HomeMy WebLinkAboutAccounts Payable Batch - Accounting (002)Payable batches audited and certified by the auditing officer as required by RCW 42,24.080 and those
expense reimbursement claims certified as required by RCW 42.24,090, have been recorded on a
listing which has been made available to the Board:
As of this date, 02/1612023 the Board, by a majority vote, does approve for payment those payable batches
Payable Total: 2,361.00
'Z
Reviewed and certified by:
----------------
Commi s,tA,R.e.r
Commissioner
Chairman I oLibaZol7d' of Commissioners
Date: 2/16/2023
Invoices/Batches not approved-,
Double Checked by:
Date:
AP BATT IIS. GCEMG 2/16/2023
Grant County Claims Clearing Account - 9201 AP COMPLETED BY: N.`fANEZ
Name
FUND
AMOUNT
JOURNAL ENTRY:
CURRENT EXPENSE
001.000.
COUNTY ROADS
101
TREASURER NOTIFIED:
CARES ACT - ELECTIONS
102
VETS ASSISTANCE
104POSTING
COMPLETED BY:
HAMA 3 ELECTIONS
106
FEDERAL DRUG
107
CHECKS:
606773
606775
MENTAL HEALTH
108
2,361.00
VOIDED:
..
ST DRUG SEIZURE
109
LAS! LIBRARY
110
BATCH
PMCHK
CREDITS PMTRX
TREASURER O/M
$ _
$ $ _
MAIL CONCESSION
11
$ -
$
$
ECON ENHANCMNT
113
$ y
$ _
$ w _
TOURIST ADVERT
114
$ ..
$ $ _
COUNTY FAIR.
116
$ w
$ -
$ _ $ _
INET INVESTIGATION
118
PROS CRIME VICT
120
$ 2,361.00
$ 4,72.2,00
$ 4,722.03 RENEW -02.11 523Rd
LAW & ,JUSTICE
121
$ w
$
$
TURNKEY LIGHT
122
$ _
$ -
$ » $
AUDITOR O/M
124
$ »
$ -
$ $
DD RESIDENT PRQG
12
R.E.E.T. ` st 1/4%
1.2
$ -
$ - $
TRIAL COURT IMPROV.
127
$
$
$ »
DOM VIOL SRVCS
128
$
$ Y
$ - $ _
.AFF HOUSING
129
$ _
$
$ _ $
HMLS HS LOC
130
$ -
w
$ w $
BEET 2nd 1/4%
132
$ Y
$
$ w $ _
Econ Enh. Rural Co
133
$ w
$ _
$ Y $ »
Dispute Resolution
136
$ �
$
$ � $ »
Building
133
$ .
$ y
$ ,. $
BEET Admin
139
$
$ w
$ _ $ _
SHERIFF SURPLUS
140
$ «
$ w
$ w $ _
SHS 1406
141
$
w
$ « $ _
GC ABATEMENT
150
$ y
$ -
$ - $ _
HILLCREST CRID
161
$
$
$ $
GRANTS ADMIN.
190
$
$ _
$ _ $ w
AICPA
191
$
w
$ $
AOC BLAKE DECISION
192
$ -
$ -
$ $ »
MUSEUM CQNTRUCTIQN
304
$ _
$
$ w $
MACC Bond
307
$ _
$ «
$ « $
MCKINSTRY ESSEN'TION
308
$ _
$ w
$ « $
COUNTY FAIR SEINER
309
$
$
$ w $ _
PROP 1 STALES TAX
311
-
$
$ _ $ y
ERP RESERVE
312
$ -
$
$ _ $
SOLID WASTE
401
$ -
$ -
$ _ $
DATA PROCESSING
501
$ _
$ w
$ $ _
INSURANCE
503
$, _
$ »
$ $ «
INTFUND BENEFITS
505
$
$ _
$ _ $ _
UNEMPLOY COMP
506
$ y
$
$
DENTAL INS,
507
$ _
$
$
OTHER PR BEN,
508
$ _
$
$ $ ».
