HomeMy WebLinkAbout310034 04/10/17 Q
CITY OF CARMEL, INDIANA VENDOR: 366749
ONE CIVIC SQUARE MALINOWSKI CONSULTING INC CHECK AMOUNT: $""'9,500.00'
CARMEL, INDIANA 46032 755 W CARMEL DRIVE STE 203 CHECK NUMBER: 310034
CARMEL IN 46032 CHECK DATE: 04/10/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 R4340400 24824 2170154 9,500.00 RECOUP MEDICAID FEES
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MALINOWSKI CONSULTING, INC.
Invoice
Date: 3/ 7/2017 Invoice #: 20170154
To:
Chief Dave Haboush
Carmel-Fire Department
2 Civic Square, Station 41
Carmel, IN 46032
For Professional Services
Rendered:
For preparation of Medicaid Ambulance Cost Report for the Year Ended December 31,
2014.
Per negotiated specifications.
Totalinvoice amount .................. $9,500.00
Invoices are due in full 45 days of receipt. Please make all checks payable to:
Malinowski Consulting, Inc.
...............................................................................................................................................................................................
755 W Carmel Drive,Suite 203 1 Carmel,IN 46032
317.818.1876 877.346.7986 malconindiana.com
Form w-9 Request for Taxpayer Give Form to the
(Rev.December 2014) Identification Number and Certification requester' not
Department of the Treasury
ury 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.
Malinowski Consulting, Inc.
C\i 2 Business name/disregarded entity name,if different from above
d/b/a Malcon
m
CL 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to
C certain entities,not individuals;see
N [:]Individual/sole proprietor or E] C Corporation Q El Corporation ❑ Partnership Trust/estate Instructions on page 3):
CL Exempt Icy code d any)
C single member LLC Exem payee.0 E]Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)10,
p 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
H the tax classification of the single-member owner. code(if any)
ructions)
CL c ❑Other(see instIN- to
V accou ft mined auLtide Me U.S.)
5 Address(number,street,and apt.or suite no.) Requester's name and address(optional)
v
a 755 W Carmel Drive, Ste.203
to 6 City,state,and ZIP code
Carmel Fire Department
Carmel, In 46032 Carmel, IN
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
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 I Employer identrficatlon number
guidelines on whose number to enter.
2 0 - 8 6 9 1 5 4 1 6 1 4
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 U.S.person► Yom• i {� Date► S-17- 17
General Instructions
•Form 1098(home mortgage interest),1098-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(ITIN),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 to be issued),
you,or other amount reportable on an information return.Examples of information
returns include,but are 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 from 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-B(stock 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 What 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.10231X Form W-9(Rev.12-2014)