Exh 4Bs `mil R
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~ - l~.- 9g
CITY OF ATLANTIC BEACH
t CITY COMMISSION MEETING
STAFF REPORT
~'
AGENDA ITEM: Insect Control & Fertilization of City Lawns and Landscaped Areas
And Pest Control for City Buildings
SUBMITTED BY: Timmy Johnson, Recreation Director
DATE: March 19, 1999
BACKGROUND: The Awards Committee met Wednesday, March 17 at 3:00 PM
to open bid number 9899-17 entitled, Insect Control & Fertilization
of City Lawns and Landscaped Areas and Pest Control for City
Buildings. The Committee received the following bids:
` McCall Service, Inc. $ 7,092
Pest Master Services, Inc. $ 7,500
Pest Control, Inc. Incomplete
The funding for this service was approved during the budget
process. This bid is $4081ess than last year's bid.
RECOMMENDATION: Award bid no.9899-17 to McCall Services, Inc. in the amount of
$7,092 for Insect Control & Fertilization of City Lawns and
Landscaped Areas and Pest Control for City Buildings.
ATTACHMENTS: Bid Specifications
Bid Tabulation Sheet
Bid from McCall Services, Inc.
REVIEWED BY CITY MANAGER:
AGENDA IT
~~
TABULATION OF BIDS
INSECT CONTROL s FERTILIZATION
FOR OF CITY LAWNS AND LANDSCAPED ARE CITY OF
ATLANTIC BEACH, FLORIDA
S~ Date of Opening 3/17/99
Department ALL
AND PEST CONTROL FOR CITY BUILDI CS.
'
BID NUMBER 9899-1~ BUG OUT SERVICE. INC.
Jacksonville. FL McCALL SERVICE, INC.
Neptune Beach, FL PESTMASTER SERVICES
Jacksonville, FL
ITEM BRIEF DESCRIPTION UNIT PRICE EXT. PRICE UNIT PRICE EXT. PRICE UNIT PRICE EXT. PRICE UNIT PRICE EXT. PRICE UNIT PRICE EXT. PRICE
1. QUARTERLY COST TO TREAT ALL
LIFT STATIONS: i,5 /35
2. TOTAL ANNUAL COST TO TREAT ALL
.LOCATIONS PIONTHLY AND QUARTERLY: rJS CO
K
BID BOND / /
ORIGINAL INSURANCE CERTIFICATES fY~lSS~nIG / ~/
THREE (3) REFERENCES / / /
PROOF OF OCCUPATIONAL LICENSES / / /
BID SUBPIITTED IN TRIPLICATE ~ / /
DOCUh1ENTS RE UIREPIENTS CHECKLIST ~ / /
~~
COMMENTS ~!{s ~- ~~CP.i:F1l !C[V S Tl9~F= Rf~ev-rG; ~t/O f7wilKQ t rt!~'• ~/1(j /LeJ~+9~C::~ 9~~1~ -/ 7 i e~
/LICCHLG $EllVf C~~Si/G /iv ~fE.~~ ,~;l~lGtJn~ r ~ ,~ rI,O~.2' U~ 1~G37~ ~X!
Amount Budgetc~
ma,
~'
800 SEbiINOLE ROAD
ATLANTIC BEACH, FLORIDA 32233-54.15
TELEPHONE (904) 247-5800
FAX (904) 247-5805
February 23, 1999
CITY OF ATLANTIC BEACH
INVITATION TO BID
BID NO. 9899-17
NOTICE is hereby given that the City of Atlantic Beach, Florida, will receive sealed bids IN
TRIPLICATE in the Office of the Purchasing Agent, 1200 Sandpiper Lane, Atlantic Beach,
Florida 32233, until 2:30 P.M., Wednesday, March 17, 1999, for INSECT CONTROL &
FERTII,IZATION OF CITY LAWNS AND LANDSCAPED AREAS; AND PEST CONTROL
(ROACHES, ANTS, SILVERFISH) FOR CITY BUII,DINGS. Thereafter, at 3:00 P.M., the
bids will be opened in the City Hall Commission Chamber, 800 Seminole Road, Atlantic Beach,
Florida.
