Signed Copy of Personal Services Agreement IRS Form W9
Checklist of Items Required from Service Provider:
□ Signed Copy of Personal Services Agreement □ IRS Form W9 (write phone number on top of form) □ Criminal History Check Form AND Application for Non-Paid Position* □ Government-issued Photo Identification* □ Invoice (if applicable)* *For all individuals who will be performing services at LISD
Personal Services Agreement This Personal Services Agreement (hereinafter, “Agreement”) is made this ___ day of ____________, 2016, by and between the Lenawee Intermediate School District, a Michigan intermediate school district organized and operating under the provisions of the Revised School Code, MCLA 380.1 et seq., as amended, whose address is 4107 North Adrian Highway, Adrian, Michigan 49221-9309 (hereinafter, “LISD”) and the following personal services provider: Service Provider Name: ________________ Service Provider Address: ________________________________________________________ (hereinafter, “Service Provider”). With the signatures of their respective representatives, the parties to the Agreement voluntarily bind themselves to the covenants contained herein and their mutual consideration establishes the basis for this Agreement. 1.
LISD and Service Provider agree that Service Provider will perform certain services to and on behalf of the LISD as is more specifically described in Exhibit A, which is incorporated into and made part of this Agreement (hereinafter, “services”).
2.
Service Provider may terminate this Agreement by providing written notice to the LISD at least 30 days prior to the date on which the services are to be performed. LISD may terminate this Agreement by providing written notice to the Service Provider at least 30 days before the date on which the services are to be performed. Notwithstanding the foregoing, in the event that the LISD activity or function for which Service Provider’s services were required is cancelled, Service Provider shall have no obligation to perform the Services described herein nor shall the LISD have any obligation to Service Provider. The LISD agrees to make reasonable effort to provide advance notice of any activity or event cancellation.
3.
Service Provider warrants and affirms that Service Provider is sufficiently qualified to perform the services and that Service Provider will perform the services in a professional manner customary of the industry that Service Provider represents, and that Service Provider will adhere to all mutually agreed upon delivery schedules, which are identified in Exhibit A. Service Provider understands that time is of the essence with respect to the performance of the services.
4.
Service Provider understands and acknowledges that the LISD is a Michigan public school district and as such will be required to conduct criminal history information checks on Service Provider and any assistants. Service Provider agrees to comply with any criminal history information check requirements of the LISD, and understands that failure to do so, or unsatisfactory criminal history information check results will immediately terminate this Agreement. The satisfactory completion of a criminal
1
history information check or a valid waiver of such by LISD is a condition precedent to Service Provider’s performance of the services. 5.
In exchange for Service Provider’s services as described in Exhibit A, LISD will pay Service Provider a lump sum amount of $_________, which shall be payable within 30 days of the conclusion of Service Provider’s performance of the services described in Exhibit A and upon Service Providers delivery of an undisputed invoice and properly completed IRS Form W9, both of which shall be a condition precedent to payment.
6.
Service Provider will serve as an independent contractor of LISD. Service Provider alone is responsible for the hiring, supervising, and payment of any assistants, subcontractors, or other individuals necessary for Service Provider’s performance of the services. Furthermore, Service Provider alone is responsible for the payment of any State and Federal income or other taxes which may become due as a result of Service Provider’s performance of the services. Because Service Provider is an independent contractor, Service Provider is not eligible to receive any benefits from LISD, including but not limited to contributions to any retirement system (such as the Michigan Public Schools Retirement System). Service Provider understands and acknowledges that Service Provider is providing services to LISD as an independent contractor, as such Service Provider agrees to indemnify and hold LISD harmless from any and all claims, causes of action, or liability which may arise out of a finding that Service Provider was an employee of the LISD.
7.
Service Provider may be required to provide the LISD with proof that Service Provider has a commercial general liability insurance policy, which covers the services to be provided to LISD. If proof of insurance is required, such must be provided to LISD prior to Service Provider’s provision of the services described in Exhibit A.
8.
Service Provider agrees to indemnify and hold harmless the LISD from any and all claims, causes of action, or liability of any nature, whether arising out of tort, contract, statute, ordinance, or otherwise, which may be asserted against the LISD due to the acts or omissions of Service Provider, its agents, employees, or subcontractors.
