HomeMy WebLinkAboutCOOPERATIVE PERSONNEL SERVICES, DBA CPS HUMAN RESOURCES (3)INSURANCE NOT REQUIRED
WORK R44Y MUM
CLERK VF +,01UNCII
DATE: NOY 2 0 2014
N-2014-151
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Please have the head of your agency (or the person who can enter into contract on your agency's behalf) initial
each page as well as sign and date page 3. It will be important that the individuals listed as Authorized
Representatives receive a copy of the Agreement so they are aware of our policies and procedures and
also sign the agreement on the designated area.
Please fax all completed pages of the agreement to 916-921-6240 or email to testrental c sp hnus. *Foryour
convenience you can complete most of the agreement electronically and print for initials and signatures.
Feel free to contact any of our Test Rental Team members if you have any questions.
cps HR mm CONSULTING
onalz
CPS HR — Test Rental
241 Lathrop Way
Sacramento, CA 95815
testrental gpshr.us
(t) 915,263.1800
(f) 916.921.5240
www.cpshr.us
®e'
Veronica Lara -Lopez
Program Coordinator Order inquires/requests, scoring,
veronica@cpshr.us
account receivables/payables, skills
online administration, credit card
payment, general in uiries
Sheila Jones
Technician Test orders, review copy requests,
sones Dc shr.us
scoring, billing uestions.
Meagan Olson
Technician Test orders, review copy requests, test
molson@cpshr_us
publishing
Ashley Maxwell
Office Assistant Test orders, review copy requests,
amaxwell@cpshr.us
scoring
Holly Hatada
Consultant Test selection, interpretation of
hhatada@cpshr us
statistics/test analyses/item analyses,
ass point setting
Ana Costa
Consultant Test selection, interpretation of
acosta c)c sp hr.us
statistics/test analyses/item analyses,
ass point setting
Stephen Nakagawa
Consultant Test selection, interpretation of
snakagawa@cpshr.us
statistics/test analyses/item analyses,
ass point setting
Amy Blgone
Manager Test Rental Agreement change
abiaone@coshr.us
re uests; an other client concerns
cps HR mm CONSULTING
onalz
CPS HR — Test Rental
241 Lathrop Way
Sacramento, CA 95815
testrental gpshr.us
(t) 915,263.1800
(f) 916.921.5240
www.cpshr.us
TEST RENTAL AND USE AGREEMENT
This Test Rental and Use Agreement ("Agreement') is by and between Cooperative Personnel Services,
dba CPS HR Consulting, a California Joint Powers Authority ("CPS HR") and the Agency or Organization
named in the signature block at the end of the Agreement ("Client').
A. Purpose. This Agreement defines CPS HR test rental,
use and security policies and procedures.
CPS HR develops and rents tests for a number of
purposes and in a number of formats (including but not
limited to print and electronic media). For that reason,
some of the below paragraphs apply under certain
circumstances. But, unless specifically limited, each
paragraph applies to all testing purposes and formats.
B. Ownership of CPS HR Tests.
1. CPS HR owns all rights, title and interest, including
copyrights, in all tests provided under this
Agreement. They are the property of CPS HR and
shall remain the property of CPS HR, even while in
the custody of Client.
2. Additionally, tests that have been constructed or
modified based on information provided by the client
shall not be considered works made for hire, as that
term is defined under U.S. Copyright Law. CPS HR
shall own all rights, title and interest, including the
copyright, in any test it creates for the Client.
3. Ownership of tests specifically developed for a client
and of individual test questions supplied by Client, if
any, shall be governed by a separate Agreement
between CPS HR and Client.
C. Test Materials. Test Materials consist of all used and
unused test booklets, proctors instructions, proctors
manuals, scoring instructions, key sheets, key overlays,
keyed booklets, scoring keys, instructions, CDs (for oral
tests), and any other materials generated at the test
administration, such as completed answer sheets (if
applicable), scratch paper, note paper and the like.
D. Test Security. CPS HR security standards are designed
to protect the mutual interests of all Clients that use Test
Materials as well as the interests of applicants who take
CPS HR tests. In order that no person may gain special
advantage by having improper access to the material, all
users must sign this Agreement and agree to fulfill its
terms, before the Agreement is effective.
