Robert Sheres
NEW VENDOR PACKET - JANUARY 2020 (with IRS Forms) NEW VENDOR FORMS AND REQUIREMENTS
RVB PG STV
ACCOUNTS PAYABLE MAINTENANCE
Sign and hand deliver or fax to the Purchasing Department
OCL GLD TIF
ADD
CHANGE
DELETE
VENDOR NAME: REMIT TO ADDRESS: CITY: TELEPHONE: ORDER CONTACT:
UNIPRO VENDOR:
CATEGORY MANAGER # TERMS: PRIMARY BUYER # SEAFOOD
STATE:
ZIPCODE:
FAX #:
EMAIL ADDRESS: _______________________
YES
IF YES #:
NO
PROGRAM MANAGER #
YES
NO
VENDOR PICKUP INFORMATION MAINTENANCE PICKUP ADDRESS: PICKUP CITY/STATE: PICKUP PHONE: PICKUP CONTACT:
INSURANCE CARRIER:
PROVIDE CURRENT COPY OF LIABILITY INSURANCE
FOOD MANUFACTURER
YES
NO
IF YES BIOTERRORISM ACT REGISTRATION NUMBER: TYPE OF PRODUCT TO PURCHASE:
IN ORDER TO MAINTAIN THE VENDOR LISTING ACCURATELY, DO NOT MAKE ANY CHANGES YOURSELF.
A/P DEPT. USE ONLY DATE
BUYER'S NAME VENDOR #
INITIALS
Attn: Dave Rawicz or Michael Francois DdmaeivADdmcpheateitrtavcp.@nheeto:rl.caff@hoe@DfSlcefcahnS@ahveeafceenyefhneebRteetyyrnayyboewb&r&tyohribctoReRzhrtroiheiosstsrer.khcksrMeo.scrm.oisccm.ochmoamel Francois
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Cheney Brothers, Inc. Vendor Requirements Check list.
Purpose: We manufacture none of the products we sell. Therefore, our vendor requirements are a
proactive step aimed at ensuring we receive safe quality products. We expect our vendors to comply with all applicable federal, state and local requirements for making and holding food, including 21 CFR § 117, 21 CFR § 120 and § 123.
*Prior to purchasing any product from a vendor the Safety & Risk Department must be provided with the following:
ALL Vendors/Suppliers:
1. A copy of vendor business license/permit. 2. Completed Food Safety Questionnaire:
· A copy of recent food safety inspection report from a federal, state, local or other inspection agency.
3. Completed Food Security Questionnaire: 4. A signed Certificate of Liability Insurance (COI);
· Cheney Brothers, Inc., Its Subsidiaries, Affiliates, and/or Divisions must be added as additional insured (See Certificate of Liability Insurance Letter for requirements)
5. A signed Continuing Letter of Guarantee Agreement. 6. A signed Purchase Order Terms and Conditions
Vendors Supplying Products with Nutrition Facts Labels
· A signed Nutrition Facts Label and Service Size Verification Form
Seafood Vendors:
A Certificate of Origin. (Must be provided for each order,) · Certificate of Origin must list U.S. firm as consignee. · A shipment date of product should be listed on Certificate of Origin. · Safety and Risk Department must receive a new Certificate of Origin and Seafood Vendor Declaration/Correlation Letter with each product shipment. · Commodities should be separated by; item: quantity and weight. · Species and Market name must be applicable to the species in each container. · Verifiable purchase order number must be listed on Certificate of Origin.
Importers:
1. A signed Food Safety Modernization Act/Foreign Supplier Verification Program Letter
Bottled Water Vendors:
2. A signed Bottled Water Verification Form
Kombucha Vendors:
3. A signed Continuing Letter of Indemnity and Guarantee Agreement (Kombucha)
Alcohol Infused Frozen Dessert Products Vendors
4. A signed Continuing Letter of Indemnity and Guarantee Agreement (Alcohol Infused Frozen Dessert Products)
Corporate Headquarters
One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Attn: Dave Rawicz or Michael Francois Dept. of Safety & Risk daver@cheneybrothers.com michaelf@cheneybrothers.com
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Cheney Brothers, Inc. New Vendor Pallet Criteria
TO: All Cheney Brothers, Inc. Suppliers
We have formalized our pallet specifications throughout our operation for food and personal safety as well as economic reasons. As a supplier of palletized product, this letter is to inform you of our standards. At a minimum, we require that all loads be received on Grade #2 or B Grade pallets (Typically, these grade of pallets meet the Grocery Manufacturers Association (GMA) standards that include pallets that have been repaired by a companion stringer, block stringer and double stringer. and all damaged deck boards have been replaced resulting in a fairly clean pallet that is structurally sound).*
Pallets should conform to the following conditions to facilitate load acceptance:
· Cracks or unsound knots may not exceed ¼ of stringer thickness and unsound knots should not be present in notch area.
· No broken deck boards.
· All stringers or companion stringers must be in good repair.
· Pallets should be in fresh clean condition
Pallets with shoddy or unprofessional looking repairs will not be accepted.
In addition, several studies have reported a potential contamination link between pallets and the products they carry.** Pallets that are observed to be stained, soiled or otherwise contaminated will not be accepted.
Please keep in mind that any product received on pallets not meeting these specifications may either be returned or restacked at your expense. Thank you in advance for your cooperation in this matter.
