4112 Nicols Rd - Reimbursement 10_20_2010City af Eaau cleimVuueher
INFLOW & INFILTRATION REIMBURSEMENT PROGRAM
Make Check Payable to: ,,\CA S '.i
(Propert name)
And (if applicable) (U E $ ey '4 i E t. E 1 MC. -..
(Contractor /Company name)
Property Address: L 1 - act ,s
1✓PG�!'rrLl r l�
5
Total Costs incurred by Property Owner: $ 0
Total Eligible Costs as determined by Staff: $
Total Amount of Reimbursement to be issued (check one)
50% of eligible costs
100% of eligible costs- Only if assessed
$ ,91.
(1)
( 2 )
(100% option MUST have signed Assessment Waiver( Form attached)
Account Code: #6245 -6440
CHECK ALL AT'TACHMENIS THAT APPLY
)( Private Contractor's Original Quote and Final Invoice
Property owner's original receipts (must be on S'/ x 11 paper)
A horized CiiStaff
g Copy of Certificate of Compliance LL.
Contractor's Lien Waiver (in lieu of being named as a co - payee on City check)
(1) Taxpayer Identification Number and Certification (IRS Form W - 9)
(Required if reimbursement amount exceeds $600)
(2) Waiver of Special Assessment Hearing Form (Note: Claim must exceed $200)
1 declare that this claim is just and in accordance with the City Council's Inflow & Infiltration (1 & I)
Reimbursement Policy and that no part of it has been paid.
Printed NnRignature
Form date 09 01 - 10, REV, 9 - 27 - 10
Date
Bill Ti
Ttacy ohnson
(651) : 95 -5590
Date
1 1 /1 /10
PO Box 247
Loretto, MN 55357
Description
lnstalledl (1) pipe "patch" linen to block drain tile connection to sanitary sewer line
Excavated pothole to access sewer line
C.leaned4and prepped pipe
City permit
Partial payment of $1000 received on 10/1/10 check #221.3
Any cp. :Scions pleAse contact Troy (612) 751 -6888
Fax (763) 478 -9589
troyo @ linemysewer,corn
sosirrom
DIS.9YER
Jobsite Address
4112 Nicols Rd
Eagan
Invoice
Date Invoice #
10 /1 /10 2450
P.O. #
Terms
Amount
Total $ 1850.00
Payments /Credits $1000.00
Balance Due $ 850.00
i t
T I13‘ City of EaRafi
SANITARY SEWER SYSTEM
CERTIFICATE OF COMPLIANCE for
INFLOW & INFILTRATION
City of Eagan, Minnesota.
Propetty Address:
City of Ea
COUP ►C• r I A I , .E
❑ r'his ib to certify that the property listed above has been inspected by authorized City personnel on
and found to be in compliance with Section 3 40 of the City Code and no corrective work was required.
201
QO LL C.AP'CER OItEEC lyt o
0 m D
This i to certify that the property listed above has been found to be in . comp linnet with Section 340 of the CI Code
after sefAsfactorily completing the required corrective repair wont under (check all that a
I City Sanitary Sewer Permit apply):
❑ City Plumbing Petmit
r NOTE: Aplyiierrble only f box is claeclisd:
rseommend�vj that periodic cleaning or future Bnsp ctions beperfor mew e Sewer o minimize Service p i o to t nti ra blo ckage al blo to�,/repnr on fie, at iv Grease Buildup, Root Intrusion, Dip/Settle ,,rent in Pipe, Other: ckage due to„
City Approved:
White dopy: Property Owner
Yellow Copy: Ciry of Eagan (Parcel File)
rov 2 2320
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OC 19 2010 112 : 01 PM
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Name (26 shown on your interne to return)
Busirstn!l Nam, If different from nbove
Sign Sigtratrare a4
Were u.sl person P.
General instructions
EAGAN UTILITIES
Part I
Address (number, street, And opt or su1t no
'I/?jijit.Oir
City, 5td1 7;:, not 21P code
Last arraslunt number(s) here (onto if
Section referesicee ere to the Internal Revenues Code unless
otherwise no! el
Purpose tf Form
A person who lie required to file an information return with the
IRS must obtain your correct taxpayer identification number (TIM
to report. far itrample, Income paid to you, real estate
trtsntetrtIono, diortgage interest you paid, acquisition or
abandonment I)f sect :rod property, cancellation of debt, or
contributions tau made to an IRA.