1. Client agrees to take all reasonable and diligent
steps to keep CPS HR tests, sample tests, and
testing processes confidential and free from
unauthorized access and use. This includes, but is
not limited to, client agreeing not to divulge, convey,
copy in whole or part, duplicate, convert to another
format or medium, or otherwise disseminate tests,
portions of tests, or test materials.
2. For on-line tests, client further agrees to take all
reasonable and diligent steps to prevent any
modification to or reverse engineering of the testing
software, and any transfer, storage or dissemination
of tests or testing software and data on any storage
medium or computer server other than those
specifically authorized by CPS HR.
3. Should Client suspect any breach of test security,
Client agrees to immediately notify CPS HR and
immediately take all steps necessary to preserve
2014 -2016 CPS HR —Test Rental 2 Year Agreement
evidence of or related to the breach, whether
physical or electronic.
E. Test Review, Ordering and Administration.
1. Review Copies. Review of CPS HR tests, regardless
of format, is subject to the test security standards.
(a) Test Rental Division: To help in deciding
whether to rent exams, Client may review CPS
HR stock tests and other stock test materials
free of charge (e.g., stock supplements,
structured interview packages, and specialized
item sets).
(b) SLPP: CPS HR does not offer review copies of
the Spanish Language Proficiency Program
(SLPP) tests. However, for new clients, CPS
HR can provide a sample written test booklet
showing the different components of the test.
(c) On-line Testing: To help in deciding whether
to utilize on-line testing, Client may review
sample on-line tests free of charge.
2. Ordering Testing Materials and Scheduling of
Examinations.
(a) Test Rental Division and SLPP:
(i) To insure materials are received in time,
Client must notify CPS HR at least 10
business days prior to the test date of the
total number of candidates in each job
classification to be tested. If orders are
placed less than 10 -business -days prior to
the test date, rush shipment charges may
apply and timely delivery cannot be
guaranteed.
(ii) Client shall rent one test booklet per
candidate to be tested, CPS HR shall
provide Client with Test Materials including
instructions for administering the test,
sufficient test booklets and any other
material CPS HR deems necessary.
(b) On-line Testing:
(i) To insure Client equipment is functioning
and capable of administering on-line
testing, Client must request testing from
CPS HR at least 10 business days prior to
the test date on the first time Client utilizes
on-line testing. After Client has successfully
used on-line testing, 5 working days notice
is normally sufficient for subsequent testing.
(ii) Client recognizes that CPS HR has no
control over the functioning of the internet,
and any problems with on-line testing due
to the failure thereof are not attributable to
CPS HR.
Client Initials
3. After the test date.
H. Client Responsibilities.
(a) Test Rental Division and SLPP:
1.
Client shall perform all parts of the testing process
(i) Within 10 business days of the test date,
which are not performed by CPS HR. Client has the
Client shall return to CPS HR all Test
responsibility for assuring that the testing process
Materials including all materials provided by
performed by Client conforms to any applicable laws,
CPS HR for the test administration.
rules or ordinances, and for the test as a whole.
(ii) Client shall not reuse printed tests on the
Under the federal Uniform Guidelines on Employee
test date or on any other date but shall
Selection Procedures, the Client as test user is
return Test Materials to CPS HR, whether
responsible for the results of the selection process,
or not the test was administered.
and Client understands and acknowledges that it
must be prepared to demonstrate that the process is
(b) On-line Testing:
valid and meets other testing standards if it adversely
(i) After the scheduled test date(s), CPS HR
affects groups protected by fair employment laws.
will suspend access to the on-line test site,
2.
Client is responsible for insuring that all persons who
(ii) Within 10 business days of the test date,
handle or have access to Test Materials in any
Client shall destroy all CPS HR Test
capacity for Client shall do so in compliance with this
Materials including scratch paper and note
Agreement, and are trained to handle Test Materials
paper in a way that make the materials
and administer tests before they do so.
unrecoverable.