*
Reference......* Uniform Standard for Wood Pallets, © 2005 by the National Wooden Pallet and Container Association.
**
Reference...... **Hidden Dangers of Wooden Pallets Escalate, ©2010 PR Newswire Association LLC.
Corporate Headquarters One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
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Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Cheney Brothers, Inc. Vendor Food Safety Questionnaire
Please provide answers to any of the following questions that apply to your business or provide your standard documentation to such security inquires. Attach any letters or documentation.
1. Has your facility received GFSI (e.g., SQF, BRC, ISO, etc.) Certification? If so, please provide all certificates.
2. Provide a copy or brief outline of your HACCP plan. What are identified hazards, critical control points and critical limits? How are limits monitored?
3. Do you have someone certified to new FSMA standards? Attach copy 4. Describe program you have in place for allergens. 5. Describe program you have in place for prevention of cross contamination. 6. Do you have an environmental monitoring program? If Yes, Describe. 7. Describe program you have in place for glass and brittle plastics. 8. How are your employees monitored for hygiene and disease? 9. Describe ingredient/product receiving inspections and procedures. 10. Recall program: Describe methods you use to track ingredients and products
into, through and from your facility. 11. Provide copy of a recent pest control service report. 12. Provide a copy of most recent USDA, FDA or 3rd party audit.
Corporate Headquarters One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
ADADtetettpnpnt:t.:.oDDof afaSvvaSefeaeRftRayewat&ywicR&zicioszRrkoiMsrkicMhaicelhFarealnFcoriasncois ddaavveerr@@cchheenneeyybbrrooththeersr.sc.ocmom mmiicchhaaeellff@@cchheenneeyybbrrooththeresr.sc.ocmom
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Cheney Brothers, Inc. Vendor Food Security Questionnaire
Please provide answers to all of the following questions or provide documentation for these security inquires. Attach any documents or letters and return with packet.
1. Facility: · Do you have a Food Defense Plan? · Have you ever had a food defense audit? · Is your Facility registered under the Bio-terrorism Act? · If yes, facility registration #:________________________.
2. Personnel Screening: · What is your method of pre-employment screening? · What is the average length of employment?
3. Access: · How do you limit or restrict access to your building/ facility? · How do you limit or restrict access to sensitive areas of your operation? · How is this access monitored?
4. Raw Materials and Packaging: · Do you have vendor qualification procedures in place? · Elaborate on vendor qualification requirements. · How are incoming raw materials and packaging secured and monitored?
5. Distribution: · How do you protect your products during distribution? · Do you distribute your own product? · What screening is done for outside haulers?
Company: _____________________________________ Address: ______________________________________ Phone: _______________________________________ Fax: __________________________________________ Date: _________________________________________
Print name: ____________________________ Title: __________________________________ Signature: ______________________________ E Mail: _________________________________
Corporate Headquarters One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Attn: Dave Rawicz or Michael Francois Dept. of Safety & Risk daver@cheneybrothers.com michaelf@cheneybrothers.com
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Certificate of Liability Insurance Letter
To whom it may concern,
All vendors selling products or services to Cheney Brothers, Inc. are required to provide A signed Certificate of Liability Insurance (COI); meeting the following requirements:
COI naming Cheney Brothers, Inc., Its Subsidiaries, Affiliates, and/or Divisions, 1 Cheney Way, Riviera Beach, FL 33404 as an "Additional Insured" with respect to any negligent act or omission caused in whole or in part by you or anyone acting on your behalf. Additional Insured Coverage should extend to both ongoing and completed operations. Insurance should be underwritten by an insurance company with at least an "A-VII" rating as defined by A.M. Best. If applicable to your operations, General Liability and Workers Compensation policies must contain a "Waiver of Subrogation" naming Cheney Brothers, Inc., Its Subsidiaries, Affiliates, and/or Divisions and be shown on the COI. Insurance coverage is to be "Primary and Non-contributory" to any other insurance available to the certificate holder. Further, the COI shall specify that Cheney Brothers, Inc. shall be given at least thirty (30) days prior written notice by the insurer of any change, modification, cancellation, or termination of coverage. Limits of Insurance shall be no less than:
GENERAL LIABILITY
AUTO LIABILITY WORKERS COMPENSATION UMBRELLA/EXCESS
Each Occurrence Damage to Rented Premises Med Exp (any one person) Personal & Adv. Injury General Aggregate Products Comp/OP AGG Combined & Single Limit Each Accident Pertinent State Statutory Req. Each Occurrence/Aggregate
$2,000,000 $2,000,000 $5,000 $2,000,000 $5,000,000 $2,000,000 $2,000,000 $1,000,000 Statutory $1,000,000
If you have any questions please contact me via e-mail at michaelf@cheneybrothers.com or Dave Rawicz at DaveR@cheneybrothers.com or at (561) 845-4700 Ext. 1185
Michael Francois
Michael Francois Sanitation Manager/HACCP coordinator
Corporate Headquarters One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Attn: Dave Rawicz or Michael Francois ADttenp:tD. oafveSaRfeatwyic&zRoirsMk ichael Francois Ddeapvte.ro@fcSheanfeeytybr&othReirssk.com dmaviecrh@acehlfe@ncehyebnreoythbreortsh.ceorms.com michaelf@cheneybrothers.com
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Continuing Letter of Guarantee Agreement
Hereafter, each article contained in a shipment or other delivery made by the supplier to or on behalf of Cheney brothers, Inc., Its Subsidiaries, Affiliates, and/or Divisions is guaranteed by supplier, to be:
Not adulterated or misbranded within the meaning of the Federal Food, Drug and Cosmetic Act (21 USC § 301, et seq.)
