HomeMy WebLinkAbout312101 06/05/17 CITY OF CARMEL, INDIANA VENDOR: 371717
ONE CIVIC SQUARE INDY COOL SUPPLIERS CHECK AMOUNT: $""*'*340.00*
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CARMEL, INDIANA 46032 PD BDx 24754 CHECK NUMBER: 312101 SPEEDWAY IN 46224 CHECK DATE: 06/05/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1095 4239040 4001 340.00 FOOD & BEVERAGES
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Form W 9 Request for Taxpayer Give Fora,to the
Qte11-Dsuerrrber2014) Identification Number and Certification requester.Do not
cep■bnaioltho7reesay send to the IRS.
htsmd lieversa Sarrice
1 Naar(as shown on your income tax return).Name Is required on this line;do not leave this line blank
L L
V4 2 Bu&ms noWdisregarded entity nine,If different from above
1i
a 3 Check appropriats box far federal trot classification;check only one of finer following seven boxes: 4 Exarnptions(codes appy only to
C
❑IndividuaVaole propristor or ❑ C Corporation ❑S Corporallon D Partnership ❑TrusVestate rption�a d Sin apply o see
c single-mamberLLC
Limited 9abrdy company.Enter the tax clauftation(C-C corporation.SeS corporation.Npannership)I- Exempt payee code(9 arty)
n Fxern from FATCA
Note.For a skpl►msmther LLC that Is dhraparded,do not ClueClt LLC;check the appropriate box In the Itrre above for Ptd reporting
c the tax daselticatlon of the skglstnarnber owner. aceta of )
d ❑Other(am instroctions)e Nwrswa.em.v.r..rr�eaaaka.e.ua!
g 3 Address(number,afrest,and apt.or suite no.) Raqumb is name and address(optional)
m ;^� Ver
8 City.shb,and LP code
s l&1>W , --T-ti Lf6 act
7 Ust account numbers)We(optional)
111121111111111111 Taxpayer Identification Number IN
Enter your TN In titer appropriate box.The TiN provided must match the name given on Mo 1 to avoid Social security number
resident
withholding.lding.For individuals,this is generally your social security number ASSN) However,for a
resklent erten,sofa proprfetw,or disregarded tlrRhy,sae the Part I instructions on page 3.For other
entities.it Is your employer klerthlcatlon number(BN).If you do not have a number,ace How to get a
TiN on page 3. Or
Note.If the account Is In more than one name,we the instructions for line 1 and the chad on page 4 for Employer Identillution number
guidNUres on whose number to enter.
y7
Certification
Under penalties of perjury,I certify that:
1. The number shown on this forth Is my correct taxpayer Identification number(or I am waiting for a number to be Issued to mak and
2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding or lb)1 have not been notified by the internal Revenue
Service QRS)that I am subject to backup withholding as a result of a failure to report all Interest or dividends,or(c)the IRS hits notilied me that I am
no longer subject to backup withiolding;and
3. 1 am a U.S.citizen or other U.S.person(defined below};and
4.The FATCA code(k)entered on this form 0 any)Indicating that I am exempt from FATCA reporting is correct
Certification instructions.You must cross out hem 2 above If you have been notified by the IRS that you are currently subject to backup withholding
because you have felled to report all interest and dividends on your tax return.For real estate trarisactkxts,Item 2 does not apply.For mortgage
intertest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arras gement PRA),and
generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct 71N.See the
Instructions on page 3.
Sign Signature of
Here U.S persons Onto S
General Instructions C!6m t09a(harrernortgagowere t).1oae- W derrtlaentrxarasq 10WT
(tuition)
Section eefrares are to tiro Internal Revenue Code unless otherwise noted. IRorm 1099-C(canceled debt)
Future devsiopmants.'"Awnnallon about developments affeetirg Form W-9(such Morm IOWA(aequbition or abandonment of secured property)
as legislation area ted after we release k)le at wwwJmgoWfw9.
Use Form W-9 only■you aro a U.S.person(Including a residerd alien]to
Purpose of Form provide yourcarecinfi.
An IndlMur or emery(Form W-9 requesto whole required to fie an information a you do not realm Form W-9 to the reQuedw with a TIN,you might be subject
return with the IRS must obtain your carver t taxpayer IdenBlkatkin number(11N) to backup with hoWing.See What is backup wW*mldIng?on papa 2-
which
which may be your socio security number(SSR),individual taxpayer MentMk ation By signing the raw-out lam.you-"*
number OMNI adoption taxpayer Wentreation number(ATIN),or employer
Identification number(EW X to report on an Wormation return the amount paid to I.to��that the TIN you are giving b correct(or you am waft for a number
ou,
yor other amount reportable on an information return.Examples of Infonnatlon
returns include.but are not limited to,tra following: 2.Certify that you are not subject to backup withhokift.or
(kam 1099-INT(Interest earned or pail) 3.Claim exemption from backup withholding r you ars a U.S.exempt payee.N
Corin 1oWDN(dMdends.including those from stocks or mutual funds) °PPlicable,you are also certifying that as a U.S.parson,your aflocaWs share of
aliform I OWMISC Wlous types of Income,pricers,awards.or areas proceeds) wwiithholdP ng tax artnerstilpan nme�m a U.S.trade or business Is not subject to the
Dorm 1099-8(stock or mutual fund ads&and certain other transactions 4. TCA c defs)padrnt share of is loan Qr connected income,that
and
��) by Certify that FATCA coda(s)entarod on this form(Ir airy)indicating That you ars
exempt from tin ► mt—a2muL&A WMA a FATCA reporting?on
L#orm 1099-B(pit ceaft hom red estate bansac-ns) page 2 for furth +t v
Uam 1 OWK(merchant card and third party network Manssctions)
CaL No.10231X brm W-9(Itev.12-2014)
BY`:
Indy Cool Suppliers
PO Box 24754
Speedway,IN 46224
Bili To:
L"
DATE: of 61'k
INVOICE#
DESCRIPTION AMOUNT
�0 /4 4 vi2))L rn i XFJ -C E YS
17
UPC CODES:
Blueberry-Raspberry 8 51239 005010
Mango 8 51239 00503 4
Wild Cherry 8 51239 00502 7
Strawberry-Lemonade 8 51239 00500 3
TOTAL S
Make all checks payable to: Indy Cool Suppliers LLC
For any quesdons concerning this Invoice,call: Carol Wellman, 317-5094219
Carol(ftoolsupollers.com
www.facebook.com►nyscoops www.coolsupr)liers.com
THANK YOU FOR YOUR BUSINESS!