9.
Service Provider agrees that LISD will not be liable to Service Provider, or any third party, for: (1) any liability claims, loss, damages, or expense of any kind, including, but not limited to any loss of profits or eligibility to receive profits, arising directly or indirectly out of Service Provider’s provision of the services; (2) any incidental or consequential damages, however caused, and Service Provider agrees, to the extent allowable by law, to indemnify and hold LISD harmless against such liabilities, claims, losses, damages (consequential or otherwise) or expenses, or actions in respect thereof, asserted or brought against LISD by or in right of third parties; or (3) any punitive damages. For purposes of this Agreement, incidental or consequential damages shall include, but not be limited to, loss of anticipated revenues, income, profits or savings; loss of or damage to reputation or good will; loss of students; loss of business or financial opportunity; or any other indirect or special damages of any kind categorized as consequential or incidental damages under Michigan law.
2
10.
This Agreement may only be modified or amended through written Agreement of the Parties.
11.
This Agreement is enforceable only by the LISD and Service Provider. No other person may enforce any of the terms contained in this Agreement, nor is the Agreement intended to confer third party beneficiary status on any third party.
12.
The Parties agree that they will not assign or transfer any rights or duties contained herein, without first obtaining the expressed written consent of the other party. The parties understand and acknowledge that either party may withhold consent regardless of the reasonableness of such.
13.
This Agreement represents the entire agreement between the Parties with respect to Service Provider’s provision of the services described in Exhibit A.
14.
This Agreement shall be deemed to have been executed in the state of Michigan and the substantive laws of the state of Michigan shall govern the enforcement of this Agreement and the rights and remedies of the Parties.
Service Provider: __________________________
Lenawee Intermediate School District
____________________________________ (signature)
____________________________________ Mark E. Haag, Ed.S., Superintendent
Date: ______________________________
Date: ______________________________
Checklist of Items Required from Service Provider:
□ Signed Copy of this Agreement □ IRS Form W9 □ LISD Electronic Payment Agreement (if applicable) □ Sales Tax Exemption Form (if applicable) □ Criminal History Check Form*AND Application for Non-paid Position □ Government-issued Photo Identification* *For all individuals who will be performing services at LISD
3
Personal Services Agreement Exhibit A Personal services purpose and description: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Service Performance date(s): _____________________________________________________ Service Performance times: ______________________________________________________ Service Performance location: ____________________________________________________ Additional information: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (Attach additional pages as necessary, identified as “Exhibit A”)
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W-9
Form (Rev. December 2014) Department of the Treasury Internal Revenue Service
PHONE NUMBER: ______________ Request for Taxpayer Identification Number and Certification
Give Form to the requester. Do not send to the IRS.
Print or type See Specific Instructions on page 2.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification; check only one of the following seven boxes: C Corporation S Corporation Partnership Trust/estate Individual/sole proprietor or single-member LLC Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) a Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.
4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.)
Other (see instructions) a 5 Address (number, street, and apt. or suite no.)
Requester’s name and address (optional)
6 City, state, and ZIP code
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 backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.
Social security number
–
–
or Employer identification number
–
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 Revenue Service (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 am no 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 withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.
Sign Here
Signature of U.S. person a
Date a
General Instructions
• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)
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 as legislation enacted after we release it) is at www.irs.gov/fw9.
• Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.
Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:
If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.
• Form 1099-INT (interest earned or paid)
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If 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 the withholding tax on foreign partners' share of effectively connected income, and
• Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions)
By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.