In compliance with all applicable federal, state and local laws.
Not an article which may not, under provisions of the Federal Act (21 USC § 344 or § 355) be introduced into interstate commerce.
Compliant with current good manufacturing practice, hazard analysis, and risk-based preventative controls for human food (21 C.F.R. § 117) and HACCP regulations (21 CFR §§ 120 & 123).
Supplier also agrees to provide Cheney Brothers, Inc., Its Subsidiaries, Affiliates, and/or Divisions with the necessary information to comply with the record keeping provisions of any federal, state or local laws.
Vendors selling products to Cheney Brothers, Inc., Its Subsidiaries, Affiliates, and/or Divisions are required to provide a new Letter of Guarantee; guarantee letter renewal will be required every three years.
(This form must have original signature; copies or faxes will not be accepted.)
Company: ______________________________ Print name: _________________________________
Address: _______________________________ Title: _______________________________________
Phone: _________________________________ Signature: ___________________________________
Date: __________________________________ E-mail:______________________________________
The person signing this letter on behalf of supplier certifies that he or she has been duly authorized to do so by supplier.
Corporate Headquarters One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Attn: Dave Rawicz or Michael Francois Dept. of Safety & Risk daver@cheneybrothers.com michaelf@cheneybrothers.com
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Nutrition Facts Label and Service Size Verification Form
Dear Valued Vendor:
As you are aware, on May 27, 2016, the Food and Drug Administration ("FDA") published final rules on the new Nutrition Facts label for packaged foods to reflect new scientific information. In 2018, the FDA issued a final rule to extend the compliance dates for the Nutrition Facts label final rules from July 26, 2018 to January 1, 2020.1 For information and questions regarding these rules, including specific labeling requirements that may pertain to you or your products, please contact the FDA or visit their website at www.FDA.gov.
Cheney Bros., Inc. d/b/a/ Cheney Brothers, Inc. ("Cheney Brothers") relies entirely upon its vendors to ensure that all products labeled for and/or sold to Cheney Brothers and its customers are in compliance with all applicable federal, state, and local laws, rules, and regulations and are not adulterated, misbranded, or mislabeled in any way.
By signing this notice, you acknowledge that you are aware of and fully understand your responsibilities and have not relied upon Cheney Brothers for legal or regulatory advice, guidance, or otherwise. You further warrant, represent, and guarantee that all products contained in any shipment or other delivery made by you to or on behalf of Cheney Brothers, including but not limited to private labeled items, are in compliance with the Federal Food, Drug and Cosmetic Act, Fair Packaging and Labeling Act, and Nutrition Labeling and Education Act, including all amendments and updates thereto.
You further agree to indemnify, defend, and hold Cheney Brothers harmless for any damages, claims, suits, fines, costs, or liabilities including reasonable attorneys' fees that Cheney Brothers, its affiliates, and customers may incur arising out of or relating to your failure to comply with your obligations referenced herein as well as the representations set forth herein.
_____________________________________ (Print Vendor's Name)
_____________________________________ (Signature)
By: _________________________________
Title:________________________________
Date: ________________________________
1 Compliance dates may vary based upon the particular manufacturer's annual sales and/or products.
Corporate Headquarters One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Attn: Dave Rawicz or Michael Francois Dept. of Safety & Risk daver@cheneybrothers.com michaelf@cheneybrothers.com
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Country of Origin/Method of Production Labeling Requirements
To: All Vendors and Manufactures,
In order to comply with USDA Country of Origin requirements verification of country of origin and method of production (farm or wild caught) will be required. Seafood, fresh or frozen, subject to some exemptions is a covered commodity. The following measures must be taken in order for us to purchase your product(s).
Label all products clearly with country of origin and method of production: either farm or wild caught. The smallest identifiable unit must be labeled accordingly.
All invoices, packing lists and bills of lading will describe the country of origin and method of production by line item.
Maintain records and a verifiable audit trail to establish the accuracy of the country of origin and method of production information. This may include: invoices, receiving records, purchase records, sales receipts and other pertinent records.
Products must be segregated by country of origin and method of production throughout your process and until they are delivered to Cheney Brothers, Inc. Your company must maintain documentation verifying your segregation plan.
Indemnify Cheney Brothers, Inc., Its Subsidiaries, Affiliates, and/or Divisions for any cost or losses that we may incur as a result of the country of origin and method of production information that is insufficient or not provided.
Your company agrees to comply with these requirements as a condition of business with Cheney Brothers, Inc., Its Subsidiaries, Affiliates, and/or Divisions.
Michael Francois
Michael Francois/HACCP Administrator
Corporate Headquarters One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Attn: Dave Rawicz or Michael Francois Dept. of Safety & Risk daver@cheneybrothers.com michaelf@cheneybrothers.com
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Seafood Vendor Declaration/Correlation Letter
This is to certify that the following seafood sold to Cheney Brothers, Inc., Its Subsidiaries, Affiliates, and/or Divisions will correlate to the specific Certificate of Origin. (Please write legibly, as illegible documents may be returned.)