Use Form -9 only if you are a U.S. person (Including a
resident ellen) to provide your correct TIN to the person
requesting it ( th requester) and, when appllooble, to
1. Certify that the TIN you era giving is correct (er you are
waiting fora number to be Issued),
2 Certify tit tt you are not subject to baclnap withholding, or
3. Claim ex .mption from Imola* withholding if you era a U.S.
exempt payers] If applicable, you are also oartl Ins that as a
U.S person, your allocable ahem of any partnership Inooma from
a U.S. trade o(' business is not subject to the withholding tax on
foreign partners' share of effectively connected income.
Note_ if a requester gives you t3 form other than Form W -9 to
request your 111N, you must use the requester's form If It Is
!aubnthntlolly s miler to this Form W-9.
Request for Taxpayer
identification Number and Certification
alxpa)er Identification Number aim
Choc :< atproptfate boo X Individual /Bole proprlatar Carperatlon 0 Partnership
1:1 Line Q AWN oonikornr. Enter ¶10 lax ala2arlfiaail p= dieregerd01 nrtr /, C=corpmgllon, P=P dt nip) P • •
❑ OW S•e IMITttalona)
Enter your TIN n the appropriate box. The TIN provided must match the name given on Line 1 to avoid
backup withho11ing: For lndivfduals, this le your soda' aftogrlty number (SSr ). However, for a ra,aldent
otion, ogle prop'letor, or disregarded entity, see the Perri Instructions on page 3. For other entities, it is
your ampIDyrar rdnntlflentinn number (EIN), ff you do not have a. number, sm How to get a TIN on page 3
Note. If the ac nuns le in more titan one name, see the chart on page 4 for guidelines on whose
number to entel:
FIZEIgertification
NO 8198 P. 4
C9We form to the
regUester. Do not
send to the IRS.
F�campt
QUOc
i=lequester's r,amo and address (eptIonnl)
eoelal security number -
or
Employer identification number
Underpenaltiea of perjury,'I certify that
I. The nuanbc shewrr on this form is my oarrcot taxpayer Identilloation number for 1 trm wafting for a number to be issued to me), and
2. I am not subject to backup withholding tlecausR: (a) I am exempt from backup withholding, or (b) I have not bean notified by the Internal
Revenue Service (IRS) that I am subJsrct to backup withholding tam a result of a failure to report rail interest or dividends, or (c) the IRS has
notified me that 1 Earn no longer subfeot to backup withholding, and
3, I am a Li,9 citizen or other U.S, person (defined below),
Certification i a.truction,. You must oreAR out Item 2 above If you have been notified by the IRS that you are currently aubjeot to backup
withholding bedause you have fnilcd to report all intirma And dividends on your tax return, For root notate trant4otions, Item 2 does not apply
For mortgage l teraat paid, acquisition or abandonment of secured property, cenoellation of debt, contributions to an individual retirement
arrangement (I A), and generally, payments other than interest and dividends, you ars not required to Dien the Certification, but you must
provide your ctlrrect TIN. See the instructions on page et.
Dotp*' /O Jla
Definition of a U.S, WW1. F or federal tax purposes, you are
considered a U.S . parson If you are:
. An individuai who Is a U.S. Citizen or U„E., resident alien,
• A partnership, darpotatlon, carllpeny, or association created or
or In the United States or under the laws of the United
states,
s An estate (other than q foreign estate), or
to A dom trust (as denied In Regulations coction
301 7701 -7).
Special rulae'lor partnership*. Partnerships that conduct a
trade or business in the United States are generally required to
pay a withholding tax on any foreign partners' share of Income
from such business, Further, In certain acmes where a Form W -9
has not been received, a partnership is required to presume that
a plarlrv�r is a foreign person, and pay the withholding tax,
Therefore if you are a U,S, person that Is a partner in a
partnership condueting o trade or business in the United States,
provide Forrn W -9 to the parttlarship to establish your U.S.
stEltua and avoid withholding an your shwa of partnership
Income.