VISION BENEFITS
509
$ 2,361.00
$ 4,722,04
$ $ 4,722.00
EQUIP RENTAL -- ---- -- - -----
510
$ 2,361.00
$ 4,722.00
$ $ 4,722.00
COMMUNICATIONS
511
$ Y
$ Y
$ Y $
PITS & QUARRIES
560
$ 2,361.00
$ 4,722.00
$ - $ 4,722.00
TOTAL TRANSFER:
21361.00
System: 2/16/21023 0/12: 58 �m County oc Grant Pap: I
User Dat -e: 2/I6/2023 CASH REQUIREMENTS REPORT User zo, oayanez
Payables Management
Ranges:
Vendor ID: z-zzozzozzxzzzzo
Vendor Name: First -Last
Vendor Class: rirmt-Last
oaec.oeziued 1,., �Last-
Sorted
zst - s�
oorted ay` Vendor zo
eomienterior-ity' First -Last
�eoa�' �c�-Laa
W-sooun nate, Ficst-Laet
Payment oate'2/oo/2ooz
�
vdo m Vendor Name �
e ou�n�
Document
GL Account
Amman t
On Hold
rota
mu m be r
--------------------- I
Date
zS'vO-,EL mooE1,10 12542-257-020323
2/15/2023
08.150.0o.0000.564004/02
$1,200.00
$0.00
$I,200.00
EMIL J&V INVESTORS LLC 1253o115-020923
2/15/2023
108.150.00.0800.564004502
$672.00
$0.00
$672.00
Wp-MGC WINnEPMEEm ef"WemRTrmamaGE 12530255-021023
2/15/2023
108.150.00.0000.584004582
$*89.00
$0.00
$489.00
TOTALFOR
--------------
FUND# 108
$2,361.00
__-____--------------
$0.00
$2,361.00
GF-AND TOTAL
_______ ----------------
82,361.00
--------------
$0.00
$2,3Gl.00
System: 2/15/2023 1-13314 PM
County of Grant
Page:
0.00
User Date: 2/15/2023
PAYABLES TRANSACTION EDIT LIST
User ID:
rgonzales
Payables Management
Batch ID. RENEW-02.1523RG
Batch Comment:
Batch Frequency:
Single Use
Trx Total Actual., 3
Trx Total Control: 3
Audit Trail Code:
Batch Total Actual: $2,361.00
Batch Total Control: $2,361.00
Batch Error Messages:
Posting Date:/
User posting access denied
Vendor ID Document Number
Document Date Voucher Number
Purchases
Document Total
Vendor Name
Terms Disc Avail
ECONL 12532115-020923 2/15/2023 0383110
J&V INVESTORS LLC
Description 12532115- OBRA EMER. HOUSING
Payment Information Checkbook/Card Payment Number Document
Check
Distribution Messages:
Work Messages:
$672.00 - $672,00
Date Amount
0/010000 $0.00
General Ledger Distributions
Account Account Description Account Type Debit Amount Credit Amount
108. 150-00.0000-564004502 MENTAL HEALTH .... EMERGEt PURCH 672.00 0.00
602.001.00.0000.21 000000 WARRANTS PAYABLE PAY 0.00 67Z00
----------------- ----------
672,00 672.00
Vendor ID Document Number Document.Date Voucher Number- Rurchases Do met T
n otal
Vendor Name T6rms, Disc Avail
MOISM 12542257-020323 2/15/2023 0383108
ISMAEL MORENO
Description 12542257- OBRA. EMER.HOUSING
Payment Information Checkbook/Card Payment Number Document
Check
Distribution Messages:
Work Messages:
General Ledger Distributions
Account Account Description Account Type
108.150.00.0000.564004502 MENTAL HEALTH... EMERGEl' PURCH
692,001.00.0000.211000000 WARRANTS PAYABLE PAY
1,200.00 $1,200.00
Date Amount
0/0/0000 $0.00
Debit Amount
Credit Amount
1,200.00
0.00
0.00
11200.00
11200.00
-----------------
1,200.00
System: 2/1512023 1:33.-14 PM County of Grant Page: 2
User Date: 2/15/2023 PAYABLES TRANSACTION EDIT LISTUser ID- r9onzales
Batch ID RENEW-02.1523RG Payables Management
---- - -------- --
Vendor ID Document Number Document Date Voucher Number Purchases Document Total ...