1. Description of Product (As written on certificate of Origin):________________________________ ____________________________________________________________________________________________
2. Species name(s): o ________________________________________ o ________________________________________ o ________________________________________ o ________________________________________
3. Number of packages (As written on certificate of origin):
____________________________________________________________________________
4. Certificate number (As written on certificate of origin):
______________________________________________________________________________
5. Cheney Brothers, Inc. Purchase Order Number:
_______________________________________________________________________________
Company: ______________________________ Address:________________________________ Phone:__________________________________ Fax:____________________________________ E-mail:________________________________________
Print name:_____________________________ Title:___________________________________ Signature:_______________________________ Date:___________________________________
Corporate Headquarters One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Attn: Dave Rawicz or Michael Francois Dept. of Safety & Risk daver@cheneybrothers.com michaelf@cheneybrothers.com
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Foreign Supplier Verification Program Letter to Importers
Dear Valued Importer:
As you may be aware, in accordance with the Food Safety Modernization Act (FSMA), the FDA implemented Foreign Supplier Verification Programs (FSVP) for importers of food for humans and animals. The FSVP requires that importers perform certain risk-based activities to verify that food imported into the United States has been produced in a manner that meets applicable U.S. safety standards. Specifically, an FSVP is a program that importers must have in place to verify that their foreign suppliers are producing food in a manner that provides the same level of public health protection as the preventative controls or produce safety regulations, as appropriate, and to ensure that the supplier's food is not adulterated and is not misbranded with respect to allergen labeling. Accordingly, importers are responsible for actions that include:
Determining known or reasonably foreseeable hazards with each food;
Evaluating the risk posed by a food, based on the hazard analysis, and the foreign supplier's performance;
Using that evaluation of the risk posed by an imported food and supplier's performance to approve suppliers and determine appropriate supplier verification activities;
Conducting supplier verification activities;
Conducting corrective actions; and
Identifying the FSVP importer when filing for entry with U.S. Customers and Border Protection using the FSVP importer's name, electronic mailing address, and unique facility identifier recognized as acceptable to the FDA (i.e. DUNS number).
FSMA requires that importers develop, maintain, and follow these FSVPs for each food brought into the United States and the foreign supplier of that food. The evaluation of the risk posed by the imported food and the supplier's performance must be reevaluated at least every three years, or when new information comes to light about a potential hazard or the foreign supplier's performance.
Hazard Analysis: With respect to the importer's hazard identification and evaluation requirements, importers are required to identify and evaluate (based on experience, illness data, scientific reports and other information) the known or reasonably foreseeable hazard for each type of food it imports to determine if there are any hazards requiring control. These hazards include biological hazards (i.e. parasites and disease causing bacteria), chemical hazards (i.e. radiological hazards, pesticide and drug residues, natural toxins, food decomposition, unapproved food or color additives and food allergens), and physical hazards (i.e. glass). Other hazards include those likely to cause illness or injury that occur naturally, are unintentionally introduced, or are intentionally introduced for purposes of economic gain such as substituting less costly ingredients. The importer's analysis must assess the probability that these hazards will occur in the absence of controls and the severity of the illness or injury that could occur. Factors to be considered in the analysis include: (a) formulation of the food; (b) condition, function, and design of the establishment and equipment of a typical entity that produces the food; (c) raw materials and other ingredients; (d) transportation practices; (e) harvesting, raising, manufacturing, processing and packaging procedures; (f) packaging and labeling activities; (g) storage and distribution; (h) intended or reasonably foreseeable use; and (i) sanitation, including employee hygiene. While the FDA has noted that an importer may rely on another entity to conduct the hazard analysis, the importer must still review and assess the relevant documentation.
Corporate Headquarters
One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Delivering Southern Hospitality Since 1925
www.cheneybrothers.com
Evaluation of Food Risk and Supplier Performance: In addition to the hazard analysis, the importer must evaluate: (a) the entity that will be significantly minimizing or preventing the hazards, such as the foreign supplier or the supplier's raw material or ingredient supplier; (b) the foreign supplier's procedures, processes, and practices related to the safety of food; (c) applicable FDA food safety regulations, and information regarding the foreign supplier's compliance; (d) the foreign supplier's food safety history, including the responsiveness of the foreign supplier in correcting past problems; and (e) other necessary factors, including storage and transportation practices. Although the FDA permits an importer to rely on another entity (other than the foreign supplier) to perform the evaluation of risk, the importer must review and assess the relevant documentation.
Supplier Verification: Based upon the evaluation of risk conducted, the importer must establish and follow written procedures to ensure that it only imports from approved foreign suppliers and must conduct appropriate supplier verification activities. While importers have flexibility to tailor supplier verification activities to the unique food risks and supplier characteristics, the FDA explains that the importer's options include: (a) annual on-site audits of the supplier's facility; (b) sampling and testing; and/or (c) a review of the supplier's relevant food safety records. Although the FDA permits an importer to rely on another entity (other than the foreign supplier) to determine and perform appropriate supplier verification activities, the importer must review and assess the relevant documentation.
Corrective Actions: FSMA provides that if the importer determines that a foreign supplier has not used processes and procedures that provide the same level of public health and protection as required under the produce safety and preventative controls regulations or that the suppler produces food that is adulterated or misbranded with respect to allergen labeling, the importer must promptly take appropriate corrective actions. The specific corrective measures will depend on the circumstances but could include discontinuing use of the foreign supplier until the cause of noncompliance, adulteration or misbranding has been adequately addressed.
