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Page 1
The Navajo Nation
Department of Water Resources
REQUEST FOR PROPOSALS
PROPOSAL DUE DATE: September 2, 2015 @ 4:00 PM (MST)
DESCRIPTION: Navajo Nation Department of Water Resources -
Technical, Construction and Operations Branch
BID# 15-08-1421VJ- Project# NN-12-12-034
Environmental Assessment Report – Captain Tom
Irrigation Project
CONTACT PERSON: Reynalden Delgarito, Associate Civil Engineer
Phone Number: (928) 729 – 4145
RETURN ALL PROPOSALS CLEARLY MARKED,
“DO NOT OPEN – BID No. 15-08-1421VJ, TO:
DELIVER TO: Navajo Nation Department of Water Resources
(FedEx/UPS Address) Technical, Construction, and Operations Branch
Navajo Route 12
Fort Defiance, AZ 86504
MAIL TO: Navajo Nation Department of Water Resources
Technical, Construction, and Operations Branch
P.O. Box 678
Fort Defiance, AZ 86504
Attn: Reynalden Delgarito, Assoc. Civil Engineer
The Navajo Nation Department of Water Resources – Technical, Construction, and Operations Branch (TCOB) reserves the right to reject any or
all proposals and to waive any informality in the proposals received whenever such rejection or waiver is in the best interest of the Navajo Nation.
Page 2
Navajo Nation Technical, Construction and Operations Branch
BID: 15-08-1421VJ
PART I
General Information
A. Request for Proposal: The Navajo Nation Department of Water Resources – Technical,
Construction, and Operations Branch (TCOB) is seeking qualified contractors to perform
an Environmental Assessment (EA) Report, to include a Biological Evaluation (BE) and an
Archaeological Survey (AS). The Captain Tom Irrigation Project is located within the
Newcomb and Two Grey Hills Chapters. These requirements are to adhere to all Tribal
and Federal Regulations, with a complete report of their findings. All interested firms are
invited to submit a proposal in accordance with instructions herein.
B. This RFP provides prospective firms with sufficient information to enable them to prepare
and submit proposals in the provision of environmental site assessment services to TCOB.
C. This RFP contains the instructions governing the proposal to be submitted and the
documents to be included therein and mandatory requirements which must be met to be
eligible for consideration.
D. Schedule of Activities:
1. Advertisement Period August 22-24, 2015
2. Proposal Due Date September 2, 2015 @ 4:00 PM (MST)
3. Evaluation of Proposals September 3-4, 2015
4. Notice of Intent to Contract September 8, 2015
E. Inquiries: Prospective Firms may make inquiries concerning the RFP to obtain
clarification of requirements by contacting Reynalden Delgarito, Associate Civil Engineer,
NNDWR – TCOB, at Phone: (928) 729-4145 or email: reynaldendelgarito@navajo-
nsn.gov.
F. Proposal Standards: The Proposal will not exceed 25 pages (8-1/2” X 11”) in length,
single-spaced, 12-pt. font, including resumes, title page, table of content, and other
pertinent forms that is required. Proposals that exceed these limitations will be
disqualified. Four over-sized sheets, up to 11” X 17” will be allowed as 8 ½” x 11” pages.
Additional over-sized sheets will be counted in terms of equivalent 8-1/2” X 11” pages.
Incidental use of fonts in charts and tables down to 10-pt. font necessary to make charts or
tables fit pages will be allowed. An original and six (6) copies of the proposal will be
submitted in a sealed envelope clearly marked, “Do Not Open –BID: No. 18-08-1421Vj”,
by September 2, 2015 @ 4:00 PM (MST). The Fee Schedule must be included in a
Page 3
separate, sealed envelope marked, “FEE SCHEDULE”. Mail Proposal addressed to the
Navajo Nation Technical, Construction, and Operations Branch, P. O. Box 678, Ft.