• Form 1099-K (merchant card and third party network transactions) Cat. No. 10231X
Form W-9 (Rev. 12-2014)
LENAWEE INTERMEDIATE SCHOOL DISTRICT
APPLICATION FOR NON-PAID POSITION (This form must be completed once each year. If background check is required, you may not volunteer until background check has been conducted. All areas with an Asterisk and BOLDED need to be completed before your application will be considered.) NAME: ______________________________________________________________ DATE ____________________
LAST
FIRST
MIDDLE
MAIDEN/FORMER
NAMES USED: ___________________________________________________________________________________ ADDRESS: ________________________________ CITY: _______________ STATE: ______ ZIP: _________ (For college students, please use your permanent home address) VOLUNTEER ACTIVITY: __________________________________________________________________________ WEEKDAYS/TIMES AVAILABLE: ___________________________________________________________________
Phone: _____________________ (home / cell / work)
E-Mail Address: ______________________________________
Emergency Contact__________________________________________ Phone _________________________________ PLEASE READ CAREFULLY I hereby authorize and unqualifiedly grant permission to the Lenawee Intermediate School District (LISD) and its administration to make inquiries to verify the contents of this application, and any representations made verbally or in any letter of interest that I may have submitted. Further, I unqualifiedly authorize and grant permission to the LISD and its administration to contact any and all of my personal references or former or current employers to obtain information concerning my character, reputation, and/or work experience. I further release the LISD and its administration, as well as any reference source, from any liability in connection with the release or use of such information. I further authorize and unqualifiedly grant permission to the LISD and its administration to make inquiries and to obtain any records from law enforcement and/or judicial authorities to determine whether any record of criminal conviction exists, and whether any felony charges are pending against me, including the nature of the offenses. Waiver and Release of LISD from Liability I know and understand that my volunteering with the LISD may expose me to risks, such as illness, injury, death, or loss of property. I voluntarily accept those risks and agree that the LISD, its Board of Education, its staff, its students, its agents, and its representatives, is not liable for any injury, death, or loss of property that is caused by the negligence of the LISD, its Board of Education, its staff, its students, its agents, or its representatives. I understand that by signing this application and accepting a volunteer assignment with the LISD, I am giving up my right to sue for negligence. I also understand and agree that if the LISD is sued by or required to pay any third party because of my conduct, I will reimburse the LISD for its costs, including any and all legal costs and costs due to the third party. Through my signature, I acknowledge that I have read this waiver and release section of this application, I understand what I am agreeing to, and am freely signing it, and further certify that the statements contained in this application are true and complete.
APPLICANT’S SIGNATURE (if under 18 requires parent signature)
DATE
Thank you for completing this application and for your interest in the Lenawee Intermediate School District. We would like to assure you that your opportunity with this organization will be based only on your merit and on no other consideration. The Lenawee Intermediate School District does not discriminate in any of its educational programs and services, activities, or employment practices, on the basis of race, color, religion, national origin or ancestry, age, sex, height, weight, marital status, sexual preference, disability, or English speaking ability. Direct inquiries to: Executive Director of Staff Resources, Lenawee Intermediate School District, 4107 North Adrian Highway, Adrian, Michigan 49221-9354; (517) 265-2119.
-----------------------------------------------------------------------------------------------------------------------------------------------------------APPLICANTS - DO NOT WRITE BELOW THIS LINE – FOR LISD USE ONLY Is Background Check Required: Please Consider:
x Yes No
If Yes:
x ICHAT/OTIS ICHAT/OTIS/Fingerprints
Does the assignment involve an overnight stay? Does the assignment span multiple school years? Does the assignment have the potential for unsupervised access?
Background Check conducted and approved by Staff Resources of Individual to provide Services: ____________________________ Specifics of Assignment - please provide details such as: Time frame of the assignment. Assignment Information_____________________________________________________________________________________ Dates of Assignment______________________________________ Location________________________________________
APPROVALS L.I.S.D. Staff Supervisor ______________________________________________________ / ____________________________ Signature Date Assistant Superintendent_____________________________________________________ / ____________________________ Signature Date Report any assignment-related accidents / illness to the L.I.S.D. Supervisor immediately.