Exemptions and Modified Standards: There are a number of exemptions and modified FSVP requirements applicable to certain small importers and importers of certain specific products. Information regarding these exemptions as well as all other information relevant to importers' duties can be found on the FDA's website at www.fda.gov.
Please be advised that neither Cheney Bros., Inc. d/b/a Cheney Brothers, Inc. ("Cheney Brothers") nor any of its affiliates are FSVP importers. Accordingly, you acknowledge and agree that you have not and will not (a) identify Cheney Brothers or any of its affiliates as an FSVP importer, owner, or consignee of any products imported into the United States; or (b) an agent or representative of any foreign owner or consignee of products imported into the United States.
Cheney Brothers relies upon its importers to ensure that they are in compliance with all local, state, and federal rules, regulations, and laws including, without limitation, the FSMA. By signing this notice, you acknowledge you understand your responsibilities under the FSMA, have not relied upon Cheney Brothers for legal advice, guidance, or otherwise, and warrant and represent to Cheney Brothers that you are in compliance with your obligations with respect to all products imported into the United States and supplied to Cheney Brothers. You further agree to indemnify and hold Cheney Brothers and its affilaities harmless for any damages, claims, suits, fines, costs, or liabilities (including in-house and outside attorneys' fees) that Cheney Brothers or its affiliates may incur arising out of or relating to your compliance or failure to comply with your obligations referenced herein as well as the representations set forth herein.
_____________________________________ (Print Vendor's Name)
_____________________________________ (Signature)
Signatory's Name: _____________________ Title: ________________________________ Date: ________________________________
Corporate Headquarters
One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Attn: Dave Rawicz or Michael Francois Dept. of Safety & Risk daver@cheneybrothers.com michaelf@cheneybrothers.com
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Bottled Water Verification Form
Dear Valued Bottled Water Vendor:
As you are aware, the Food and Drug Administration ("FDA") has implemented specific
regulations relating to the labeling of bottled water for human consumption including, without
limitation, 21 C.F.R. § 165.110. Section 165.110, amongst other things, specifies when certain
nomenclature such as "spring water" may be used on the labels for bottled water. Cheney Bros.,
D
Inc. d/b/a Cheney Brothers, Inc. ("Cheney Brothers") relies upon its vendors to ensure that all
products labeled for and/or sold to Cheney Brothers and its customers are in compliance with
all applicable federal, state, and local laws, rules, and regulations and are not adulterated,
misbranded, or mislabeled in any way.
By signing this notice, you acknowledge that you understand your responsibilities, have not relied upon Cheney Brothers for legal advice, guidance, or otherwise, as well as warrant, represent, and guarantee that all bottled water contained in any shipment or other delivery made by you to or on behalf of Cheney Brothers, including but not limited to private labeled items are:
Not adulterated or misbranded within the meaning of the Federal Food, Drug and Cosmetic Act (21 U.S.C § 301, et seq.) (the "FDAC") and otherwise fully in compliance
21 C.F.R. § 165.110;
Compliant with all applicable federal, state and local laws;
Not an article which may not, under provisions of the FDAC be introduced into interstate commerce; and
Compliant with current good manufacturing practice, hazard analysis, and risk-based
preventative controls for human food (21 C.F.R. §117) and processing and bottling of bottled drinking water (21 C.F.R. § 129).
You further agree to indemnify and hold Cheney Brothers harmless for any damages, claims, suits, fines, costs, or liabilities (including in-house and outside attorneys' fees) that Cheney Brothers, its affiliates, and customers may incur arising out of or relating to your failure to comply with your obligations referenced herein as well as the representations set forth herein.
_____________________________________ (Print Vendor's Name)
_____________________________________ (Signature)
Signatory's Name: _____________________ Title: ________________________________ Date: ________________________________
Corporate Headquarters One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Attn: Dave Rawicz or Michael Francois Dept. of Safety & Risk daver@cheneybrothers.com michaelf@cheneybrothers.com
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Continuing Letter of Indemnity and Guarantee Agreement
(KOMBUCHA)
Vendor desires to supply Cheney Bros., Inc. d/b/a Cheney Brothers, Inc. ("CBI") with Kombucha, a fermented beverage made from brewed tea and sugar. Kombucha tea is a fermented product that can be produced with an end result of alcohol that varies from a trace level to over 2.5% alcohol concentration. Vendor acknowledges that if the end product contains a level greater than 0.5% alcohol by volume, the Kombucha tea is considered an alcoholic beverage and subject to state regulation by the Florida Department of Business and Professional Regulation, Division of Alcoholic Beverages and Tobacco (ABT) and, potentially, other state regulators who regulates the sale, labeling and distribution of alcoholic beverages. Additionally, alcoholic beverages are subject to federal regulation by the U.S. Department of Treasury, Alcohol and Tobacco Tax and Trade Bureau (TTB).
Vendor acknowledges that CBI does not intend to and will not knowingly purchase, sell, or distribute any alcoholic beverages. Vendor therefore agrees not to supply CBI with any alcoholic beverages or products that may become alcoholic beverages with the passage of time.