Included in the letter of DOCUMENTS REQUIRED TO BE SUBMITTED IN BID PACKAGE
AT BID OPENING is the following: Bid Bond in the amount of 5% of the bid. Other
requirements are outlined in the bid documents.
Bid Forms, specifications and information regarding the bid, maybe obtained from the Office of
the Purchasing Agent, 1200 Sandpiper Lane, Atlantic Beach, Florida 32233, telephone (904) 247-
5818.
FLORIDA TIlVIES-UNION: Please publish one time in LEGAL SECTION on Sunday, February
28, 1999.
Submitted by Joan LaVake- 247-5818.
BID N0. 9899-17 - INSECT CONTROL & FERILIZATION OF CITY LAWNS AND LANDSCP.PED
AREAS; AND PEST CONTROL (ROACHES, ANT, SILVERFISH) FOR CITY
BUILDINGS
CITY BUILDINGS LOCATIONS: MONTHLY COST
( ~ TREAT OUTSIDE
City Hall & Commission Chamber
800 Seminole Road ~ 30.00
Public Safety Department 70.00
850 Seminole Road $
Adele Grage Community Center
716 Ocean Boulevard
Wastewater Treati-fent Plant
1100 Sandpiper`Lane
Water Treatment Plant'~1
469 11th Street
Water Treatment 'Plant ~`2
2301 Mayport Road
4
Donner Community Center (INSIDE ONLY)
2072 George Street
45.00
100.00
50.00
public Works Department
1200 Sandpiper Lane
l
Russell Park Concession Stand (INSIDE ONLY)
(Adjoins City Hall-800 Seminole Road)
50.00
40.00
S
Buccaneer Water & Sewer Adm. Office (INSIDE ONLY)
902 Assisi Lane
Buccaneer Wastewater Treatment Plant (INSIDE ONLY)
&~( Wonderwood Road
MONTHLY COST
TREAT INSIDE
~ 35.00
16.00
~
12.00
S
20.00
S
1+.00
S
12.00
~
~ 10.00
24.00
8.00
10.00
10.00 '
Lift Stations (OUTSIDE ONLY-QUARTERLY ONLY):
"B" Station-425 11th Street; "C" Station-69 Donner Road;
"D" Station-1799 Selva Marina Drive; "G" Station-359 20th St.'
(K" Station-2230 Seminole Rd.; "M" Station-West 3rd & Camelia;
"N" Station-West 14th St. & Camelia.
QUARTERLY COST TREAT
ALL LIFT STATIONS
S 15.00
TOTAL ANNUAL COST TO TREAT ALL LOCATIONS 7,092.00
t40NTHLY AND QUARTERLY: ~
(Dollars)
l
CITY OF ATLANTIC BEAC'c~
DOCU"r~NT REQUIP.~WNTS CHEC"cQ.IST
- BID N0. 9899-17
CI BID BOi17i . in the amount of 57 of the bid.
OP.IGINAL Insurance Certificates
(copies, ~.erores,
or facsimiles are U2~ACCEPTl~BLE); naming the City of
Atlantic Beech as Certificate Solder, showing they
have obtained and will continue to carry 'rlorkers'
Compensation, public and private liability, and
,property daaage insurance during the life of the
'contract.
L=' ~ Three (3) references from companies or individuals
. for whoa the bidder has completed work or provided
. a product during the past 12 nonths, of a comparZble
size and nature as this project. However, naming
the City of Atlantic Beach as a reference or. n3st
` projects is UNACCEPTABLE.
1 ~
Proof of OCCUPATIONAL ;,•
icense (copies ARE
acceptable).
L.~ Bid submitted IN TRIPLICATE (three (3).sets).