—Vendor Name Terms Disc Avail
WPMGC 12530255-021023 2/15/2023 0383107 $48 0 9.00PION - ------- $489.00
WINDERMERE PROPERTY MANAGEMENT GRANT COUNTY, INC
Description 12530265- OBRA EMER. HOUSING
Payment Information Checkbook/Card Payment Number Document Date Amount
Check 0/010000 $0.00
Distribution Messages:
Work Messages:
General Ledger Distributions
Account Account Description Account Type Debit Amount
108.150-00.0000,564004502 MENTAL HEALTH. . ...EMERGEt PURCH 489.00 Credit Amount
692.001-00.0000.211000000 WARRANTS PAY0.00 489
ABLE PAY 0.00
,00
----------------- ------------------
489.00 489.00
Purchases Amount Terms Disc Avail Document Total
---------------- ------------------------------------
$2,361.00 $0.00 $2,361.00
State of Washington -County of Grant
1, the undersigned, do hereby certify under penalty of perjury that the
materials have been furnished, the services rendered or the labor performed
as described herein, that any advance payment is due and payable pursuant
to a contract or is available as an option for full or partial fulfillment of a
contractural obligation, and that the claim is a just, due and unpaid
obligation against the county, and that I am authorized to authenticate and
certify to said claim.
Subscribe day of
(SQ igned) For
Department
Approved and
Authorized By
. . ..... .. ----
Date Allowed
Commission'er M.
Commissioner
Commissioner
enm'za
RECEIVED FEB 10 2023
renew
Grant Behavioral Heolth a Wellness
x
Name, Date,:.
item(s) Requested ("Include a photo if you need a spec"fic
i item)
Appr11
oximate Cost,
r7')
Funding Source, "if knownZ
- - - -------
Supervisor"s Signature
De
fir'...
at
Please have your supervisor sign the form and
IN
then return it to the Finance Department,
Form V, VU i&- 19 W Roquest for Tax*payer
(tau Colobor 2018) MentifiCEIVO)l NuMbey eind Certifflo;ation
e Trv-'Ipury
t').WV1V1"MVQV1FVrM" for ri-st uctio i hhd the liatast 11gorMap
if
tj.
AMS (pq 5 INno'n
17N . I 1 .11"11 on Ml s 11ne; 30 'ticyfl�ve tw Brie
2 Q'Us'%eea �n8meern, �Grn��
if diva eibove
GNO Form to the
raquer. Do riot
-send to the iRS1,
3 Check ppproprlat
Person whm,-L nwe is wtered or, ljpG 1, 0190k Ohly One rjf j
ibRowing saven �pxoq, he 4
cc EXQMPUOrw� (codes ppply DHy to
P-1 cartn)o (�ntjvo$�, nrA In . dTv1duaW-,; sr,*
Irittmot[one on plig
indhAkfaUsole propOotor Or El C COrpomllan OaWaffan El parttjert�jp
Olngfo-mojyiber LL D TrwAlottato
[�Xempt piayt8 00d'G (if SPA
LWIted liabillit/ compmy. Enter the *
n Q=Q fggporaqoh, 5=8
'rohP) A
Note: Otlack thp inpprQ:pdjAte bOX M U16 U0 i�bays for the tx< oJeEdficatitirl ofths
LLD 'if ft LLO is cJfjgg[r1ed;a$ a E;."
LW that fg 014W 11'Q
W or the C; s ni FA'rGA raporting
'qnofther LLG that W nPt �RBrPggrdr;d frQm Jhe owner f5r US, fpdqFUj taX pe o ri, oft LL :-pit
(if ally)
M0561�, 0ftrwf4ea single -Member LLO that!
dilreglarded fthl Me OvMdr should check ffie apprapoatq bob fOr the jax,clasafff Q*tforl
Ofh4r (Wip IrMWInne) 11,
(Avg*-' to
tr
�rtr tui;
0 Addras;R (num4er, r9ifts , -an apt. or $Ulte tjol) Isft lfttfu i�ci , 3 ..
fjr�*�' (options])
6 0y, etE4 and 4P wdo
7 L1.-;-,t;Re,1wunf number(s) fjeM options .r
11
------------ "I ----------
lvi�p arl If4e I to AVQ!d
.............. ..........