In order to ensure that it is compliant with the terms hereof and its obligations to CBI, Vendor agrees to perform the following for the benefit and on account of CBI: (1) monitor the pH of Vendor's products; (2) monitor the alcohol content of Vendor's products; (3) follow a scientifically validated process such as a process authority evaluation or peer review scientific journal article; (4) operate under an approved Process Alternative, and Hazard Analysis and Critical Control Point Plan (HACCP); and (5) immediately inform CBI, in writing, if it becomes aware of or otherwise suspects that any of its products supplied to CBI may be considered an alcoholic beverage by any local, state, federal, or other governmental agency or is otherwise not permitted to be purchased or sold by CBI.
Vendor shall indemnify and hold CBI, including but not limited to, its agents, employees, directors, officers, attorneys, affiliates, parents, successors, owners, predecessors, assigns, and related entities and persons, harmless from and against any claims, known or unknown, arising out of or connected in any way with products provided by Vendor or its agents to CBI, regardless of the cause of any injuries or damages giving rise to such claims, even if caused by the sole negligence of CBI or its agents, as well as any breach of this agreement.
_____________________________________ (Print Vendor's Name)
_____________________________________ (Signature)
Signatory's Name: _____________________ Title: _________________________________ Date: _________________________________
Corporate Headquarters
One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Attn: Dave Rawicz or Michael Francois Dept. of Safety & Risk daver@cheneybrothers.com michaelf@cheneybrothers.com
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
Revised January 2020
Continuing Letter of Indemnity and Guarantee Agreement
(ALCOHOL INFUSED FROZEN DESSERT PRODUCTS)
Vendor desires to supply Cheney Bros., Inc. d/b/a Cheney Brothers, Inc. ("CBI") with the alcohol infused frozen dessert products and/or other products containing alcohol listed on Exhibit "A" hereto (referred to herein as "AIFD Products") for the distribution and/or or sale of same in the following states (the "Jurisdictions")2:
Florida
Georgia
** Check all that apply ** North Carolina South Carolina Tennessee
Virginia
Alabama
In order to induce CBI to purchase the AIFD Products from Vendor, Vendor warrants and represents as follows:
Vendor has obtained (and will continue to maintain) all required licenses, permits, registrations, and other authorizations from all applicable local, state, and federal authorities including, without limitation, Florida Department of Business and Professional Regulation, Division of Alcoholic Beverages and Tobacco (ABT) and U.S. Department of Treasury, Alcohol and Tobacco Tax and Trade Bureau (TTB) to manufacture, distribute, store, transport, and/or sell the AIFD Products to CBI.
The AIFD Products are not considered to be alcoholic beverages by the ABT or any administrative, local, or state rules, regulations, laws, or governing authorities in any of the Jurisdictions. For all AIFD Products containing 2.5% or more alcohol by volume (ABV), Vendor has obtained a Certificate of Label Approval (COLA) for such product, the TTB ID referenced on the COLA for same is identified on Exhibit A and a copy of the COLA is enclosed herewith.3
The AIFD Products are not considered to be adulterated, misbranded, or mislabeled products by the TTB or any administrative, local, state, or federal rules, regulations, laws, or authorities in any of the Jurisdictions.
The AIFD Products are permitted to be transported into or sold to any food service entity in all of the Jurisdictions by CBI without the necessity of CBI or any food service entity obtaining a license or permit to sell products containing alcohol from any local or state government authority in the Jurisdictions (i.e. state departments of revenue and/or agriculture).
Vendor will continuously remain apprised of and update CBI on the status of its authority to manufacture, store, transport, and sell the AIFD Products to CBI and CBI's authority to distribute and sell the AIFD Products in the Jurisdictions. Vendor will immediately inform CBI, in writing if: (a) Vendor becomes aware of or otherwise has reason to suspect that any of the above representations are no longer accurate or complete; and/or (b) any of the AIFD Products supplied to CBI are (or are likely to be) considered an alcoholic beverage by any local, state, or other governmental agency in any Jurisdiction or otherwise regulated by any local, state, or governmental authority in any Jurisdiction.
Vendor shall indemnify, defend, and hold CBI, including but not limited to, its agents, employees, directors, officers, attorneys, affiliates, parents, successors, owners, predecessors, assigns, related entities and persons, and customers harmless from and against any claims, known or unknown, arising out of or connected
2 Nothing herein shall obligate CBI to purchase any AIFD Products or sell AIFD Products in any of the Jurisdictions. 3 The COLA may be located on the TTB's website https://www.ttbonline.gov/colasonline/publicSearchColasBasic.do
Corporate Headquarters One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
Delivering Southern Hospitality Since 1925 www.cheneybrothers.com
in any way with AIFD Products provided by Vendor or its agents to CBI, regardless of the cause of any injuries or damages giving rise to such claims, even if caused by the sole negligence of an indemnified party or its agents, as well as any breach of or misrepresentation in this agreement. This defense and indemnification obligation shall include, but shall not be limited to, any and all fines, claims, fees, and penalties which may be levied or sought against CBI in any way relating to CBI's transportation, storage, purchase or sale of the AIFD Products.
This agreement and any action arising out of or relating to same shall be governed exclusively by the laws of the State of Florida without regard to principles of conflicts of law. Venue for any action arising out of or relating to this agreement or the AIFD Products shall be exclusively in the Palm Beach County, Florida and Vendor submits to personal jurisdiction in same.