I. Legal Proceedings Involving Test Materials.
F. Billing, Pricing, and Payment.
1.
If Client receives notice of any administrative or court
1. CPS HR shall bill Client at the billing address
proceeding involving a CPS HR test, or a request for
provided in Exhibit A, unless notified in writing of a
disclosure of Test Materials, such as a subpoena, or
new billing address,
a public records or freedom of information request,
2. The bill shall be derived from the most current
Client shall notify CPS HR of such request
applicable Rate Sheet (s): Exhibit B for Test Rental,
immediately and well before a response is due.
Exhibit C for SLPP, and Exhibits D and E for On-line
2.
Upon CPS HR request, Client shall maintain the
Testing. Client acknowledges and understands that
confidentiality of the Test Materials pending the grant
the Test Price List(s) are only effective as of the date
or denial of a protective order or the decision of a
shown each of them and are subject to change,
court or administrative body as to whether the
3. Client shall be billed for any work done on a canceled
requested Test Materials must be disclosed under
or postponed test up to the time CPS HR is notified
the applicable public records statute.
of such cancellation or postponement, Under certain
3.
Client shall cooperate with CPS HR in seeking any
circumstances, and in CPS HR's sole discretion,
relief necessary to maintain the confidentiality of the
credit may be given for work already performed if the
Test Materials.
test is rescheduled.
4.
Client shall indemnify and hold CPS HR harmless
4. CPS HR may charge Client for lost or compromised
from and against any and all claims, costs, damages,
tests if Test Materials are not timely returned,
losses, liabilities and expenses (including reasonable
S. Client agrees to and shall pay all invoices within thirty
attorney fees and costs) arising out of or in
(30) days of receipt of invoice.
connection with administration of a test, or with
maintaining confidentiality of Test Materials,
G. Candidate Inspections
J. Term and Termination of Agreement.
1. Test Materials.
1.
Term. This Agreement is effective beginning the
CANDIDATE INSPECTION OF TEST MATERIALS
date it is signed by both parties and continuing for
SHALL NOT BE ALLOWED EXCEPT IN CASE OF
two years thereafter unless earlier terminated by
ANSWER SHEETS AS DESCRIBED BELOW
either party as stated below.
2. Answer Sheets.
2.
Immediate Termination upon Material Breach. Either
(a) If a candidate files a protest regarding the
party may terminate this Agreement immediately
scoring of his or her test, inspection of a
upon any material breach by the other party. For
candidate's own answer sheet(s) for the
purposes of this Agreement, but without limiting the
purpose of detecting whether any clerical or
meaning of material breach, any breach of the test
other error has been made in the scoring of the
security provisions, however minor, shall be
answer sheets shall be allowed, upon request
considered a material breach. Client understands
by the Client, for a 10 -business -day period
and acknowledges that immediate termination by
immediately following the notification to the
CPS HR may result in the withholding or recall of
candidate of test results.
Test Materials.
(b) Candidates are not allowed to review the
3.
Termination Without Cause. CPS HR and Client may
question booklet during this inspection period.
terminate the Agreement without cause upon thirty
(c) Not more than one hour will normally be
days written notice to the other party.
allowed for answer sheet(s) review. A
4.
Return of Test Materials. Upon termination of the
representative of Client's Personnel or
Agreement, Client shall immediately return to CPS
Administrative office shall be present to assure
HR any Test Materials that it possesses.
that no changes or marks of any kind are made
by the candidate on the answer sheet(s) or
keyed answer sheet.
2- Client Initials
2014 — 2016 CPS HR —Test Rental 2 Year Agreement
K. Miscellaneous.
1. Notices. Any notice to the parties required or
Permitted under this Agreement shall be given in
writing and shall be sent to Client at the address
provided for the Principal Signer and to CPS HR at
241 Lathrop Way, Sacramento, CA 95815.
2. Dispute Resolution; Remedies.
(a) In the event of a dispute, the parties may agree
to pursue mediation or either binding or
nonbinding arbitration to resolve their dispute,
under such rules as the parties may agree.