Defiance, AZ. 86504, or deliver, FedEx or UPS to the Navajo Nation Technical,
Construction, and Operations Branch, Navajo Route 12, Ft. Defiance, AZ, 86504,
Telephone: (928) 729-4145. Firms who are mailing their proposals should allow sufficient
time for mail delivery to ensure receipt by the time specified. No proposals will be
accepted after the due date. No faxed or e-mailed proposals will be accepted.
G. Late Receipt of Proposals: Late proposals will not be accepted. It is the responsibility of
the Firm to ensure the proposal arrives at TCOB before the due date and time specified.
H. Rejection of Proposals: The TCOB reserves the right to reject any or all proposals and to
waive informalities in the proposals received whenever such rejection or waiver is in the
best interest of the Navajo Nation.
I. Proprietary Information: Any restrictions on the use of data contained within any
proposal must be clearly stated in the proposal itself. Each and every page of the
proprietary material must be labeled or identified with the word, “Proprietary”.
J. Response Material Ownership: All material submitted regarding this RFP will become
property of TCOB and will not be returned to the Firm. Responses received will be
retained in a file. The TCOB has the right to use any or all system ideas presented in
response to this RFP, subject to limitations outlined in paragraph J above. Disqualification
or non-selection of a Firm or proposal does not eliminate this right.
K. Incurring Costs: The TCOB is not liable for any cost incurred by the Firm prior to
issuance of an agreement, contract and/or purchase order.
L. Acceptance of Proposal Content: The contents of the proposal of the successful firm will
become contractual obligations if acquisition action ensues. Failure of the successful firm
to accept these obligations may result in cancellation of the award and such firm may be
removed from future solicitation. The TCOB reserves the right to pursue appropriate legal
action in the set of circumstances in Navajo Nation Tribal Courts.
M. Acceptance Time: The TCOB intends to make a selection within thirty (30) calendar days
after the closing date of receipt of proposal. No inquiries will be accepted during the
evaluation period. The evaluation period will begin on the specified time and may last up
to ten (10) working days thereafter.
N. Notice of Intent to Contract: The successful Firm will be sent a notice of intent to
contract letter. If negotiations are successful, a contract will be developed, which includes
the scope of work, costs, and other elements of the proposal submitted.
Page 4
O. Proposal Evaluation:
1. Proposal shall be evaluated on the basis of demonstrated competence and
qualifications for the type of service required, and shall be based on the evaluation
factors set forth in this RFP. For the purpose of conducting discussions, proposal
may be initially classified as:
a. Acceptable.
b. Potentially acceptable, that is, reasonably assured of being made acceptable.
c. Unacceptable (Firms whose proposals are unacceptable shall be notified
promptly).
2. The TCOB shall have the right to waive technical irregularities in the form of the
Proposal of the Firm, which do not alter the quality or quantity of the services.
3. Preference of Navajo and Indian-owned businesses will be given under the Navajo
Nation Business Opportunity Act, 5 NNC §201 et. Seq., and the Navajo Nation
Procurement Act, 12 NNC §203. The Navajo Nation Department of Justice has
determined that Navajo Preference does not apply to qualification based solicitations;
however evaluation points will be awarded to Navajo and minority respondents.
P. Standard Contract: The TCOB reserves the right to incorporate contract provisions
based upon the negotiations with the successful firm as a result of a proposal submitted in
response to this RFP.
Q. The Laws, Rules and Regulations of the Navajo Nation Code, latest edition, shall govern
the procurement of these services, specifically, the Navajo Nation Business Opportunity
Act (5 NNC §201 et. Seq.), and the Navajo Nation Procurement Act (12 NNC §203).
R. Professional Liability Insurance: The successful Firm shall provide a Certificate of
Liability Insurance.
