member LLC The partnership 12. A broker or registered nominee The broker or nominee 13. Account with the Department of The public entity Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments 14. Grantor trust filing under the Form The trust 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i) (B)) List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person's number must be furnished. 2 Circle the minor's name and furnish the minor's SSN. s You must show your individual name and you may also enter your business or DBA name on the "Business name/disregarded entity" name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN. 4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 2. *Note. Grantor also must provide a Form W-9 to trustee of trust. Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed. Secure Your Tax Records from Identity Theft Identity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund. To reduce your risk: • Protect your SSN, • Ensure your employer is protecting your SSN, and • Be careful when choosing a tax preparer. If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter. If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039. For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance. Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 orTTY/TDD 1-800-829-4059. Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft. The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts. If you receive an unsolicited email claiming to be from the IRS, forward this message to phishingGirs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at: spam@uce.gov or contact them at www.fic.go0citheff or 1-877-IDTHEFT (1-877-438-4338). Visit IRS.gov to learn more about identity theft and how to reduce your risk. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil 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.