Signed copy of Documents Requirements Checklist.
The above requirements have been noted and are understood by bidder.
SIGNED: 1` `
(Bidder or Agent)
DATE: 3 ~~b /4'9
BID N0. . (Q ~ ~",~'7
BID N0. 9899-17 - INSECT CONTROL & FERTILIZATION OF CITY LAWNS A~iD LANDSCAPED
(. AREAS; AND PEST CONTROL (ROACHES, ANTS, SILVERFISH) FOR
CITY BUILDINGS
l '
SUBMITTAL:
c ~ ~ L Sr~Ui ~~ Div c , BY : ,1< ~ /-'la~lJr I~ l ~ (./e
c7 L '~C fwd.
~ ~- ~+ (~
BUSINESS ADDRESS SIGNATURE
~ ne ~c~ L X226
C TY, STATE & ZIP CODE
~~'~~c.~1 ~~tyiGz~°r
TITLE
DATE: ~'~ ~~ Get ~ ~~ ~ 1 ~ l a Y6' y(~~ i
BUSINESS TELEPHONE
CONTACT PERSON : (C_ 0I~ ~ l~ (,~
l
TELEPHONE: ~ -''L ~~
(~ Bm Bo1vn
KNOW ALL MEN BY THESE PRESENTS, that we McCall Service, Inc. as Principal,
hereinafter called Principal, and US Fire Insurance Company, a corporation duly
organized under the laws of the State of New York, as Surety, hereinafter called the
Surety, are held and firmly bound unto The City of Atlantic Beach Florida as Obligee,
hereinafter called the Obligee, in the sum of 5% of Seven Thousand and Ninety Two
Dollars, for the payment of which sum well and truly to be made, the said Principal and
the said Surety bind ourselves, our heirs, executors, administrators, successors and
assigns, jointly and severally, firmly by these presents.
WHEREAS, principal has submitted a bid for Bid #9899-17.
NOW, THEREFORE, if the Obligee shall accept the bid of the Principal and the
Principal shall enter into a Contract with the Obligee in accordance with the temis of such
bid, and give such bond or bonds as maybe specified in the bidding or Contract
Documents with good and sufficient surety for the faithful performance of such Contract
and for the prompt payment of labor and materials furnished in the prosecution thereof, or
in the event of the failure of the Principal to enter such Contract and give such bond or
bonds, if the Principal shall pay to the Obligee the difference not to exceed the penalty
hereof between the amount specified in said bid and such larger amount for which the
Obligee may in good faith contract with another party to perform the Work covered by
~, said bid, then this obligation shall be null and void, otherwise to remain in full force and
effect.
Signed and Sealed this 17th day of March, 1999.
McCall Service, Inc.
(Principal (Seal)
~~
Q.,t..t;- Cit. /t.~,~ '~.fL~.. '' ~
(Witness) 2t e
/G~ti .G~-~5.~~
U.S. Fire Insurance Company
(Surety) (Seal)
('~
(Witness) Attorney In Fact/ Licensed Resident Agent
POWER OF ATTORNEY < 717 5 2
UNITED STATES FIRE INSURANCE COMPANY
PRINCIPAL OFFICE, NEW YORK, N.Y.
~' KNOW ALL MEN BY THESE PRESENTS: That the UNITED STATES FIRE INSURANCE COMPANY a
Corporation duly organized and existing under the laws of the State of New York, and having its administrative offices in
the Township of Moms, New Jersey, has made, constituted and appointed, and does by these presents make, constitute
and appoint Carl Carlson, Dora Paratore, and Anita R. Pierce of Jacksonville, Florida, each
its true and lawful Agent(s) and Attorney(s)-in-Fact, with full power and authority hereby conferred in its name, place
and stead, to execute, seal, acknowledge and deliver: Any and all bonds and undertakings SUBJECT TO THE
EXCLUSIONS LISTED BELOW:
Bid, Proposal and Final Bonds and Undertakings guaranteeing contracts for the construction or erection of public
or private buildings, improvements, and other works and guaranteeing public and private contracts for sum '
and to bind the Corporation thereby as fully and to the same extent as if such bonds had been duly executed and
acknowledged by the regularly elected officers of the Corporation at its offices in Morris Township, New Jersey, in their
o~vn proper persons.