S. Protests: In accordance with Navajo Business Opportunity Act, any contractor who is
concerned about the award of a contract may protest to the Navajo Nation’s Business
Regulatory Department. The protest must be submitted in writing to:
Navajo Business Regulatory Dept. Mr. Najam Tariq, Director
P.O. Box 663 Navajo Nation Department of Water
Window Rock, AZ, 86515 Resources - Technical, Construction,
Tele: (928) 871-6714 or 6718 & Operations Branch
P. O. Box 678
Ft. Defiance, AZ 86504
Tele: (928) 729-4004 Protest must include the name and address of the protestant, the solicitation number, and a
statement of grounds for protest, including appropriate supporting exhibits.
Page 5
PART II
Scope of Work
Summary:
The Navajo Nation Department of Water Resources (NNDWR) – Technical, Construction, and
Operations Branch (TCOB) is seeking qualified Firms to conduct Environmental Assessment, to
include a Biological Evaluation and Archaeological Survey, of an 18.1 mile total length of
irrigation canal located west of and within the Newcomb NavaFarm community. This system
will be evaluated and analyzed for canal rehabilitation and/or improvement. Alternatives are:
Diversion 1
1. Rehabilitate diversion structure;
a. Line canal with suitable material feeding the main canal into the Captain Tom
Reservoir meeting water management plans
b. Include a pump capable of drawing water up from a sump into an
underground pipe system at diversion 1, feeding the main canal into the
Captain Tom Reservoir meeting water management plans
2. Redesign and construct a new diversion structure;
a. Line canal with suitable material so as to meet water management plans for
Captain Tom Reservoir
b. Include a pump with underground pipe system so as to meet water
management plans for Captain Tom Reservoir
3. No action
Diversion 2
1. Rehabilitate Diversion 2;
a. Include a pump and pipe system meeting crop demand
2. Redesign and construct a new diversion structure;
a. Include a pump and pipe system meeting crop demand
3. No action
NavaFarm Canals
1. Line canals with suitable material to meet crop irrigating requirements
2. Place underground piping system to meet crop irrigating requirements
3. No action
Page 6
Figure 1: Mapping location of site
(ESRI based GIS information will made available upon request)
Table 1: Site Information
The NavaFarm community currently uses an earthen canal to divert water form Captain Tom
Wash into Captain Tom Reservoir. A primary diversion structure with a manual gate is in place
approximately ¾ of a mile (3752 feet) west of Two Grey Hills Chapter house. Approximately
half the irrigation conveyance leading to Captain Tom Reservoir is a natural wash which will be
left undisturbed. The feeder canal from diversion 1 is to replenish the water supply for the
farming community. A concrete lined canal starts from the Captain Tom Reservoir to the
farming community to supply the farmers with water during non-monsoon seasons.
A secondary diversion is located approximately 1 mile (5100 feet) south of the Reservoir and
feeds directly into the farming community. There are several arterial canals feeding each farm
Page 7
plot within the farming community and crossing under Highway 491. The community irrigation
canals are earthen and have turnouts for each farm plot to access flow from the main canals.
The Scope of Work is outlined in the Tasks that follow. The scope is divided into seven (7)
sections:
Task 1. Project Initiation
The Consultant will conduct a work session with NNDWR – TCOB to confirm project
objectives, define the proposed action and the range of alternative actions for evaluation in the
Environmental Assessment Report (EA), prepare a detailed project schedule and prepare a
detailed work plan. The cooperators on this project are the Newcomb NavaFarm Board,
Newcomb Chapter, and NNDWR - TCOB.
Task 2. Description of Project Purpose/Background and Alternatives
As a first step toward preparation of an EA, the Consultant will describe and document the
purpose and need for the action, the history and background of the proposed action, the essential
characteristics of the proposed alternative actions being considered for evaluation, and the
institutional framework for the environmental review process.
Task 3. Public Scoping
The Consultant will be responsible for arranging, noticing, and conducting any public scoping
meetings, and preparing and distributing scoping information to potentially affected and/or
interested individuals, organizations, and agencies.
The Consultant will be responsible for preparing and maintaining a complete and accurate record
of all public scoping meetings and public comments submitted as part of the scoping process.
Based on input from potentially affected/interested parties during the scoping process the
Consultant will identify any major issues and concerns relevant to the proposed action.