NAME: ______________________________________________________________ DATE ____________________
LAST
FIRST
MIDDLE
Criminal History Check Form As a prospective (SELECT APPROPRIATE BOX): Class/Program Volunteer Field Trip Chaperone
Student Teacher/Classroom Observation Student in the Certified Nursing Assistant (CNA) Program
Guest Presenter (i.e. Professional Development) Foster Grandparent Other:____________________________________
for the Lenawee Intermediate School District, I understand that it is this agency’s policy to secure criminal conviction history information using the information provided. BIRTHDATE: __________/__________/__________ RACE: ______________________
MONTH
DAY
GENDER: _________
YEAR
Driver’s License Passport State Issued ID (Photo ID requirement may be waived for individuals under 18 years of age with Administrator approval)
REQUIRED - Please include a copy of photo id:
Administrator signature for waiver: _____________________________________________________________________
Statement Of Understanding Pursuant to 1993 Public Act 68, I, (PRINT NAME), ___________________________________________represent that (SELECT APPROPRIATE BOX):
I have not been convicted of, or pled guilty or nolo contendere (no contest) to any crimes.
I have been convicted of or pled guilty or nolo contendere (no contest) to the following crimes. If desired, attach a separate sheet to explain nature of conviction, date and court. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
I understand and agree that pursuant to 1993 Public Act 68: (1)
The Board of Education of the school district or government body of the nonpublic school (the “School”) must request a criminal history check and criminal records check on me from the Central Records Division of the Michigan Department of State Police and the Federal Bureau of Investigation (“FBI”);
(2)
Until the aforementioned checks are received and reviewed by the School, I am regarded as a conditional volunteer/CNA Student;
(3)
If the information on the aforementioned checks received from the Department of State Police and/or FBI is not the same as my representation(s) above respecting either the absence of any conviction(s) or any crimes of which I have been convicted, my application to volunteer or participate as a student in the CNA Program is voidable at the option of the School.
I understand that the above information is required by the Central Records Division of the Michigan State Police, Lansing, Michigan. I authorize the LISD to utilize the above information for the sole purpose of obtaining a file search of criminal conviction history. Please forward the criminal history/record to LISD, Executive Director of Staff Resources, 4107 N. Adrian Hwy., Adrian, Michigan 49221. I agree that LISD may provide the criminal conviction history/record information received to other prospective employers and/or Lenawee Medical Care Facility as part of the CNA Program.
____________________________________________________________ SIGNATURE (IF UNDER 18 REQUIRES PARENT SIGNATURE)
_________________________ DATE
INVOICE Pay to: Address: Phone: Date:
Invoice Date:
Description
Amount
Total Due
$
□ Signed Copy of Personal Services Agreement □ IRS Form W9 (write phone number on top of form) □ Criminal History Check Form AND Application for Non-Paid Position* □ Government-issued Photo Identification* □ Invoice (if applicable)* *For all individuals who will be performing services at LISD
Personal Services Agreement This Personal Services Agreement (hereinafter, “Agreement”) is made this ___ day of ____________, 2016, by and between the Lenawee Intermediate School District, a Michigan intermediate school district organized and operating under the provisions of the Revised School Code, MCLA 380.1 et seq., as amended, whose address is 4107 North Adrian Highway, Adrian, Michigan 49221-9309 (hereinafter, “LISD”) and the following personal services provider: Service Provider Name: ________________ Service Provider Address: ________________________________________________________ (hereinafter, “Service Provider”). With the signatures of their respective representatives, the parties to the Agreement voluntarily bind themselves to the covenants contained herein and their mutual consideration establishes the basis for this Agreement. 1.
LISD and Service Provider agree that Service Provider will perform certain services to and on behalf of the LISD as is more specifically described in Exhibit A, which is incorporated into and made part of this Agreement (hereinafter, “services”).
2.
Service Provider may terminate this Agreement by providing written notice to the LISD at least 30 days prior to the date on which the services are to be performed. LISD may terminate this Agreement by providing written notice to the Service Provider at least 30 days before the date on which the services are to be performed. Notwithstanding the foregoing, in the event that the LISD activity or function for which Service Provider’s services were required is cancelled, Service Provider shall have no obligation to perform the Services described herein nor shall the LISD have any obligation to Service Provider. The LISD agrees to make reasonable effort to provide advance notice of any activity or event cancellation.
3.
Service Provider warrants and affirms that Service Provider is sufficiently qualified to perform the services and that Service Provider will perform the services in a professional manner customary of the industry that Service Provider represents, and that Service Provider will adhere to all mutually agreed upon delivery schedules, which are identified in Exhibit A. Service Provider understands that time is of the essence with respect to the performance of the services.