VENDOR Company: Address: ______________________________________________ Phone:
Signature: Print Name: Title: E-Mail:
Corporate Headquarters One Cheney Way, Riviera Beach, FL 33404-7000 561.845.4700 office 800.432.1341 toll-free 561.845.4701 fax
W-9 Form
(Rev. October 2018)
Department of the Treasury Internal Revenue Service
Request for Taxpayer Identification Number and Certification
a Go to www.irs.gov/FormW9 for instructions and the latest information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Give Form to the requester. Do not send to the IRS.
2 Business name/disregarded entity name, if different from above
Print or type. See Specific Instructions on page 3.
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.
Individual/sole proprietor or single-member LLC
C Corporation
S Corporation
Partnership
Trust/estate
4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
Exempt payee code (if any)
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) a
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
code (if any)
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions) a 5 Address (number, street, and apt. or suite no.) See instructions.
(Applies to accounts maintained outside the U.S.)
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 instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester 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 for Part II, later.
Sign Here
Signature of U.S. person a
Date a
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.
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. · Form 1099-INT (interest earned or paid)
Cat. No. 10231X
· 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)
· Form 1099-K (merchant card and third party network transactions)
· Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)
· Form 1099-C (canceled debt)
· 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.
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, later.
Form W-9 (Rev. 10-2018)
Form W-9 (Rev. 10-2018)
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
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
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, later, for further information.
Note: If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:
· An individual who is a U.S. citizen or U.S. resident alien;
· A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States;
· An estate (other than a foreign estate); or
· A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners' share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.
In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States.
· In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;
· In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and
· In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.
Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).
Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items.
1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the exemption from tax.
5. Sufficient facts to justify the exemption from tax under the terms of the treaty article.
Page 2
Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.
If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 24% of such payments. This is called "backup withholding." Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.
You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.
Payments you receive will be subject to backup withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the instructions for Part II for details),
3. The IRS tells the requester that you furnished an incorrect TIN,
4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or
5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information.
Also see Special rules for partnerships, earlier.
What is FATCA Reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.
Form W-9 (Rev. 10-2018)
Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Line 1
You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.
If this Form W-9 is for a joint account (other than an account maintained by a foreign financial institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9.
a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.
Note: ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.
b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or "doing business as" (DBA) name on line 2.
c. Partnership, LLC that is not a single-member LLC, C corporation, or S corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.
d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.
e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a "disregarded entity." See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, "Business name/disregarded entity name." If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.
Line 2
If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.
Line 3
Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3.
Page 3
IF the entity/person on line 1 is THEN check the box for . . . a(n) . . .
· Corporation
· Individual
· Sole proprietorship, or
· Single-member limited liability company (LLC) owned by an individual and disregarded for U.S. federal tax purposes.
Corporation
Individual/sole proprietor or singlemember LLC
· LLC treated as a partnership for U.S. federal tax purposes,
· LLC that has filed Form 8832 or 2553 to be taxed as a corporation, or
Limited liability company and enter the appropriate tax classification. (P= Partnership; C= C corporation; or S= S corporation)
· LLC that is disregarded as an entity separate from its owner but the owner is another LLC that is not disregarded for U.S. federal tax purposes.
· Partnership · Trust/estate
Partnership Trust/estate
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you.
Exempt payee code.
· Generally, individuals (including sole proprietors) are not exempt from backup withholding.
· Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.
· Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.
· Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC.
The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4.
1--An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)
2--The United States or any of its agencies or instrumentalities
3--A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities
4--A foreign government or any of its political subdivisions, agencies, or instrumentalities
5--A corporation
6--A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession
7--A futures commission merchant registered with the Commodity Futures Trading Commission
8--A real estate investment trust
9--An entity registered at all times during the tax year under the Investment Company Act of 1940
10--A common trust fund operated by a bank under section 584(a)
11--A financial institution
12--A middleman known in the investment community as a nominee or custodian
13--A trust exempt from tax under section 664 or described in section 4947
Form W-9 (Rev. 10-2018)
The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.
IF the payment is for . . .
THEN the payment is exempt for . . .
Interest and dividend payments
All exempt payees except for 7
Broker transactions
Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012.
Barter exchange transactions and Exempt payees 1 through 4 patronage dividends
Payments over $600 required to be Generally, exempt payees
reported and direct sales over $5,0001
1 through 52
Payments made in settlement of Exempt payees 1 through 4 payment card or third party network transactions
1 See Form 1099-MISC, Miscellaneous Income, and its instructions.
2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with "Not Applicable" (or any similar indication) written or printed on the line for a FATCA exemption code.
A--An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)
B--The United States or any of its agencies or instrumentalities
C--A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities
D--A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)
E--A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i)
F--A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state
G--A real estate investment trust
H--A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940
I--A common trust fund as defined in section 584(a)
J--A bank as defined in section 581
K--A broker
L--A trust exempt from tax under section 664 or described in section 4947(a)(1)
Page 4
M--A tax exempt trust under a section 403(b) plan or section 457(g) plan
Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.
Line 5
Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns. If this address differs from the one the requester already has on file, write NEW at the top. If a new address is provided, there is still a chance the old address will be used until the payor changes your address in their records.
Line 6
Enter your city, state, and ZIP code.
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN.
If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner's SSN (or EIN, if the owner has one). Do not enter the disregarded entity's EIN. If the LLC is classified as a corporation or partnership, enter the entity's EIN.