The person who givaa Form W-910 the partnership for
purposes of establishing its U.S. state® and avoiding withholding
on its allocable chest of net ihoome from the partnership •
conducting a trade or businesa in the United States Is in the
following cant:
• The U S owner of a disregarded entity and not the entity,
Oat No 102.31X Form W - (Roy, 'I D.2107)
Farm W -9 {Rev. 10 -2007}
• The U.S grantor or other owner of a grantor trust and not the
trust, and
• The U.S. trust (other than a grantor trust) and not the
beneficiaries of the trust.
Foreign person. If you are a foreign person, do not use Form
W -9. Instead, use the appropriate Form W -8 (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 not subject to
backup withholding, give the requester the appropriate
completed Form W -8
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, 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 ]I
instructions on page 3 for details),
3. The IRS tells the requester that you furnished an incorrect
TIN,
Page 2
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 the instructions below and the separate
Instructions for the Requester of Form W -9.
Also see Special rules for partnerships on page 1
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
Name
If you are an individual, you must generally enter the name
shown on your income tax return. However, if you have changed
your last name, for instance, due to marriage without informing
the Social Security Administration of the name change, enter
your first name, the last name shown on your social security
card, and your new last name.
If the account is in joint names, list first, and then circle, the
name of the person or entity whose number you entered in Part I
of the form.
Sole proprietor. Enter your individual name as shown on your
income tax return on the "Name" line. You may enter your
business, trade, or "doing business as (DBA)" name on the
"Business name" line
Limited liability company (LLC). Check the "Limited liability
company" box only and enter the appropriate code for the tax
classification ( "D" for disregarded entity, "C" for corporation, "P"
for partnership) in the space provided.
For a single- member LLC (including a foreign LLC with a
domestic owner) that is disregarded as an entity separate from
its owner under Regulations section 301.7701 -3, enter the
owner's name on the "Name" line. Enter the LLC's name on the
"Business name" line
For an LLC classified as a partnership or a corporation, enter
the LLC's name on the "Name" line and any business, trade, or
DBA name on the "Business name" line
Other entities. Enter your business name as shown on required
federal tax documents on the "Name" line. 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 the "Business name" line
Note. You are requested to check the appropriate box for your
status (individual /sole proprietor, corporation, etc )
Exempt Payee
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status,
then check the "Exempt payee" box in the line following the
business name, sign and date the form.
IF the payment is for ...
THEN the payment is exempt
for...
Interest and dividend payments
All exempt payees except
for 9 .
Broker transactions
Exempt payees 1 through 13.
Also, a person registered under
the Investment Advisers Act of
1940 who regular[y acts as a
broker
Barter exchange transactions
and patronage dividends
Exempt payees 1 through 5
Payments over $600 required
b be reported and direct
safes over $5,000'
Generally, exempt payees
1 through 7
Form W -9 (Rev. 10 -2007)
Generally, individuals (including sole proprietors) are not exempt
from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends
Note.. If you are exempt from backup withholding, you should
still complete this form to avoid possible erroneous backup
withholding„
The following payees are exempt from backup withholding:
1,. An organization exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(6)(7) if the account
satisfies the requirements of section 401(1)(2),
2. The United States or any of its agencies or
instrumentalities,
3. A state, the District of Columbia, a possession of the United
States, or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding
include:
6. A corporation,
7 A foreign central bank of issue,
8. A dealer in securities or commodities required to register in
the United States, the District of Columbia, or a possession of
the United States,
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10 A real estate investment trust,
11. An entity registered at all times during the tax year under
the Investment Company Act of 1940,
12. A common trust fund operated by a bank under section
584(a),
13. A financial institution,
14. A middleman known in the investment community as a
nominee or custodian, or
15. A trust exempt from tax under section 654 or described in
section 4947
The chart below shows types of payments that may be
exempt from backup withholding, The chart applies to the
exempt payees listed above, 1 through 15.
`See Form 1099 -MISC, Miscellaneous Income, and its instructions.
Z However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 6045(1), even if the attorney is a
corporation) and reportable on Form 1099 -MISC are not exempt from
backup withholding: medical and health care payments, attorneys' fees. and
payments for services paid by a federal executive agency,
Page 3
Part 1. 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 page 2), 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 Social Security
Administration office or get this form online at wwwssa.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.govlbusinesses 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 www.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,
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 domestic entity that has a foreign owner
must use the appropriate Form W-8.