4.
Service Provider understands and acknowledges that the LISD is a Michigan public school district and as such will be required to conduct criminal history information checks on Service Provider and any assistants. Service Provider agrees to comply with any criminal history information check requirements of the LISD, and understands that failure to do so, or unsatisfactory criminal history information check results will immediately terminate this Agreement. The satisfactory completion of a criminal
1
history information check or a valid waiver of such by LISD is a condition precedent to Service Provider’s performance of the services. 5.
In exchange for Service Provider’s services as described in Exhibit A, LISD will pay Service Provider a lump sum amount of $_________, which shall be payable within 30 days of the conclusion of Service Provider’s performance of the services described in Exhibit A and upon Service Providers delivery of an undisputed invoice and properly completed IRS Form W9, both of which shall be a condition precedent to payment.
6.
Service Provider will serve as an independent contractor of LISD. Service Provider alone is responsible for the hiring, supervising, and payment of any assistants, subcontractors, or other individuals necessary for Service Provider’s performance of the services. Furthermore, Service Provider alone is responsible for the payment of any State and Federal income or other taxes which may become due as a result of Service Provider’s performance of the services. Because Service Provider is an independent contractor, Service Provider is not eligible to receive any benefits from LISD, including but not limited to contributions to any retirement system (such as the Michigan Public Schools Retirement System). Service Provider understands and acknowledges that Service Provider is providing services to LISD as an independent contractor, as such Service Provider agrees to indemnify and hold LISD harmless from any and all claims, causes of action, or liability which may arise out of a finding that Service Provider was an employee of the LISD.
7.
Service Provider may be required to provide the LISD with proof that Service Provider has a commercial general liability insurance policy, which covers the services to be provided to LISD. If proof of insurance is required, such must be provided to LISD prior to Service Provider’s provision of the services described in Exhibit A.
8.
Service Provider agrees to indemnify and hold harmless the LISD from any and all claims, causes of action, or liability of any nature, whether arising out of tort, contract, statute, ordinance, or otherwise, which may be asserted against the LISD due to the acts or omissions of Service Provider, its agents, employees, or subcontractors.
9.
Service Provider agrees that LISD will not be liable to Service Provider, or any third party, for: (1) any liability claims, loss, damages, or expense of any kind, including, but not limited to any loss of profits or eligibility to receive profits, arising directly or indirectly out of Service Provider’s provision of the services; (2) any incidental or consequential damages, however caused, and Service Provider agrees, to the extent allowable by law, to indemnify and hold LISD harmless against such liabilities, claims, losses, damages (consequential or otherwise) or expenses, or actions in respect thereof, asserted or brought against LISD by or in right of third parties; or (3) any punitive damages. For purposes of this Agreement, incidental or consequential damages shall include, but not be limited to, loss of anticipated revenues, income, profits or savings; loss of or damage to reputation or good will; loss of students; loss of business or financial opportunity; or any other indirect or special damages of any kind categorized as consequential or incidental damages under Michigan law.
2
10.
This Agreement may only be modified or amended through written Agreement of the Parties.
11.
This Agreement is enforceable only by the LISD and Service Provider. No other person may enforce any of the terms contained in this Agreement, nor is the Agreement intended to confer third party beneficiary status on any third party.
12.
The Parties agree that they will not assign or transfer any rights or duties contained herein, without first obtaining the expressed written consent of the other party. The parties understand and acknowledge that either party may withhold consent regardless of the reasonableness of such.
13.
This Agreement represents the entire agreement between the Parties with respect to Service Provider’s provision of the services described in Exhibit A.
14.
This Agreement shall be deemed to have been executed in the state of Michigan and the substantive laws of the state of Michigan shall govern the enforcement of this Agreement and the rights and remedies of the Parties.