This Power of Attorney limits the act of those named therein to the bonds and undertakings specifically named therein,
and they have no authority to bind the Company except in the manner and to the extent therein stated.
~~
This Power of Attorney revokes all previous powers issued in behalf of the attorney(s)-in-fact named above.
IN WITNESS WHEREOF the United States Fire Insurance Company has caused these presents to be signed and attested
by its appropriate officers and its corporate seal hereunto affixed this 25th day of July, 1996.
Attest:
istant Secretary
es R. Van Buskirk
STATE OF NEW JERSEY)
COUNTY OF MORRIS )
ss..
UNITED STATES FIRE INSURANCE COMPANY
Vice Pre dent
Richard A. Annese
On this 25th day of July, 1996, before the subscriber, a duly qualified Notary Public of the State of New Jersey, came the
above-mentioned Vice President and Assistant Secretary of United States Fire Insurance Company, to me personally
known to be the officers described in, and who executed the preceding instrument, and they acknowledged the execution
of the i it r ~b~ng by me duly sworn, deposed and said, that they are the officers of said Compariy aforesaid, and that
tiLe,` x~aii,,dS~$~receding instrument is the Corporate Seal of said Company, and the said Corporate Seal and their
~~ ` °'res ~sA~~ ~t~re duly affixed and subscribed to the said instrument by the authority and direction of the said
,~Co~pa~ _ - .
SIN ~'ES/T~~I~~ W~$EOF, I have hereunto set my hand and affixed my seal at the Township of Moms, the day and
~~ear"~stfabove`~,w~rften~ pEBORAH M. GRECO
~'~. ,~ cJ`G`~.~`~ NOTARY PUBLIC OF NEW JERSEY ~ .
(S a°4s'~1~tr JrER~~~~` MY COMhSISS10N EXPIRES JULY 11,1949
(Seal) Notary Public
;;,..;:.;; , DATE Ir.1MlDD/YYI 5~.:,
..: ::. >:...~1 fi ~:~:A'E'~:~:;::.~~ ~~1 Lt"~'.Y:::~ R~ S:I~.~A~ :...:...:::::::::::::::::::::::.::::::::::.:,.:.:..::::: 3/, 6/99 s;
,., rw ::~~..: .... ............
PRODUCER 904.633-9400
Palmer & Cay of Florida, lnc.
