THE SCHOOL DISTRICT OF OSCEOLA COUNTY, FLORIDA 817 Bill Beck Boulevard Kissimmee, FL 34744-4495 (407) 870-4600 VENDOR INFORMATION FORM ‘Vendor Information For, W-9, andthe Vendor Cenification Fenn MUST be completed before we can add your company to our vendor files lease retum completed form tothe address above: ATTN: ACCOUNTS PAYABLE DEPT. ‘Purchase arders are required for all purchases. No sehool district employee i authorized 10 place an order for merchandise or services without @ ‘printed purchase order. The Schoo! Distretis nt obligated to pay far any goods or services that have not been authorized by purchase order. ‘The timelines for payments to vendors are governed by the Flarica Prompt Payment Act (See. 218.70 FS). This provides that payments shal! be made within 45 days fron: delivery of goods and receipt of« proper invoice for won-construction purchases aid within 20 days of completion of work and receipt of proper invoice for construction services. gal Tame ffm egistered wiSiave FFL: lobo used on Purchase Orders) Baie TEES 7 Phone we iy Sate, Fae Vendor Email address: ‘Vendor Contact Name: Do you sccept: CrecitCard Payments? __Yes _No ACH Payments?’ _ves No Ferianas nation aaah ar] "Aces Pajalte Use OR Rares Vendor iy, Site, De Tone Saas Taal Please Bi YES or NO to the following questions: yes | no | aPuse| ‘wi payments to you from the Schoo! Oise be for mecieal or neath care services? ve ‘Ae you incorporated? ‘wi any payments to you tom the School Disc be for serons? tyes, what ype? we ‘Are you a prowder of egal services? (Example: Atomey or Law Firm) ve ‘Ase you an employee ofthe Osceele County School Board (ether reguiar or substitute)? EP Is any employee ofthe School District of Osceola County, Florida an ouner (5% or more), proprietor, partner, rector, or oicer ‘oft ousinass? ve iryes, Employes name: Je any over (5% or mera), propristor, parner, director, or officer of hs business the spouse or child of any employee ofthe ‘School istrict of Oscenla County Foie? vs Ifyes. Employee name: Have you EVER been employed by a Frida Retirement System employe’? Yes No 'S00¢ USE ONLY: Requested by Facity Description of Purchase: ‘An Equal Opportunity Agency FC-700-1375 (Rev. 02/1617)Give Form to tha requester. Do not rom W-9 Request for Taxpayer cpanel ; oa Bo auma09 Identification Number and Certification eee feareseteny TS To ST _ aR TET 8 8 | check sosrorine bx fx federal tax casio ‘Exemptions ee insuctna: ai Cincividuatsoie proprietor —] CComporation ] corporation [] Parmeren [1] Tructsetate 2 nots ci tan BE) Cl unate cna tt cn ti 8 con Pee Emote fon TCA weteg 5 conten FE | 7 om teerenctony {psoas aT TTI EST 8 orem acre 3 TR TTT ‘Taxpayer Identification Number (TIN) in the appropriate box. The TIN proviced must match the name given on the “Name” ine [Social security namber_ ] Yur eocialeoourty number (SEN). However, fora resident allen, sole proprtor, or dsregerded ently, cee te Pal nsinctons on page &. For other, - -| nttes, tis your employer identifcation number (EN). you donot have 2 manbar, S80 HOW fo get @ Tiv en page 8. ‘Note the accounts in more than ons name, soe the chart on page 4 for guidelines on whose omer to ent. ‘Ceriification Lncer penis of pay cary tas 1. The number shown on this form i my comect taxpayer identification nur (or am waling for umber tobe issued to mel, and 2 Lam not subject to backup wtnolding because: a) am exempt rom backup withholding, () Ihave ot been noted by te ntemal Revenue Service (RS) tna | am subject o backup withholding asa result of fale to report antares or vicend, or) the IRS has notice to thet | am ‘no longer subject to backup withing, anc 8, Lam aU clizen or other US. parson (defined below), and 4. The FATCA codels) entered on ths frm tan incating tet | am exempt rom FATCA reporting is comect. Certication instructions. You mt cross out tam 2 above if you have baee Aoife bythe IRS thet you are curently subject to backup withholding ‘because you have feed 16 report ll interest and cvionds on you tax return, Ferrel estate transactions irr’ doe nat opp, Por mongage Interest pai, acquisition or abandonment of secure provery,carcaltion of dsb, contributions ta en inGMidualrerernent erengerort (EA) a general, payments other than interest and cvends, yeu are no! require to sign tne certiestion, bul you must prove Your coraer TIN, Soy fe ‘Bsvuctons on page 8 Sign | stanature of Here | Usrenan> Deter General Instructions ‘Section rfrnces ae oho real Revenue Code ures others ed Future developments. ne IS has crested a pape en RS. fr nforaton ‘Sout Fer et nw gee. ncrmaton aoa ry knee cotloomarts ‘ein rom Vi chs egaton raed are rere wb ed ontar Pooe Purpose of Form person woos requ ole an formation ret th he FS mest obi yur ‘rect payer fensaton umber (TN) 0 repr, tor expe poor pas Yu, payer ra to vou stern’ of pyar ard nd thr rary feo {casts el eile reactions, metsdoe Met You ps sokusto ‘Seronert of cred propery, croton o dos, crcomrbutsre you Mace Use Fm 29 ony you a7 BUS. person ott ares ao rv yor crac Toh peraen eguesing th req ad hen Stet Set he you argh corer you ewan fra mubar 2 arty hat youre net subjc ackup witking, 7 5. Cis exertion from backup weotsng yeu ae aUS, exempt payee, ¥ sopteable, you sre abo cathy tat ar 8 US, para your alse sat si Sy puttin income toms Ucar batness et pects oxo Toa ‘wiolcing axon fern parce share feet conecod coe, ond “4 Carty that FATCA cel entered ont om ary nleating that you sre svat rn the PATEA poring, eae. Nts you we aS pron ar argues gives you ce than Form WS roe TH youre oresonars em FS sur Defation of U.S person. Fortaders x purposes, ou econ 2 US. emmy a ‘Anindidl who ie US teen er US. resist alan, ‘Apannerstin, coreraon conan. asocaton create oregano ‘Unto States ost the le fe United Ses “+ Anette tehan afore este cr ‘ Acomoste oust ae cetnac n Roquson ston 201.7701, ‘Speci ues or parnerstips.Patestip hat cons a rade bute n {Te Una Sse re goer utes py a wane tx tnd secs sat busines Pr cana ses whe Form oh or bene ieelgepaton tnd pata sacle nas nrg tanire Pysoaes US Sirsn a! ou pone apartetipconcucing aad tures the Une Snes, prove Fm Veo tne prnesp eb your Sata ‘std avid ecton 1440 walolsng on Your share of paren come FomWO fe 8201S)THE SCHOOL DISTRICT OF OSCEOLA COUNTY, FLORIDA Vendor Certification No Sex Offenders or Sexual Predators During the 2005 Legislative Session, House Bill 1877, the Jessica Lunsford Act was passed and was approved by Governor Bush ‘on May 2, 2008, with an effective date of September 1, 2005. Included in this Bil is language that alters the provision of 1012.465, Florida Statutes. The applicable language reads as follows: ‘Norrinstructional school district employees or contractual personnel who are permitted access on schoo! grounds when students are present, who have direct contact with students or who have access to or control of school funds must moet level 2 ‘screening requirements as described in s. 1012.32. Contractual personnel shell include any vendor, individual, or ently under Contract with the school board.” In compliance with the ebove mentioned “evel 2 screening requirements” this Vendor Certification form must be completed by applicable vendors, “contractual personnel", and received by the School District of Osceola Counly before any ofthe individuals listed below shall be permitied access to any School District of Oscoola County school or propery. This Vendor Certfication shall become par of any existing contract between the undersigned and the School Board of Osceola County, Florida. This Certification shail be retuned to the Schoo! District of Osceola County, 817 Bill Beck Bd. Building 1000, Accounts Payable Department, Kissimmee, Florida 34744, ‘The undersigned hereby attests and affirms that he/she has accessed the Florida Department of Law Enforcement’s website at www fdle.state.flus and the United States Department of Justice's website at www.nsoow.cov, and has provided the information ‘equifed at the websites on each of the individuals listed bolow necessary to determine if any of the individuals are listed as a Sex Offender or Sexual Predator. The undersigned also affirms that none ofthe individuals listed below were found to be listed as elther a ‘Sex Offender or a Sexual Predator at the Florida Department of Law Enforcement's website, ‘The Vendor shall assign @ person within the organization to be the Finger Print Coordinator for this statutory requirement. This ‘person shall be responsible for seeing that any staff member, under this new State mandate, meet this requirement. ing needed, attach additional sheets Last Name First Middle Dos 2 a Do you work for a Sub-Contractor presently working for the School District? If so, the District will need the name, address, hone number and contact person of the Contractor: If you feel this does not apply to your company, please indicate here. [] f return this form even if no one from ny will be on district . This form should ced to Schoo! Di ‘Osceola County's Department at 407. This day of. 20 Name of Company "Your Company Finger Print Coordinator (Please Print) iasress Giy, State, Zip ‘mail adaress ‘Authorized Company Representative Signature Phone Number Print Name Tite Revised: 7.11.12