(b) If either CPS HR or Client determines to file a
judicial action, then, in addition to any other
remedies available at law or In equity to the
parties for breach of this Agreement, Client
acknowledges that breach of this Agreement
may result in irreparable harm to CPS HR for
which damages would be an inadequate
remedy and, therefore, in the event of a
breach, In addition to its rights and remedies
otherwise available by law, CPS HR shaii be
entitled to seek equitable relief, Including
injunction.
3. Attorneys Fees. If any legal action or arbitration or
other proceeding is brought to enforce or construe
the term of this Agreement or because of an alleged
dispute, breach or default in connection with any
provision of this Agreement, the successful or
prevailing party shall be entitled to recover
reasonable attorneys fees and other costs incurred in
that action, arbitration or proceeding in addition to
any other relief to which it may be entitled,
4. Waiver, The failure of any party at any time or times
to require performance of any provisions of this
Agreement shall In no manner affect its right to
enforce such provision at a later time. Nor shall the
waiver by either party of a breach of any provision of
this Agreement be taken or held to be a waiver of the
provision itself. No waiver shall be enforceable
unless made in writing and signed by the party
granting the waiver.
S. Entire Agreement; Modifications. This Agreement
constitutes the entire Agreement between the parties
regarding the subject matter hereof and supersedes
all other Agreements, representations and
warranties. All modifications and supplements to this
Agreement must be in writing and signed by both
parties.
6. Counterparts; Facsimile Signature; Electronic
Signature. This Agreement may be executed in any
number of counterparts. If this Agreement or any
counterpart is signed and then faxed or e-malied by
PDF or otherwise, the faxed or e-mailed copy bearing
the signature shall be as good as the original wet -ink
signed copy for all intents and purposes.
Z Interpretation; Jurisdiction. This Agreement shall
be interpreted and enforced under the laws of the
State of California and jurisdiction shall be in
Sacramento County, California. The Agreement shall
be interpreted in a fair and balanced manner to best
preserve its intent, and without bias against the
drafter.
8. Authority to Sign. The person signing this
Agreement on behalf of the Client (the Principal
Signer) represents that he or she is the head of the
agency or is otherwise duly authorized to sign this
Agreement and to bind the Client.
Principal Signer By signing below, I represent that the persons(s) listed in Exhibit A and on any attached
sheets is/are authorized to handle CPS HR Test Materials on Clients behalf. I affirm that I will handle all CPS
HR Test Materials in accordance with the terms of the CPS HR Test Rental Agreement then in'f'ect
will insure all individuals handling and/or administering tests are properly trained. Akp ft I'�t', a k,'')T® FOF
Cooperative Personnel Services dba Client
CPS HR Consulting,
A California Joint Powers Authority
Aute rinedSigna re ' I N
By: �� N"U U By r, f�-,,..m�^ k✓�,.., ,,,,,,.....,
fit, d Authorized Signattfre
Name: Amy Bigone
Title: Test Rental Program Manager
Date:—q�J�(r
ATTESM
MARIA D. HUITAR (✓(
CLERK OF THE COUNCIL
2014 — 2016 CPS HR — Test. Renta P 2 Year Agreement
Name: Edward Rava
Title: Eueouti,ro Director, Pargnnnag Svcs.
Email: eraya@santa—ana.org
Date: 9/25/14
3David Cavazos, City Mana er,
--
Exhibit A
Authorized Re presentative(s) (use an additional page if needed) By signing as an Authorized Representative, I affirm
that I will handle all CPS HR Test Materials in accordance with the terms of the CPS HR Test Rental Agreement then in effect.
Name, Title
S' na u
Donna Stu i1z St. Pet6onnet AnaC ht
Maribel Carmona, Sr. Personnel Technician
E-mail Address
d6tupik@,santa-ana. o&g
Phone Number
M4) 647 -
E-mail Address
Phone Number
irwarmon0santa-an714
647-5 5
Name, Title
ature
Donna Stu i1z St. Pet6onnet AnaC ht
�
E-mail Address
d6tupik@,santa-ana. o&g
Phone Number
M4) 647 -
Name, Title
Maty Ket ey, St. Peuonnet Anakyst
Sign {ure�
7
E - 'I ss
r ey@zanta-ana. ahg
AW
Phone u �� e
( �1r
47-5437
Name,Title
jXq�r SA
Signature
E-mail Address
1A,ommeu@,santa-ana.on
Phone Nu her
714 647-5348
0
Na e, TitenM Queen, St. Pex6onnek Anatyht
Sig
r
E-mail Address
aqueen@z arta-ana.oh
P o e Number
714 2 5-8670
Billing Contact
Contact Name and Title Signature Date
Maribel Carmona, Sr. Personnel Tech.