Task 4. Data Collection
The Consultant will identify and compile all existing data sources and baseline information. The
collection of baseline information will include information about the environmental effects of
implementing the proposed Federal action and other reasonably foreseeable development in the
area. The Consultant will also conduct a review of all pertinent existing documentation and
identify those subject areas requiring the generation of primary data. After conferring with the
NNDWR –TCOB and Newcomb Chapter, the Consultant will collect all primary data required
for the preparation of the EA, to include a BE and AS.
In compliance with Section 7 of the Threatened and Endangered Species Act, the document
preparer shall contact the Navajo Nation Fish and Wildlife - Natural Heritage Program
(NNNHP) for a Threatened and Endangered Species listing and prepare a biological assessment.
Task 5. Documentation of Existing Conditions for the Affected Environment
Page 8
The Consultant will define, describe and document the existing conditions of the affected
environment for the action alternatives based upon the data and information collected during
Task 4. In order to define the no action alternative, the Consultant will project current conditions
to the most reasonably foreseeable future conditions that would prevail in the absence of taking
the proposed Federal action.
Task 6. Prepare Draft EA
The draft EA will be prepared in accordance with the National Environmental Policy Act of
1969 (NEPA), the Council on Environmental Quality’s regulations for implementing NEPA (40
Code of Federal Regulations Parts 1500-1508), and the BIA’s Navajo Regional Office Division
of Environmental, Cultural and Safety Management’s Environmental Assessment Document
Content and Format (IAM Part 59, Chapter 3) (Attached)
The Consultant will provide DWR and BIA with one electronic version (MSWord preferred) and
10 copies of a preliminary draft EA for review. Following revisions based on input from
NNDWR - TCOB and BIA, the Consultant will provide 60 copies of the draft EA for public
distribution by NNDWR - TCOB and BIA.
Task 7. Prepare Final EA/Deliverables
At the end of the public review period, the Consultant will review public comments and, working
with DWR and BIA, determine the appropriateness of the comments, assist in preparing
responses to relevant questions/comments, and make revisions to the EA as appropriate. The
Consultant will prepare a preliminary final EA, revising the text as required in response to
comments, as well as an appendix of comment letters received and NNDWR - TCOB’s and
BIA’s responses. The Consultant will provide a signed FONSI from the BIA, as determined, and
identify all environmental permits needed for construction of the project.
A copy of the Cultural Resource Compliance Form, issued by the NNHPD, or equivalent
documentation, should be included as part of the EA submittal.
A copy of a Biological Resource Compliance Form, or equivalent, issued by the NNNHP, should
be part of the EA submittal.
The Consultant will provide NNDWR - TCOB and BIA with one electronic version (MSWord
preferred) and 10 copies of a preliminary final EA for review. Following revisions based on
input from DWR and BIA, the Consultant will provide 60 copies of the draft EA for public
distribution by DWR and BIA.
Page 9
Part III
RFP Evaluation Criteria and Requirements
Prospective firms must submit a complete response to the RFP. All proposals received in
response to this RFP will be retained by NNDWR-TCOB. Proposals should be prepared simply
and economically, providing complete details of the prospective firms’ abilities to perform
qualified, professional Engineering/Surveying Services.
A. Proposals must include the following:
1. General scope of services provided by the respondent firm (include business background
information).
2. Proposed scope of work to be performed. The plan should outline specific services the
firm will provide in the course of performing EA, BE, and AS for NNDWR-TCOB. A
projected schedule is to be included.
3. Proposed cost of performing afore mentioned services: provide percentage breakdown by
key cost components. Fee schedule will be included as a separate sealed envelope
marked “Fee Schedule”. The fee schedule will be opened by the Evaluation Committee if
and when a proposal is selected for negotiation.
4. Description of firm’s previous experience in the area of afore mentioned services for an
Indian Tribe or Federal Agency. (Please include a list of reference with at least two
current addresses on the Navajo Reservation).