76 South Laura St, Suite 1400 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR '
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, ,
P. O. BoX 1257 COMPANIES AFFORDING COVERAGE
Jacksonville, FL 32201-1257 COMPANY TIG Insurance Company '
A
INSURED
McCall Service, Inc. '
COMPANY Westport Insurnce Co
B
P. O. BOX 2221
Jacksonville FL 32203 COMPANY
C American Motorists Ins Co
I COMPANY
D '
CO: ~A ....... .............. ............... ..::.:.:::..:::. .............::.: •.,•::
.......,...:..:::A..,,...:., .....:.:,:.:..,.::::.,.:::.:.::.;:~.:~.:.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
R TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY1 DATEYIMMlDD/YYI LIMITS
A GENERALUABIUTY 7637975722 7/31/98 7/31/99 GENERAL AGGREGATE ( S 2000000
X COMMERCIAL GENERAL LIABILITY PRODUCTS -COMP/OP AGG S 1000000
CWMS MADE ~ OCCUR PERSONAL & AOV INJURY 5 1000000
OWNER'S & CONTRAC70R'S PROT EACH OCCURRENCE S 1000000
FIRE DAMAGE (Any ona fire! S 50000
MED EXP (Any one Dersanl S
13 AUT OMOBILE LIABILITY W$A100426 7/31/98 7/31/99
X ANY AUTO COMBINED SINGLE LIMIT S 1000000
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) S
1 X HIRED AUTOS
BODILY INJURY
X
NON•OWNED AUTOS
IPer accident) S
PROPERTY DAMAGE S
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT S
AGGREGATE S
A EXCESSLtA61L1'fY XL837975541 7/31/98 7/31/99 EACH OCCURRENCE ' S 5000000
X UMBRELLA FORM AGGREGATE S 5000000
OTHER THAN UM1IBRELLA FORM S
C WORKERSCOh1PENSATI0NAN0 386015885-01 7/31/98 7/31/99 wR5 j~11T• OTR :~~'' "~' •' •~"~ ..~.•
EMPLOYERS' LIABILITY
EL EACH ACCIDENT
S 500000
THE PROPRIETOR! INCL EL DISEASE-POUCYLIMI7 S 500000
PARTNERS/EXECUTI V E
OFFICERS ARE:
EXCL
EL DISEASE - EA EMPLOYEE
S 500000
A OTHER
WDO Inspections
Professional
Liability 7637975722 7/31/98 7/31/99
S300,000 Aggregate
5100,000 Occurrence
DESCRIPTION OF OPERATIONSJLOCATtoNSNEHICLES/SPECIAL ITEMS
:CERTIFiCR'i-E':1iCiLi~ER<<z:<»z?`<>«><>:<>>>"''<<:<>`><»>>:`>'::`:?:>'.«>s>`.
.......................
City of Atlantic Beach
1200 Sandpiper Ln
Atlantic Beach, FL 32233
..CANCEL At'I N......:....................... .........:.......
.. E:' O
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO h1A1L
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
BUT FAILURE TO MAtI SUCH N ICE SHALL IM1IPOSE NO OBUGA NOR UABIUTY
OF ANY KIND UPON THE OMPANY, ITS E S OR PRESENTATtVES.
l..
`f1'f~tl Clt;i:7 G~~C~~t11Q~t::<:::':<;::>;'...::..,....;.....;;:.,;.;...:,.:.,.,.:,..;..,;_..;.,...;_:..;..,;.:...:..,.w..,,,.;is~:'i`~:`•.iV`•.iz~:2:i:"< AUTHORIZED REPRESE ATI
_ _
ipi~~`?ii`:Li4?''ii'Yi`~i`iii":`oi>::::::.::::.;:::::.::::.<:::::.::.::z:ii.: ....... ~ ~~ri`n ~br':~n tor'ie'Ii'~rtnfU t>t9Rf
.,
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J ' 02i24i97 13 : a 2 ~'j`9Q•3 3>itt 3212 tlrt~al.l. 51:121 l r'H .. , t1E a~t1 f~; nn3
- ~_•
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. '1't•;• (,'.v:rt~~~ "/rr•~rfr• ('t~»r~nl. f tu~•p ~c•1•it~+ curt! l~rrrl Uri`u~• llnnirt nr.:; !n:?trs:rt•..
CO~'Vi1!I~RCIAI, PF_ST CUN'I'IZOL REFER~:NCES
American Ttartstech
8000 Raymcadows Rd.
Jacksonville, FJ. '
POC: Dick Rurgio 636-2130
American HeritaKe life In_s.
1776 Ameries~rt Heritage Dr.
Jacksonville, FL
POC: Tom Tate 992-2702
F]ericla School for Lhe Deaf ttir. $1utd
207 Ss;.r•. ~.~ Svc N.
St At:
Pi)C:. .. ,•;.t 3:3-4173
Universal Card St~zc:es
4787 };aypine Rd.