Part 11. 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, and 5 below indicate
otherwise.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required) Exempt payees, see Exempt
Payee on page 2.
Signature requirements.. Complete the certification as indicated
in 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
Form W -9 (Rev. 10 -2007)
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 TEN, 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 to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
5,. 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
'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
' Circle the minors name and furnish the minor's SIN.
3 You must show your indlvidusl name and you may also enter your business or 'DSA'
name on the second name line. You may use either your SSN or EIN Of you have one)
but the [RS encourages you to use your SSN
° 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 t
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
Page 4
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal
information such as your name, social security number (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
Call the IRS at 1-800-829-1040 if you think your identity has
been used inappropriately for tax purposes.
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 or TTY/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 phishing@irs.gov. You may also report
misuse of the IRS name, logo, or other IRS personal property to
the Treasury Inspector General for Tax Administration at
1 -800- 366 -4484. You can forward suspicious emails to the
Federal Trade Commission at spam @uce.gov or contact them at
www consumergov/idtheft or 1- 877 - IDTHEF 1'(438- 4338),
Visit the IRS website at www.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 who must file information returns with the IRS to report interest
dividends, and certain other income paid to you, mortgage interest you paid. the acquisition or abandonment of secured property, cancellation of debt, or •
contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return,
The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty to federal and state agencies to enforce federal
nontax 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. Payers must generally withhold 28% of taxable interest dividend, and certain other
payments to a payee who does not give a TIN to a payer Certain penalties may also apply
For this type of account
Give name and SSN of:
1
Individual
The individual
2
Two or more individuals (joint
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
trust (grantor is also trustee)
The grantor - trustee'
b. So- called trust account that is
not a legal or valid trust under
state law
The actual owner '
5
Sole proprietorship or disregarded
entity owned by an individual
The owner'
For this type of account:
Give name and EIN of:
6
Disregarded entity not owned by an
individuat
The owner
7
A valid trust, estate or pension trust
Legal entity
8
Corporate or LLC electing
corporate status on Form 8832
The corporation
9
Association, club, religious,
charitable, educational, or other
tax- exempt organization
The organization
10
Partnership or multi - member LLC
The partnership
11
A broker or registered nominee
The broker or nominee
12
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
Form W -9 (Rev. 10 -2007)
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 TEN, 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 to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
5,. 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
'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
' Circle the minors name and furnish the minor's SIN.
3 You must show your indlvidusl name and you may also enter your business or 'DSA'
name on the second name line. You may use either your SSN or EIN Of you have one)
but the [RS encourages you to use your SSN
° 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 t
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
Page 4
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal
information such as your name, social security number (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
Call the IRS at 1-800-829-1040 if you think your identity has
been used inappropriately for tax purposes.
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 or TTY/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 phishing@irs.gov. You may also report
misuse of the IRS name, logo, or other IRS personal property to
the Treasury Inspector General for Tax Administration at
1 -800- 366 -4484. You can forward suspicious emails to the
Federal Trade Commission at spam @uce.gov or contact them at
www consumergov/idtheft or 1- 877 - IDTHEF 1'(438- 4338),
Visit the IRS website at www.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 who must file information returns with the IRS to report interest
dividends, and certain other income paid to you, mortgage interest you paid. the acquisition or abandonment of secured property, cancellation of debt, or •
contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return,
The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty to federal and state agencies to enforce federal
nontax 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. Payers must generally withhold 28% of taxable interest dividend, and certain other
payments to a payee who does not give a TIN to a payer Certain penalties may also apply
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Community Services in Dakota County
7373 West 147 Street, Suite 190
Apple Valley, MN 55124
Phone number: 952 - 431 -5611
Fax number: 952 - 431 -2211
FAX COVER PAGE `-D
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04
OC 19 2010 1;00PM EAGAN UTILITIES
City of aall hM
City of Eagan Public Works Utility Department
3419 Coachman Point
Eagan, MN 56122
Phone: (651) 675-5200
Fax: (651) 676 -5211
f )/7' Jody Lewis — Dakota County People Services
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-FREW 4Q : Linda Dralie
DATE: ' 10 -19 -2010
Fax#: 982.31 -2211
Na 8198 ! P, 1
Fax #: 6514375-5211
Rl~: ' 4112 Nicola Road —Tracy Johnson
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