Agency
City of Santa Ana
Street Address, City, State, Zip
20 Civic Center Plaza M-24 714 647-5353 714 647-6930
E -Mail Phone Number Fax Number
mcarmona@santa-ana.org
III• Physical Address
Agency/ Department Name
City of
Santa Ana Personnel Services
Street Adtlreas, City, State, Zip
20 Civic Center Plaza, M-24 Santa Ana, CA 92701
2014 - 2016 CPS HR - Test Rental 2 Year Agreement
Exhibit B
CPS HR Test Rental Division Rates (Effective March 25, 2009 - Subject to Change)
Base Fee (per order) $
STdCK
TESTS*
$295.00
MODWLAR
'T;ESTS
$395.00
5EMI.STQGK
`TESTS;,..
$595.00
GUSTQM
TESTS
$995.00
q,GENCY .
.,TESTS:
$350.00
1-100 Candidates (per candidate)
$9.00
$12.00
$14.00
$15.00
$10.00
101-500 Candidates (per candidate)
$8.50
$11.00
$13.00
$14.00
$9.50
501+ Candidates (per candidate)
$8.00
$10.00
$12,00
$13.00
$9.00
New Item Writing/Entry
N/A
N/A
N/A
$35 per item
N/A
Pick Up/Handling
5%
5%
5%
5%
5%
Standard Shipping/Handling **
10%
10%
10%
10%
10%
Expedited Shipping/Handling **
15%
15%
15%
15%
15%
Premium Shipping/Handling **
20%
20%
20%
20%
20%
Shipping outside contiguous U.S.
CALL FOR DETAILS
Entry Law/Fire Candidate Preparation Manuals
Now vailakle Online**
Structured Interview Packages
Quantity Per Booklet/Candidate Fee
10 - 1000 $ 3.00
1001+ Call for volume discount details
Base Fee: $ 595.00
Per Candidate Fee:
1 -500 $7.50
*CPS HR will apply a credit of $35.00 for each fully paid UNOPENED package of Stock Exams of test booklets on the
current STOCK test order.
**Standard shipping applies to orders placed at least 10 business days prior to test date. Expedited shipping applies to
orders placed less than 10 business days prior to test date. Orders placed less than 3 business days prior to the test
date will be charged at the premium shipping rate.
Semi -Stock, Modular and Custom Tests require Job Analysis Workbooks or Job Specifications
* Base fee includes the following at no additional charge: Proctor's Manual, Scoring Manual, CPS HR Scoring, CPS HR
answer sheets and a scoring report.
SPECIAL SERVICES
Stock Supplements
$ 2.00 per book when ordered with a Stock test
Writing Proficiency Exam
$ 350.00 Base Fee + $ 15.00 per candidate (Professional Scoring included)
Scoring Keys
Available at no additional charge
Re-Scoring/Hand-Scoring of Answer Sheet
$ 30.00 (Requested directly by Agency)
Non-specified special services
CALL FOR DETAILS (Billed at applicable hourly rate)
Test Rental Contact Information:
CPS HR Consulting
Attn: Test Rental Division
241 Lathrop Way, Sacramento CA 95815
Telephone: 916.263.1800 / Toll Free 866.867.5272
Fax: 916.921.6240/ E-mail: testrental(a)cpshr.us
2014 - 2016 CPS HR - Test Rental 2 Year Agreement
Exhibit C
Spanish Language Proficiency Test Rental Division Rates
Effective March 25, 2009 -- Subject to Change
SPECIAL SERVICES
Faxing/Emailing Test Results Available at no additional charge
Hand Scoring $30.00
Proctoring Services Call for details/quote
SLPP Extended Use Program Call for details
Minimum cancellation charge once a SLPP order is shipped is $200.00.