...... ....... (SSN), H oWeve 1, for a
%
%
roold slfe% sola proprlator, or d1gragarded' WItY, 696 to fnsstyut*,V for Pad 1, later. iron other
onfl�e% it is aur employer Idehtificallon numbor (M), If you do not have TIN numberi.see How to gat a
,, later,
%tw- If the accoubt is In more than pno narne, asp the inWruoVnt%$ 'iror gne 1. Also Saa What Afamg and
Numbor To Gia the Raquer for guMollnes On Wbone number to entw'
PlAnber
IMI I L3
certification
vndlff Ponalt'Ift of pequryl I 00"Filry thati,
I. Th6 Nrnbershawn on VhJ:g fOrm 13 mY Ow'60tAXPAyOrldentif(cation npmbor (orf aril Waiting for a nu boy 1�o Nsued to
P.- I am not tubje-ct to backup Withholding'.tQo'ause: (a) I aM c-Xampt from bimokop WMhotding, Or M I havia nOt bW noMed by
Servico: VR$1) tfii�(t I AM M -401 0t0 �A�kuP w1thhoUng azz� *Mwlt of a fallurato rop*rt *ft'- the (Item Revenue
00 Iver su*It fQ �WWP WItM61ding,' and intiftat or di-vidends, or (0) the IRS hm notWIW me that I am
2, 1 AM A U.S. cltlzan ny othior UA person -(d8ft0d W*v�)- and
4, TM PAT QA code(g) anteirod oil thfs form (ff any) 1,161"tAtfrIg Pmt I ftM qX'eMpt from r FATCA rapoftg h toerect
CGOAMbon Instmetform, You must cross out Item 2 obove ff you havip k�een notffle t
You have Wed to rapoo a d by th,4 lj�$ that yoU are cvrrently W�&ot to baokup Wift
Interest and djvldia�140 on your tpx return, Nrre 614 ng bftau�e.
equi c --stats hn8a0V6'182 RM 2 d4jeS riot appbj. For mortgjage , I
ISIVon or Abandonment 0 s8corod propetI, cancefiation of debt, r , interost PA'd,
,0rjtdbuU0n,s DO An IndWidual retirement anangernsila, QFK and giUlOrAlly, P11
d�ymetIt!S
-PthwPhan hitaroO %d,0ivTcjejjds, you M ncA r0quired to k3lgntha *orti&W;'iQnt bus you rMrst proviYOIJ�=MtTf% ifthGUons for Pan
19- M IM—M-F.
Sign slvnaiurs of - ------
Here Ua Pema"
General Instructions Form I M9.DfV(djvjdGt1d$, Iftfuding thato, from stocks or m1utual
8eoton r6ferenOes are to thalntemal Revenue Code untesp funds)
hpted. QtharM;sL Form 1099 -MI SO (varjolls jypoa of income, Pliz*sr aw,--irds,
P tion about devol
Poture devalej ment!L ForthO lAtObtlI 0forma
r8liated-to Form W-9 wd Its legi
inshi4i"lFQrM 1 0-99-� (atook or mtAualfund ut
ons� such AU '%latjon angtoted tJby b) Ond Mtalh other
After they Wartt published, go ZO WWw,,1fs.gov1PrmW9
c, mnsedons rokum
wg-s (Prpczr
ed5 f
PUT080 Of FOrM e. . 0M Mal tat a
Fofm I 099-K (mercham
Indtgrdsnej fbjr
,�d PanY nark trarisactlons)
An il"AWal orenfity (Fon W-9 requester) who Is to fle an Fdtm I 6�8 (horno r7tartgagi� irjterj�q% 1,0ga-e (!�ttAcfent IC)an ar
infOrMation eEAurn with the IR8 alug obtain your correQt twayor 1-096-T #ufflon)
IckiffmtIon number (71N whjoh may be your social Seetzity number Foff Tj 1088-0 (cancelad &)12)
(St,,, WMI,ql taxparyer [dodWirvab"wri nvmbiw (MN), idoptlon
taApgyer Ideoffidat'lori uwmber (ATIN), or tmpffovor rcf6nrxfrgVQn numbor #1 PPrM 1099-A (acquisitor
or you
(21M, to report on an Infornial1pn ratum ffw gmount paid to ., other Or iRbarldenrlOnt a aecured proper*
ammt rvortablo on a� 1nfdrMafjQn'reTurn. Examplos of kila We Form W-9 only If you ar4 a u.8, parsQrj Oncluding a ft-m-sidgnt
retumt 1holrAd% but are not limited to, th-s f0ovving,, rmqf!Qn ;�Ienh to provide your ="td -n �4
ff d0 nor` MUM Forn? W-9 to the jrm7aetter w1th a TjNr X0 n1l,
Farm 1099 -INT Ctr&erW earned or pold) b6 YQU 'ght
-t'jb'&0t to h4a[VjP �r,:e Wh-,-)t 18 bac*W withholdIng,
later,
DaL No. 10?
plx Form W -a (00110--2018}
A
rs
renew
Grant SehQvIoral Health 6 Wenn ess
4�1 AA"tT�IWWM
—low,
Name:
Datells
Item(s) Requested (include a photo 'if you need a speCITIC item)ff
Approximate Cost,
. ..........