5. Qualifications of personnel to be assigned to this project.
6. Proposal Submission: The proposal contains substantially all components specified in
PRT IV – PROPOSAL CONTENT AND EVALUATION CRITERIA.
7. Proposal Format: Upon submission of proposals, provide an original and six (copies)
proposal packets for the evaluation committee members. In addition, it is requested that
proposals be in flat bound form to facilitate filing. Please do not submit proposals in
loose-leaf binders (3-ring), these will be rejected as non-responsive. Proposals will be
submitted in a sealed envelope clearly marked, “Captain Tom Irrigation Project – 609-13-
0001-TF04/K133042 - DO NOT OPEN RFP -” and must be received by September 2,
2015, at 4:00 P.M., MST. The fee schedule must be included in a separate, sealed
envelope marked, “Fee Schedule”.
Page 10
PART IV
Proposal Content and Evaluation Criteria
The NNDWR-TCOB intends to retain the successful proposers on a “Best Value” basis, not a
“Low Bid” basis. Therefore, the NNDWR-TCOB can properly evaluate the offers received. All
proposals submitted in response to this RFP must be formatted in accordance with the sequence
noted below. Each category must be separated by index dividers numbered and labeled with the
corresponding tab reference also noted below.
A. Tab 1: Qualification of the Firm. Proposals must specifically address and affirm the
following: 1. Letter of Interest that indicates why your firm should be selected for the job.
2. Qualification of personnel to be assigned to this project.
3. Describe in detail how the service will be provided. Include a description of major tasks
and sub-tasks.
4. Detailed resume for all management and key personnel that will be involved with
projects, including the professional qualifications and experience and a statement
indicating task each individual will be assigned to perform.
5. Submit a project plan that details the work to be conducted. Include the time line (Gantt
chart showing each phase or task of the work, when that phase or task will begin, how
long it will continue, and when it should end) for completion of the EA, BE, and AS. The
schedule should clearly delineate each point in time where project deliverables and
reports are planned.
6. The proposal must contain sufficient detail to allow proper determination of the
proposer’s ability to commit sufficient time to this NNDWR-TCOB project. Staff-hour
commitments and percentage of time committed to other work for each member will be
specified.
7. For Navajo/Minority/Small Business Preference Requirements, submit the Certificate.
The Navajo Nation Department of Justice has determined that Navajo Preference does
not apply to qualification based solicitations; however points will be awarded to Navajo
and minority respondents.
Page 11
B. Tab 2: Experience 1. The Firm will provide evidence of experience and quality services rendered relating to
the required work in the Navajo Nation. Provide evidence of work with Navajo Nation
Chapters, Divisions, and Departments on planning or development projects.
2. Provide a list of five references for contracts of similar size and scope, including at least
two references for current contracts or those awarded during the past three years.
Reference must include name of company in contract with, the length of contract term,
contract persons, addresses and telephone numbers.
3. Provide evidence that the firm has the administrative, technical and financial capability to
perform the required services.
4. Business & Staff Experience: Management capacity; staff expertise; internal quality
control; organizational structure.
C. Tab 3: Record of Past Performance
The proposing firm must demonstrate it has the administrative and technical capability to
perform the required services on time and within the project budget.
1. Record of timely completion of Water Plan(s) and Systems Upgrade analysis.
2. Internal measures proposed for timely completion and cost control.
3. Person responsible for schedule and budget.
4. Any past client contractual issues/obstacles.
D. Tab 4: Financial Stability and Capability
The proposing firm must demonstrate it has the financial capability to perform the
required services. Proposers must provide; failure to provide will disqualify your
proposal.
1. Include in your proposal, the firm’s 2011 or more recent Year End Financial
Statements, which clearly depict the stability of the firm. Financial statements must
include the Balance Sheet, Income statement, Statement of Cash Flow.
E. Tab 5: Proposed Fees
1. Provide a detailed cost breakdown for all service elements within your total cost
proposal to carry out the Scope of Work. Include all personnel, time, equipment,
supplies, overhead expenses, and profits, as well as setting out any travel expenses or
Page 12
unusual expenses if applicable.