For each lost written test, there will be a base charge of $10,000. For each additional copy (test) of
the same test that is lost, there will be a $75 char a with a maximum total charge of $20,000.
For each lost oral test, there will be a base charge of $15,000. For each additional copy (test) of the
same test that is lost, there will be a $75 charge with a maximum total charge of $20,000.
2014 — 2016 CPS HR— Test Rental 2 Year Agreement
4irRITT�N TEST
:ORAL T�ST z
m
Base Fee (per order)
$295.00
_
$295.00
**Per Booklet Fee
$9,00
N/A
***Per Tape Scoring Fee
N/A
$120.00
Expedited Shipping
*20%
*20%
*Orders placed less than two weeks prior to the exam date will incur expedited shipping charges
**Per Booklet Fee will be charged for number of books ordered
***Billed for the number rated
SPECIAL SERVICES
Faxing/Emailing Test Results Available at no additional charge
Hand Scoring $30.00
Proctoring Services Call for details/quote
SLPP Extended Use Program Call for details
Minimum cancellation charge once a SLPP order is shipped is $200.00.
For each lost written test, there will be a base charge of $10,000. For each additional copy (test) of
the same test that is lost, there will be a $75 char a with a maximum total charge of $20,000.
For each lost oral test, there will be a base charge of $15,000. For each additional copy (test) of the
same test that is lost, there will be a $75 charge with a maximum total charge of $20,000.
2014 — 2016 CPS HR— Test Rental 2 Year Agreement
Exhibit D
CPS HR On-line Skills Test Pricing Schedule
Effective January 1, 2010 — Subject to Change
;ate
bra #I�trCt$r7i"ginhL�
G.0
1 - 25 Candidates (per candidate)
$20.00
26 -100 Candidates (per candidate)
$18.00
101 -250 Candidates (per candidate)
$17.00
251 - 1,000 Candidates (per candidate)
$15.00
1,001 - 2,500 Candidates (per candidate)
$10.00
2,500 + Candidates (per candidate)
$8.00
'When multiple tests are combined into a test battery each test is charged separately.
Test Rental Contact Information:
CPS HR Consulting
Attn: Test Rental Division
241 Lathrop Way, Sacramento CA 95815
Telephone: 916.263.1800 / Toll Free 866.867.5272
Fax: 916.921.6240/ E-mail: testrental(@,cpshr.us
2014 - 2016 CPS HR - Test Rental 2 Year Agreement
G.0
E
Advanced Skills
Advanced Skills
Advanced Skills
Basic Skills
Basic Skills
Basic Skills
Standard
Standard
Standard
9 -aa ,p-�
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Advanced Skills
Advanced Skills
Computing
Basic Skills
Basic Skills
Internet
Standard
Standard
Software Skills
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:'Lh
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..._ a5M Egg
Basic Computer Literacy
Typing Test
Excel Functions
Ten Key Test
Internet Literacy (with Explorer)
Data Entry Test - Numeric
Outlook 2003 or 2007 - Standard
Data Entry Test - Alphanumeric
Publisher 2003 - Standard
Test Rental Contact Information:
CPS HR Consulting
Attn: Test Rental Division
241 Lathrop Way, Sacramento CA 95815
Telephone: 916.263.1800 / Toll Free 866.867.5272
Fax: 916.921.6240/ E-mail: testrental(@,cpshr.us
2014 - 2016 CPS HR - Test Rental 2 Year Agreement
CPS HR aw CONSULTING
November 13, 2017
Dear Business Partner,
We are excited to announce that we will be moving to a new office location in
Sacramento, effective November 20, 2017. Please update your records with our new
contact information:
Address:
2450 Del Paso Road, Suite 220
Sacramento, CA 95834
All payments should be sent to our lock box.