4%
Funding Sourceif knowwo
C -Al
Date Needed By,,,.... x.,
Supervisor's Signature ��� �-
Date
I
P a M W
wase haveyour supervisor sign the form and
then return it to the Finance DepartmentV
Supervisor's Signature ��� �-
Date
I
P a M W
wase haveyour supervisor sign the form and
then return it to the Finance DepartmentV
ol BhDROOM B
EDROOMS 3BEDROOMS
MONTHS LEASE MONTH TO MO-NTF1 LEASE
RESIDENTIAL RENTAL AGREEMENT AND SECURITY DEPOSIT
RECEIPT
6
This AGREMEN
ET is made this day of between'<, - �4-
����
hereinafter designated the LANDLORDS and hereinafter desigtiated
3 ( & ,
the TENANT(S). The said Landlord does hereby rent unto the said T'enant(s) the reside -nee at
Z
inthecityo -4oses Lake OR uWarden, Grant Count y il-I the
State of WasbAngton.
Upon the following, terms and conditions:
1. Term: The premises are rented for a MONTH-TO-MONTH TERM. Tenant shall give a 30 -day
written notice, when moving out. The Landlord shall give the Tenant a 30 -day notice to vacate promises,
2. Rent: The tenant shall pay rent in the amount of:
$ t-.0 0 - tDO � per month. The rent is due on the 1,11 day of each 111onth to the Landlord"
There shall be a late fee of $5.00 PER DAY STARTING THE FIRST day of the month,, if by
the 5'11 day of the month, the rent is not paid.
Tenant sbaR pay for services and utfflties supplied to the pren-Ases,
which will be furnished by landlord. Water and sewer in excess of $
Per month w!U bebiUed to and be the responsibility of the tenant,
2 a. DUE AT SIGNING: DEPOSIT in the amount of $
3. SUBLET: The Tenant agrees not to sublet said premises nor assi
thereof, without pfi.
or consent of Landlordgn neither tbis agreement nor any part
4. TENANT" S OBLIGATIONS: Tenant shall-,
(a) Keep sai
ol BEDROOM
V2BEDROOMS
MONTHS LEASE "' 3BEDROOMS ilk
MONTH TO MONTH LEASE
8. USEoff' PR-EMISES.- Tenant shall not use said premises for any purpose other than that of a residence
and shall not use said premises or any part thereof for an illegal purpose. Any illegal actions will he caiise
of f-eritti-nation iftimecliately. Landlord Tvill ask Tenant to leave rem within 3 days. ANY GANG O.R
GANG RELAIED ACTM
ITES) SELLING OR GRO)ITING OT -f AAT LEGAL OR ILLE GAL
SUBSTANCE,TNCL UDING AL4RIjUANA AAE A CTIONS. A T RUL BE CA U
T.E_RM1NAT10N11VMEDL4TFaLY! Tenant agrees to confolm to * kVE OF
city, county and state codes, statues
ordinances and regulations concelllinR the use and occupation of said premises, Landlord shall ivaintai'n the
premises in substantial confon-nance with all applicable provisions of city, county and state codes,
ordinances and regMations governing maintenance or operations of said premises,
9. L ANDLORDS OBLIGATIONS,*
(a) Inu-nedlately notify Tenant, by certified mail or updatedposting, of any changes as to the person or
address of the Landlord.
(b) Maintain all structural comp onencs in good repair.
jr G
(c) Keep co=on areas reasonably clean and safe from defects increasing the hazards of f e or a cenid t
(d) Provide a reasonable program for the control of infestation by insects, rodents and other pests at the
initiation of the tenancy, provided however, that the Landlord shall not be held responsible where
infestation is caused by the Tenant.