Service Provider: __________________________
Lenawee Intermediate School District
____________________________________ (signature)
____________________________________ Mark E. Haag, Ed.S., Superintendent
Date: ______________________________
Date: ______________________________
Checklist of Items Required from Service Provider:
□ Signed Copy of this Agreement □ IRS Form W9 □ LISD Electronic Payment Agreement (if applicable) □ Sales Tax Exemption Form (if applicable) □ Criminal History Check Form*AND Application for Non-paid Position □ Government-issued Photo Identification* *For all individuals who will be performing services at LISD
3
Personal Services Agreement Exhibit A Personal services purpose and description: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Service Performance date(s): _____________________________________________________ Service Performance times: ______________________________________________________ Service Performance location: ____________________________________________________ Additional information: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (Attach additional pages as necessary, identified as “Exhibit A”)
4
W-9
Form (Rev. December 2014) Department of the Treasury Internal Revenue Service
PHONE NUMBER: ______________ Request for Taxpayer Identification Number and Certification
Give Form to the requester. Do not send to the IRS.
Print or type See Specific Instructions on page 2.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification; check only one of the following seven boxes: C Corporation S Corporation Partnership Trust/estate Individual/sole proprietor or single-member LLC Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) a Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.
4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.)
Other (see instructions) a 5 Address (number, street, and apt. or suite no.)
Requester’s name and address (optional)
6 City, state, and ZIP code
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 backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.
Social security number
–
–
or Employer identification number
–
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 Revenue Service (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 am no 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 withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.
Sign Here
Signature of U.S. person a
Date a
General Instructions
• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)
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 as legislation enacted after we release it) is at www.irs.gov/fw9.
• Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.
Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:
If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.
• Form 1099-INT (interest earned or paid)
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If 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 the withholding tax on foreign partners' share of effectively connected income, and
• Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions)
By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.
• Form 1099-K (merchant card and third party network transactions) Cat. No. 10231X
Form W-9 (Rev. 12-2014)
LENAWEE INTERMEDIATE SCHOOL DISTRICT
APPLICATION FOR NON-PAID POSITION (This form must be completed once each year. If background check is required, you may not volunteer until background check has been conducted. All areas with an Asterisk and BOLDED need to be completed before your application will be considered.) NAME: ______________________________________________________________ DATE ____________________
LAST
FIRST
MIDDLE
MAIDEN/FORMER
NAMES USED: ___________________________________________________________________________________ ADDRESS: ________________________________ CITY: _______________ STATE: ______ ZIP: _________ (For college students, please use your permanent home address) VOLUNTEER ACTIVITY: __________________________________________________________________________ WEEKDAYS/TIMES AVAILABLE: ___________________________________________________________________
Phone: _____________________ (home / cell / work)
E-Mail Address: ______________________________________
Emergency Contact__________________________________________ Phone _________________________________ PLEASE READ CAREFULLY I hereby authorize and unqualifiedly grant permission to the Lenawee Intermediate School District (LISD) and its administration to make inquiries to verify the contents of this application, and any representations made verbally or in any letter of interest that I may have submitted. Further, I unqualifiedly authorize and grant permission to the LISD and its administration to contact any and all of my personal references or former or current employers to obtain information concerning my character, reputation, and/or work experience. I further release the LISD and its administration, as well as any reference source, from any liability in connection with the release or use of such information. I further authorize and unqualifiedly grant permission to the LISD and its administration to make inquiries and to obtain any records from law enforcement and/or judicial authorities to determine whether any record of criminal conviction exists, and whether any felony charges are pending against me, including the nature of the offenses. Waiver and Release of LISD from Liability I know and understand that my volunteering with the LISD may expose me to risks, such as illness, injury, death, or loss of property. I voluntarily accept those risks and agree that the LISD, its Board of Education, its staff, its students, its agents, and its representatives, is not liable for any injury, death, or loss of property that is caused by the negligence of the LISD, its Board of Education, its staff, its students, its agents, or its representatives. I understand that by signing this application and accepting a volunteer assignment with the LISD, I am giving up my right to sue for negligence. I also understand and agree that if the LISD is sued by or required to pay any third party because of my conduct, I will reimburse the LISD for its costs, including any and all legal costs and costs due to the third party. Through my signature, I acknowledge that I have read this waiver and release section of this application, I understand what I am agreeing to, and am freely signing it, and further certify that the statements contained in this application are true and complete.