Note: See What Name and Number To Give the Requester, later, for further clarification of name and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.SSA.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/Businesses and clicking on Employer Identification Number (EIN) under Starting a Business. Go to www.irs.gov/Forms to view, download, or print Form W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or SS-4 mailed to you within 10 business days.
If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write "Applied For" in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.
Note: Entering "Applied For" means that you have already applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, 4, or 5 below indicates otherwise.
For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code, earlier.
Signature requirements. Complete the certification as indicated in items 1 through 5 below.
Form W-9 (Rev. 10-2018)
1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.
2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.
3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. "Other payments" include payments made in the course of the requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), ABLE accounts (under section 529A), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account: 1. Individual 2. Two or more individuals (joint
account) other than an account maintained by an FFI
3. Two or more U.S. persons (joint account maintained by an FFI)
Give name and SSN of: The individual
The actual owner of the account or, if combined funds, the first individual on the account1
Each holder of the account
4. Custodial account of a minor (Uniform Gift to Minors Act)
5. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law
The minor2 The grantor-trustee1 The actual owner1
6. Sole proprietorship or disregarded entity owned by an individual
The owner3
7. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i) (A))
For this type of account: 8. Disregarded entity not owned by an
individual
9. A valid trust, estate, or pension trust
The grantor*
Give name and EIN of: The owner Legal entity4
10. Corporation or LLC electing corporate status on Form 8832 or Form 2553
The corporation
11. Association, club, religious,
The organization
charitable, educational, or other tax-
exempt organization
12. Partnership or multi-member LLC 13. A broker or registered nominee
The partnership The broker or nominee
Page 5
For this type of account:
14. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments
Give name and EIN of: The public entity
15. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i)(B))
The trust
1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person's number must be furnished.
2 Circle the minor's name and furnish the minor's SSN.
3 You must show your individual name and you may also enter your business or DBA name on the "Business name/disregarded entity" name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.
4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships, earlier.
*Note: The grantor also must provide a Form W-9 to trustee of trust.
Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.
Secure Your Tax Records From Identity Theft
Identity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.
To reduce your risk:
· Protect your SSN,
· Ensure your employer is protecting your SSN, and
· Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.
For more information, see Pub. 5027, Identity Theft Information for Taxpayers.
Victims of identity theft who are experiencing economic harm or a systemic problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.
Form W-9 (Rev. 10-2018)
The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at spam@uce.gov or report them at www.ftc.gov/complaint. You can contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338). If you have been the victim of identity theft, see www.IdentityTheft.gov and Pub. 5027.
Visit www.irs.gov/IdentityTheft to learn more about identity theft and how to reduce your risk.
Page 6
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.
Form W-8BEN
(Rev. July 2017)
Department of the Treasury Internal Revenue Service
Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals)
a For use by individuals. Entities must use Form W-8BEN-E. a Go to www.irs.gov/FormW8BEN for instructions and the latest information.
a Give this form to the withholding agent or payer. Do not send to the IRS.
OMB No. 1545-1621
Do NOT use this form if:
Instead, use Form:
· You are NOT an individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8BEN-E
· You are a U.S. citizen or other U.S. person, including a resident alien individual . . . . . . . . . . . . . . . . . . . W-9
· You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S. (other than personal services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8ECI
· You are a beneficial owner who is receiving compensation for personal services performed in the United States . . . . . . . 8233 or W-4
· You are a person acting as an intermediary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . W-8IMY
Note: If you are resident in a FATCA partner jurisdiction (i.e., a Model 1 IGA jurisdiction with reciprocity), certain tax account information may be provided to your jurisdiction of residence.
Part I Identification of Beneficial Owner (see instructions)
1 Name of individual who is the beneficial owner
2 Country of citizenship
3 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.
City or town, state or province. Include postal code where appropriate.
Country
4 Mailing address (if different from above)
City or town, state or province. Include postal code where appropriate.
Country
5 U.S. taxpayer identification number (SSN or ITIN), if required (see instructions)
6 Foreign tax identifying number (see instructions)
7 Reference number(s) (see instructions)
8 Date of birth (MM-DD-YYYY) (see instructions)
Part II Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)
9 I certify that the beneficial owner is a resident of
within the meaning of the income tax
treaty between the United States and that country.
10 Special rates and conditions (if applicable--see instructions): The beneficial owner is claiming the provisions of Article and paragraph
of the treaty identified on line 9 above to claim a
% rate of withholding on (specify type of income):
.
Explain the additional conditions in the Article and paragraph the beneficial owner meets to be eligible for the rate of withholding:
Part III Certification
Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that:
· I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income to which this form relates or am using this form to document myself for chapter 4 purposes,
· The person named on line 1 of this form is not a U.S. person, · The income to which this form relates is:
(a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is not subject to tax under an applicable income tax treaty, or (c) the partner's share of a partnership's effectively connected income,
· The person named on line 1 of this form is a resident of the treaty country listed on line 9 of the form (if any) within the meaning of the income tax treaty between the United States and that country, and
· For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner. I agree that I will submit a new form within 30 days if any certification made on this form becomes incorrect.
F
Sign Here
Signature of beneficial owner (or individual authorized to sign for beneficial owner)
Date (MM-DD-YYYY)
Print name of signer For Paperwork Reduction Act Notice, see separate instructions.
Capacity in which acting (if form is not signed by beneficial owner)
Cat. No. 25047Z
Form W-8BEN (Rev. 7-2017)
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