)ecksorivBle, FL
POC: Kcn Broskoski 954-5205
Riverside Presb,Yterian Residences St. Luke's Hospital
2020 Park St./1045 Oak St. 4201 Bclfort Rd.
Jacksonville, FL Jacksonville, FL
POC: Vary Tomlinson 388-9376 POC~ Nell Robinson 296-3700
Flagler Hospital Grimes Distnbution
400 Health Part Blvd. 600 Ellis Rd.
St. Augustine, FL Jacksonville, FL
P(.~C: Pamela McCoy 8?5.4423 POC• Roy Rudd/Grace 786-2173
Star Enterprises Cafe Camton c@. Cafe on the Squart
9143 Phillips Hwy - 197.1 8c 1986 San Msrco Blvd.
Jacl~ontzllc, FI. Jacksonville, FL
POC: Chu~rlcs Stanctt 363-0003 POC: 399-alas
Stone Cc+~tauter Corp.
14A0 Tra..~sport Rd.
Jacksonville, FL
POC: Peter Giannandres 741-6996
Sonny's BBQ
1935-1 Lane Ave.
JackscmvBle, FL
POC: Ted Heirs 781-1067
Rubin Brother
6746 Stuart Avc
r JacksonviIle, FL
POC: Bob Layton 783-4520
Lee's Famous Fried Chicken
9974 OId Baymeadows Rd_
' Jackscmvillr., FL
POC: 'Ken Anderson 64(.0050
First Union ?Jational Aan};
225 Water St. (Real Estate I?ivitionl
` Jacksonvt'Ile, FL
POC: Paula McFadden 361-3207
Patt-rson Dental Supply
1401 Tradcport Dr
JacksonviIle, FL 32218
POC: Richard Lewis 741-4480
JACKSONVILLE • NEPTUNE BEACH • TALLAHASSEE • OCALA • ORLAN00
wr/GmvPCRef 21sT P.O. BoY ?221 ! 2851 CotlerJt: Sirect i Jacksonv~l;e, Florida 32203
,:~ t_~:.^+~~ I'rr.+; '{RQ.S~f,t ~,1.~GT,'. F t.~llft•:47-Fi!aIIQ
7998
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~19J8-1999 OCCUP~:T I OVAL LICENSE TAX
LYNWOOD ROBERTS '
OFFICE OF THE TAX COLLECTOR
CITY OF JACKSONVILLE and/or COUNTY OF DUVAL, FLORIDA
231 EAST fORSYTH 57AEET ROOM 130, JACKSONVILLE, FL X2202 PHONE: (904)630-2080 FAX: (9041630.1432
Note - A penalty is imposed for failure to keep this license exhibited conspicuously at your .establishment or place of business.
This license is furnished in pursuance of chapter 770.772 City ordinance codes.
MCCALL SERVICE INC
720 ATLANTIC BV
NEPTUNE BCH, FL 32266-3915
County License Code: 770.323-04g County Tax: $33.75
Municipal License Code: N/A Municipal Tax: N/A
Total Tax Paid: 533.75
ACCOUNT NUMBER: 023815-0000-0
LOCATION ADDRESS: .720 ATLANTIC BV .. .~ .
. 32266-3915 ~ ~ ~ ..
' ~
DESCRIPTION: EXTERMINATOR
~'
VALID FROM OCTOBER 1, 1998 TO SEPTEMBER 30, 19gg
RCPT #: OO1T019127 DATE: 9/24/1998 AMT: S33.75
ATTENTION
09 ~.
***The Following Construction Contractors Require Additional Licensure***
POOL
BUILDING
SHEET METAL
PLUMBING
CARPENTRY
HEATING
ALUMINUM/VINYL
ROOFING
SOLAR
IRRIGATION
WATER TREATMENT
AIR CONDITIONING
ALARM
RESIDENTIAL
ELECTRICAL
MECHANICAL
GENERAL
UNDERGROUND UTILITY
REFRIGERATION
This is en occupational license tax only. It does not permit the ticensee to violate any existing regulatory or zoning laws o! the County or City.