Remit Address Only:
Department#34327
P.O. Box 39000
San Francisco, CA 94139
Our other contact information will remain the same:
Telephone: (916) 263-3600
Fax: (916) 263-3613
Website: www.cpshr.us
Please accept this letter as formal notice for change of address on all contracts between
CPS HR Consulting and your agency.
Thank you for taking the time to update your records. Feel free to contact Dimple Patel,
Contracts Coordinator at dpatel@cpshr.us with any questions.
Sincerely, //
Cr
JagNishikawa
Contracts Manager
t:916.263.3600 I:916.263.3613 www.cpshr.us
Form W"9 Request for Taxpayer Give Form to the
(Rev.December 2014) Identification Number and Certification requester. Do not
Department Rwmf the
Treasury send to the IRS.
Intioe
1 Name(as shown on your Income tax return).Name Is required on this line;do not leave this line blank.
Cooperative Personnel Services
of 2 Business name/disregarded entity name,If different from above
g, CPS HR Consulting
a 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to
ncertain entities,not Individuals;see
m ❑
Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership 0 Trust/estate instructions on page 3):
$ single-member LLC Exempt payee code(if any) 3
,F'• 0Limited(lability company,Enter the tax classification(0=0 corporation,5=8 corporation,P=partnershlp)►
`o 3 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
the tax classification of the single-member owner. code(if any) C
E 4 ❑✓ Other(see instructions)► California Joint Powers Authority !Applies to accounts maintained outside the aa)
it 6 Address(number,street,and apt.or suite no.) Requester's name and address(optional)
a 2450 Del Paso Road,Suite 220
6 City,state,and ZIP code
tj Sacramento,CA 95834
7 List account number(s)here(optional)
Part I Taxpayer Identification Number(TIN)
Enter your TIN In the appropriate box.The TIN provided must match the name given on line 1 to avoid I Social security number
backup withholding.For individuals,this is generally your social security number(SSW).However,for a
resident alien,sole proprietor,or disregarded entity,see the Part I Instructions on page 3.For other - -
entities,it is your employer identification number(EIN).If you do not have a number,see How to get 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 Employer identification number
guidelines on whose number to enter.
6 8 - 0 0 6 7 2 0 9
Part Ii Certification
Under penalties of perjury,I certify that:
1. The number shown on this form is my correct taxpayer Identification number(or I am waiting for a number to be issued to me);and
2. I am not subject to backup withholding because;(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all Interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3. I am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form(if any)Indicating that I am exempt from FATCA reporting Is correct.
Certification instructions.You must cross out item 2 above If you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than Interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
Instructions on page 3.
Sign
Signature of +r (y
Flare U S.parson yi f f l 1, Wof`I1'� Date Iv J
General Ins#rut tions •Form 1098(home mortgage interest),1008-E(student loan Interest),1098-T
(tuition)
Section references are to the Internal Revenue Code unless otherwise noted, •Form 1099-C(canceled debt)
Future developments.Information about developments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property)
as legislation enacted after we release it)Is at www.Irs.gov/fw9.
Use Form W-9 only If you are a U.S.person(Including a resident alien),to
Purpose of Form provide your correct TIN.
An Individual or entity(Form W-9 requester)who is required to file an Information if you do not return Form W-9 to the requester with a TIN,you might be subject
return with the IRS must obtain your correct taxpayer Identification number(TIN) to backup withholding.See What Is backup withholding?on page 2.
which may be your social security number(SSN),Individual taxpayer Identification By signing the filled-out form,you:
number((TIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving Is correct(or you are waiting for a number
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 to be Issued),
retums include,but aro not limited to,the following; 2.Certify that you are not subject to backup withholding,or
•Form 1099-INT(Interest earned or paid) 3.Claim exemption tram backup withholding If you are a U.S.exempt payee.If
•Form 1099-DIV(dividends,including those from stocks or mutual funds) 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
•Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and
•Form 1099-5(stook or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(If any)Indicating that you are
brokers) exempt from the FATCA reporting,Is correct.See Whet Is FATCA reporting?on
•Form 1099-S(proceeds from real estate transactions) page 2 for further information.
•Form 1099-K(merchant card and third party network transactions)
Cat.No.10231k Form W-9(Rev.12-2014)