(e) Maintain all electn*cal, plumbing, heating and other facilities and appl* up I
-worlcing orderw
lances s p1'ed by him, in goo- d
10.ACCESS: Landlord shall have the right to place and maintain 'TORRENT)) sign in a conspicuous place
on said premises for thirty (30) days prior to the vacation of said premises. Landlord reserves the n*ght of
access to the prerm* Ses for the- pui�pose of:
/ 1% Ir
(a) msp ecti on;
(b) Repairs, alterations or ftnprovements;
(c) To supply services or
(d) To exhibit or display the premises to w
prospective or actual purchasers-, mortgagers,,. tenant's,, orkman, or
contractors. Access shall be reasonable times except in the case of emergency or aba do t.
n nmen
11 SURRENDER OF PREMISES: In the event of default m* payment of any installment of rentor at the
expiration of said tenn of this agreement, Tenant shall quit and surrender the saidpremises to Landlord. if
tYs agreement is for an indefinite time
. telmifi-iations shall'be by written notice of at least twenty (20) days,
precedithe end of such monthly rental period, given. by either party to the other.
12. COSTS AND ATTORNEYS FEES: If, by reason of any default or breach on the part of either party in the
performance of any of this agreement, a legal action 'is instituted, the losing party agrees to pay all
reasonable costs and atton-ley's fees In conneption therewith, It is agreed that the venue Of any legal action
brought tinder the terms of this agreement may he M* the co-Lmty in. which thepremises are located.
13. SECURITY AND DAMAGE DEPOSIT: The Tenant has deposited the su'm of $ ('aDO , 0 0 as
security and damage deposit, receipt of which is hereby acknowledged. $100.00 will benon-reffindable for
cleaning of said premises, and Landlord may retain $ of such deposit and a refund of any
portion of such deposit is conditioned as follows,,
(a) Tenant shall fiffly perform obligations.
(b) Tenant shall occupy said premise for tenn agreed to above;
(c) Tenant shall clean; repair and restore said residence and return, the same to Landlord in its initial
condition, 1 , except for reasonable wear and tear, upon the termination of this tenancy and -vacation of
residence. A specific statement describing the condition of the preraises at commencement of the,
tenancy is to follow hereof;
(d.} Tenant shall surrender to Landlord the keys to premises; any refund from deposit, as by.itemized
statement shown- to be due to Tenant, shall be returned to Tenant when Landlord has in the
prermses after the Tenant moves out.
2
-�i rTI-I
ol Bi',i'IJR00M BEDROOMS Y-�J. L�, 1 BEDROOMS -
MONTHS LEASE MONTH TO MONTH LEASE
- - - -----------
Landlords
Date'
TENANTS' -
a e
D
---------- - - - - ------
COMMENTS:
3
renew
Gront Sehovitoral Healtfi a Wellness 03.1 G33 IAj
is
Name. Date,
a
Item(s) equested (include a photo if you need a specific item),
4,
-Ill- JW-----
-----------
."s- ..... I
M -
Approximate Cost,
--- - ---------
OIL
40L <
21
Date Needed By
Form W -i M9
(Rev. October 201 8)
1) artmen " the Treasury
lr1le,
rnal Rev
Pnue service
Request for Taxpayer
Identification Numbey and Certificat'
Wn
Go to wv1yN.1,r-s.govJFQrMjV9 for Instruotions and the latest 1 formatlot,
i Name ki tinown on your income 'tax return), Name Is re
'roll '7�rine; do �nal �Ieakle �Uiia lfn�;�bla�nk,���
qui - on thl
Windermere Property Management Grant County, Inc.
2 Business ncam di-qrPnPrdeH ontity nnryim 74w�f--Z Z
CIVio VO
GlYe Form to the
r,equester, Do not
-send to tine IRS*
Taxpayer Identificatiotl Nil or RIN)
tinter your -TIN In tho appropriate box. Tile TIN provided must match the lialle given on lin'o I to avoid
backup withholding. For individuals, this !$ generally yoursociaf security number -
(I tzr p7s�q' However, for a
resident alien, We proprilator, or disregarded entibl, see the Instructions for Part 1, later, For other
entitles, It Is Your employer Ident1floation number (EIN). If YOU do not have a number, see How to gelt
ThY, Tatar.
In
Note.- If the account Is In more than one name, see the Instructions for line 1. Also see What Ajame and
Nurnbor To Wile the Requester for guidelines on whose number to enter.