APPLICANT’S SIGNATURE (if under 18 requires parent signature)
DATE
Thank you for completing this application and for your interest in the Lenawee Intermediate School District. We would like to assure you that your opportunity with this organization will be based only on your merit and on no other consideration. The Lenawee Intermediate School District does not discriminate in any of its educational programs and services, activities, or employment practices, on the basis of race, color, religion, national origin or ancestry, age, sex, height, weight, marital status, sexual preference, disability, or English speaking ability. Direct inquiries to: Executive Director of Staff Resources, Lenawee Intermediate School District, 4107 North Adrian Highway, Adrian, Michigan 49221-9354; (517) 265-2119.
-----------------------------------------------------------------------------------------------------------------------------------------------------------APPLICANTS - DO NOT WRITE BELOW THIS LINE – FOR LISD USE ONLY Is Background Check Required: Please Consider:
x Yes No
If Yes:
x ICHAT/OTIS ICHAT/OTIS/Fingerprints
Does the assignment involve an overnight stay? Does the assignment span multiple school years? Does the assignment have the potential for unsupervised access?
Background Check conducted and approved by Staff Resources of Individual to provide Services: ____________________________ Specifics of Assignment - please provide details such as: Time frame of the assignment. Assignment Information_____________________________________________________________________________________ Dates of Assignment______________________________________ Location________________________________________
APPROVALS L.I.S.D. Staff Supervisor ______________________________________________________ / ____________________________ Signature Date Assistant Superintendent_____________________________________________________ / ____________________________ Signature Date Report any assignment-related accidents / illness to the L.I.S.D. Supervisor immediately.
NAME: ______________________________________________________________ DATE ____________________
LAST
FIRST
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Criminal History Check Form As a prospective (SELECT APPROPRIATE BOX): Class/Program Volunteer Field Trip Chaperone
Student Teacher/Classroom Observation Student in the Certified Nursing Assistant (CNA) Program
Guest Presenter (i.e. Professional Development) Foster Grandparent Other:____________________________________
for the Lenawee Intermediate School District, I understand that it is this agency’s policy to secure criminal conviction history information using the information provided. BIRTHDATE: __________/__________/__________ RACE: ______________________
MONTH
DAY
GENDER: _________
YEAR
Driver’s License Passport State Issued ID (Photo ID requirement may be waived for individuals under 18 years of age with Administrator approval)
REQUIRED - Please include a copy of photo id:
Administrator signature for waiver: _____________________________________________________________________
Statement Of Understanding Pursuant to 1993 Public Act 68, I, (PRINT NAME), ___________________________________________represent that (SELECT APPROPRIATE BOX):
I have not been convicted of, or pled guilty or nolo contendere (no contest) to any crimes.
I have been convicted of or pled guilty or nolo contendere (no contest) to the following crimes. If desired, attach a separate sheet to explain nature of conviction, date and court. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
I understand and agree that pursuant to 1993 Public Act 68: (1)
The Board of Education of the school district or government body of the nonpublic school (the “School”) must request a criminal history check and criminal records check on me from the Central Records Division of the Michigan Department of State Police and the Federal Bureau of Investigation (“FBI”);
(2)
Until the aforementioned checks are received and reviewed by the School, I am regarded as a conditional volunteer/CNA Student;
(3)
If the information on the aforementioned checks received from the Department of State Police and/or FBI is not the same as my representation(s) above respecting either the absence of any conviction(s) or any crimes of which I have been convicted, my application to volunteer or participate as a student in the CNA Program is voidable at the option of the School.
I understand that the above information is required by the Central Records Division of the Michigan State Police, Lansing, Michigan. I authorize the LISD to utilize the above information for the sole purpose of obtaining a file search of criminal conviction history. Please forward the criminal history/record to LISD, Executive Director of Staff Resources, 4107 N. Adrian Hwy., Adrian, Michigan 49221. I agree that LISD may provide the criminal conviction history/record information received to other prospective employers and/or Lenawee Medical Care Facility as part of the CNA Program.
____________________________________________________________ SIGNATURE (IF UNDER 18 REQUIRES PARENT SIGNATURE)
_________________________ DATE
INVOICE Pay to: Address: Phone: Date:
Invoice Date:
Description
Amount
Total Due
$