PART V
Rating System on Evaluation Criteria
The manner proposal will be evaluated and rated as follows. The descriptions of the
components are provided in Section IV. Proposal Content and Evaluation Criteria.
A. Qualifications. (40 points) __________
B. Experience. (35 points) __________
C. Record of Past Performance. (15 points) __________
D. Financial Stability. (10 points) __________
1. 2011 or more recent Year End Financial Statements, which clearly:
A. Depicts the stability of the firm
B. Must include the Balance Sheet and Income Statement
C. Statement of Cash Flow
Total Points (100 points possible) =========
End of Proposal.
Thank you for your interest in working with the Navajo Nation Water Management Branch.
NAVAJO NATION CERTIFICATIONRegarding Debarment and
Suspension
Applicant acknowledges that to the best of his/ her knowledge that their company and principalparticipants on this contract:
1. Are not debarred, suspended, or otherwise slated for debarment, ineligible and/ orexcluded from participation on Federal, State, and Tribal Government contracts etc.
2. Are not presently nor have been under criminal indictment or civilly charged by agovernmental entity (Federal, State, and Tribal Government) for fraud, forgery,falsification, theft, bribery, destruction of records, receiving stolen property and othercriminal offenses in the administration of government contract.
3. Have not been terminated for cause or convenience by a government entity in theadministration of a government contract (Federal, State, and Tribal Government).
4. If the Navajo Nation determines that the Certificate provided herein is not true, it will begrounds to terminate the contract and pursue other legal remedies.
Applicant' s Address Name & Signature of Applicant
Type or Print Name
SignatureDate
Office of the Controller • PO Box 3150, Window Rock, AZ 86515 • ( 928) 871- 6316 • Fox( 928) 871- 7778
Form W' 9 Request for Taxpayer Give Form to theRev. December 2014)
Identification Number and Certificationrequester. Do not
Department of the Treasury 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.
N 2 Business name/disregarded entity name, if different from above
arrnalo. 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions( codes apply only to
Individual/ sole proprietor or C corporation certain entities, not individuals; seew
po S Corporation Partnership Trust/estate instructions on page 3):a co single- member LLC
Limited liability company. Enter the tax classification C= C corporation. S= S corporation. Exempt payee code( if any)ty P Y po poration, P= partnership)
Exemption from FATCA reportingc 2 Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for
E
the tax classification of the single-member owner. code( if any)a 0 Other( see instructions) P trodaasto accounts nwnrr dumotioned mew*
5 Address( number, street, and apt. or suite no.) Requester' s name and address( optional)
mnto 6 City. state, and ZIP coded
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 numberbackup withholding. For individuals, this is generally your social security number( SSN). However, for aresident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For otherentities, it is your employer identification number( EIN). If you do not have a number, see How to get aTIN 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 Identification numberguidelines on whose number to enter.
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 RevenueService( 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 amno 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 withholdingbecause you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgageinterest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement( IRA), andgenerally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See theinstructions on page 3.
Sign Signature of
Here U. S. person Date P.
General Instructions Form 1098( home mortgage interest). 1098- E( student loan interest), 1098- Ttuition)
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/1w9.
Use Form W- 9 only if you are a U. S. person( including a resident alien), toPurpose of Form provide your correct TIN.
An individual or entity( Form W- 9 requester) who is required to file an information 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 numberidentification number( EIN), to report on an information return the amount paid toyou, or other amount reportable on an information return. Examples of information
to be issued),
returns include, but are not limited to, the following: 2. Certify that you are not subject to backup withholding, orForm 1099- INT( interest earned or paid) 3. Claim exemption from backup withholding if you are a U. S. exempt payee. IfForm 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 theForm 1099- MISC( various types of income, prizes, awards, or gross proceeds) withholding tax on foreign partners' share of effectively connected income. andForm 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? onForm 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)