Social security n6� be
or
Employer 1cfentificatior, nornber
`-( 2 1 0 1 4
0 6
ation
lix, Lluf—certlffo
Undor penalties of perjury.. I certlf} that
1, The number shown on this form Is my correct taxpayer Ide 11
2. 1 am not subject to backup Withholding bei- ntificatlon. number or I am waiting for a number to be Issued to me), and
t because: (a-� I am exemPt from backup vdthholding, or (b) I hai'ra not been notified by t�e Internal Revenue
Bernice SIRS) that I am subject '0 backup o4th holding as a result of a failure to report all interest or divid"ends, or (6) the IRS has notified me that I !arra
no longer subject to backup vilthiholding; and
Si. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA coda(s) entered on this form (If an' IndIcatirig that at I am exrOmPt fire M FATQA reporting Is correct
Certification instructiot's. You Must cross Out Rom 2 above If you haver been notified by the IRS that you are currently subject to backup WIthpaidldng becausp,
you have failed to report all interest and dividends on your tax return. For real estate transactions, ftern 2 does not apply, For mortgage Interesd,
acquIslUon or abandonment Of SeUirad property, oancellation of debt, contributions to an IndivIdual retirement arrangement �stand�generail�� payrnants
other then Interest and dividends, you cirs not reqUired to sign the o;�rtiticL9Lion, butyou must provide yourcorrect TIN. See the 'Inructons for Part 11, la"ter.
Sign Signature of
Here u.s. person:*.".*
Uenelfal Instructions Form -1 099 -DIV (dividends, Including those from- stooks or mutual
Section references are to the Internal Revenue Code unless othervilse funds)
noted. 10 Form 1099 -MI -SO (vadous types of income, prizaa, awards, or gross
Future developments. For the latest Information about dGA.elopments proceeds)
related to Form W-9 and its instructions, such as legislation enacted * Form 1099-13 (,stock or mutuaf fund sales and certain other
after they were pubH shed, go to wwK�' gov1FbrmW,9. transactions by brokers)
/M.
Purpose of Form Form 1099-8 (proceeds from real estate bansactftons)
An Individual or entity f=orte: W-9 requester who Is 'required to file an Form 1099-K (merchant card and third party nebNork. tranaaaflons)
(StLICIGnt loan Interest),
-S must obtain your correct taxpayer I 098-T (tuftlon)
Information return with the I R * Form 1098 (110me mortgage Interest), 1098-E
identification number (TIN) which may be your social security number * Form 1099-0 (canceled debt
(SSN), individual taxpayer Identification number (ITIN), adoption
taxpayer identiftettion number (A -TIN), or employer WentHfication nornber * Form 1 0�9-A (acquisition or abandonment oT secured properly
(EIN), to report on an Informaffon return the amount paid to you, or other Use Form VV -9 only N you are a U.S, person Ciricluding a roa* ent
amount reportable on an Infon-nation retum, Examples of Information alien), to provide your correct TIN, id
returns include, but are not limited to, the following,, hz YOu do n at return Fonn W-9 to the requester wfth a 77N
• you night
Form 1090 -INT (laterest earned or paid) be subject to backup withholding, See What is backup Withholding
later.
CaL NO. 10-231X Form W-
1) (R
-3 Check appropriate ba�,4 for federal tax clossific-ation of Ule person whose name is entered on line 1. Chlew
following seven box -38, -k only rine of the
4 Exempt[ons (codeq apply only -0
0
D[fldivIdual/sale proprietor or 0 CorporatIon S COrpOration EJ Partnership El Tru3tVestate
cortain entities, not Individuals, Bete
Instructions on page 3)*
0
single-mernber 1-1-0
Limited liability COMPanY. Enter the tax classification (c=c corporation, WPOMtl0n, P=Partnershlp)
Exempt pay -e code (if any)
Ar- 1z
CL
Note: Check the appropriate box In ilia line above for thG tax Classification of th- sTngla-member Owner. Do not chaQk
LLC It the LLC is classified
. as a sIngle-member ILLC that la disragarde(i frog the OW11M unlGss the owner of the LLC Is
anot)�er LLC that Is not disregarded from the owner -lor U.S. federal
�Xenlptlon from FATCA reporting
tax purposes. Othe5vise, a single -member LLL that
Is c:11sr-agarded from the owner should check the appropriate box for the tax clarssrtloat[on Of Its owner,
code (1-' any
El Other (seo Instructions)