Nor does it exempt the licensee from any other license or permit required by taw. This is not a certification o! the licensee's qualilieation.
. TAX COLLECTOR
THIS BECOMES A RECEIPT AFTER VALIDATION
Form W-9 ~ Request for Taxpayer Give form to the
(Rev. December 1996) identification Number and Certification
pepartmene or the Treasury se d t0 LheDIR$ OT
Internal Revenue Service
Name (Ir a joint account or you changed your name, see Specific Instructions on page 2.) -
n
a
T
Business name, if diKerent from above. (See Specific Instructions on page 2.)
° McCall Service Inc.
~Q, Check appropriate box: ^ IndividuatrSote proprietor ®Corporation ^ Partnership ^ Other > ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,
~ Address (number, street. and apL or suite no.) Requester's name and address (optionaq -
2861 college St.
a
City, state, and 21P code
Jacksonville, Fl 32205
Identification Number
Enter your TIN in the appropriate box. For
individuals, this is your social security number
(SSN). However, if you are a resident alien OR a
sole proprietor, see the instructions on page 2.
For other entities, it is your employer ~
identification number (EIN). tf you do not have a
number, see Hovr To Get a TIN on page 2.
Note: If the account is in more than one name,
see the chart on page 2 for guidelines on vrhose
number to enter.
Certification
Under penalties of perjury, I certify that:
Social security number
OR
Employer identification number
5"9.0 908 19 6
List account number(s) here (optional)
For Payees Exempt From Backup
Withholding (See the instructions
on page 2.)
)~
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) t am exempt from backup vrithholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup vrithholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that 1 am no longer subject to backup vrithholding. .
Certification Instructions.-You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
vrithholding because you have failed to report ail interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or ab donment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payment other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN, (,See`,the insSfuc); ns ¢n page~2.)
Sign March 15, 1999
Here Signature >~ ~ and = dwel ~ Date Y
Purpose of Form.-A person who is
required to file an information return with
the IRS must get your correct taxpayer
identification number (TIN) to report, for
example, income paid to you, real estate
transactions, mortgage interest you paid,
acquisition or abandonment of secured
property, cancellation o! debt, or
contributions you made to an IRA.
Use Form W-9 to give your correct TIN
to the person requesting it (the requester)
and, when applicable, to:
1. Certify the TIN you are giving is
correct (or you are waiting for a number to
be issued).
2. Certify you are no[ subject to backup
withholding, or
3. Claim exemption from backup
vrithholding if you are an exempt payee.
Note: ff a requester gives you a form other
than a W-9 to request your TIN, you must
use the requester's torm if it is substantially
similar to this Form W-9.
What Is Backup Withholding?-Persons
making certain payments to you must
vithhotd and pay to the IRS 31% of such
~iayments under certain conditions. This is
called "backup withholding "Payments
that may be subject to backup withholding
include interest, dividends, broker and
barter exchange transactions, rents,
royalties, nonemployee pay, and certain
payments from fishing boat operators. Real
estate transactions are not subject to
backup withholding.
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 vrill not be subject to backup
withholding. Payments you receive vritl be
subject to backup withholding if:
1. You do not furnish your TIN to the
requester, or
2. The IRS tells the requester that you
furnished an incorrect TIN, or
3. 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
4. You do not certify to the requester
that you are not subject to backup
withholding under 3 above (for reportable
interest and dividend accounts opened
after 1983 only), or
5. You do not certify your TIN when
required. See the Part III instructions on
page 2 for details.
Certain payees and payments are
exempt from backup withholding. See the
Part II instructions and the separate
Instructions for the Requester of Form
W-9.
Penalties
Failure To Furnish TIN.-1f you fail to
furnish your correct TIN to a requester, you
are subject to a penalty of 550 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 5500 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.
Cat. No. 10231X Form thf-9 (Rev. 12.96)