6 Address (number, street, and apt. or sotto no.) See tnstructlorls.
Requestiar's narne and
OlarnW Qvlmkh� ?ha U.S'�
address (aptionaq
324 S. Ash Ste SUIte A
6 City, state, and ZIP code ...... —
Moses Lake, WA 98837
7 List account number(s) here (optional)
Taxpayer Identificatiotl Nil or RIN)
tinter your -TIN In tho appropriate box. Tile TIN provided must match the lialle given on lin'o I to avoid
backup withholding. For individuals, this !$ generally yoursociaf security number -
(I tzr p7s�q' However, for a
resident alien, We proprilator, or disregarded entibl, see the Instructions for Part 1, later, For other
entitles, It Is Your employer Ident1floation number (EIN). If YOU do not have a number, see How to gelt
ThY, Tatar.
In
Note.- If the account Is In more than one name, see the Instructions for line 1. Also see What Ajame and
Nurnbor To Wile the Requester for guidelines on whose number to enter.
Social security n6� be
or
Employer 1cfentificatior, nornber
`-( 2 1 0 1 4
0 6
ation
lix, Lluf—certlffo
Undor penalties of perjury.. I certlf} that
1, The number shown on this form Is my correct taxpayer Ide 11
2. 1 am not subject to backup Withholding bei- ntificatlon. number or I am waiting for a number to be Issued to me), and
t because: (a-� I am exemPt from backup vdthholding, or (b) I hai'ra not been notified by t�e Internal Revenue
Bernice SIRS) that I am subject '0 backup o4th holding as a result of a failure to report all interest or divid"ends, or (6) the IRS has notified me that I !arra
no longer subject to backup vilthiholding; and
Si. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA coda(s) entered on this form (If an' IndIcatirig that at I am exrOmPt fire M FATQA reporting Is correct
Certification instructiot's. You Must cross Out Rom 2 above If you haver been notified by the IRS that you are currently subject to backup WIthpaidldng becausp,
you have failed to report all interest and dividends on your tax return. For real estate transactions, ftern 2 does not apply, For mortgage Interesd,
acquIslUon or abandonment Of SeUirad property, oancellation of debt, contributions to an IndivIdual retirement arrangement �stand�generail�� payrnants
other then Interest and dividends, you cirs not reqUired to sign the o;�rtiticL9Lion, butyou must provide yourcorrect TIN. See the 'Inructons for Part 11, la"ter.
Sign Signature of
Here u.s. person:*.".*
Uenelfal Instructions Form -1 099 -DIV (dividends, Including those from- stooks or mutual
Section references are to the Internal Revenue Code unless othervilse funds)
noted. 10 Form 1099 -MI -SO (vadous types of income, prizaa, awards, or gross
Future developments. For the latest Information about dGA.elopments proceeds)
related to Form W-9 and its instructions, such as legislation enacted * Form 1099-13 (,stock or mutuaf fund sales and certain other
after they were pubH shed, go to wwK�' gov1FbrmW,9. transactions by brokers)
/M.
Purpose of Form Form 1099-8 (proceeds from real estate bansactftons)
An Individual or entity f=orte: W-9 requester who Is 'required to file an Form 1099-K (merchant card and third party nebNork. tranaaaflons)
(StLICIGnt loan Interest),
-S must obtain your correct taxpayer I 098-T (tuftlon)
Information return with the I R * Form 1098 (110me mortgage Interest), 1098-E
identification number (TIN) which may be your social security number * Form 1099-0 (canceled debt
(SSN), individual taxpayer Identification number (ITIN), adoption
taxpayer identiftettion number (A -TIN), or employer WentHfication nornber * Form 1 0�9-A (acquisition or abandonment oT secured properly
(EIN), to report on an Informaffon return the amount paid to you, or other Use Form VV -9 only N you are a U.S, person Ciricluding a roa* ent
amount reportable on an Infon-nation retum, Examples of Information alien), to provide your correct TIN, id
returns include, but are not limited to, the following,, hz YOu do n at return Fonn W-9 to the requester wfth a 77N
• you night
Form 1090 -INT (laterest earned or paid) be subject to backup withholding, See What is backup Withholding
later.
CaL NO. 10-231X Form W-
1) (R