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Historic Resource Development Program Grant Application_Mines of SpainMasterpiece on the Mississippi Dubuque httil All-America i r 2007 TO: The Honorable Mayor and City Council Members FROM: Michael C. Van Milligen, City Manager SUBJECT: Historic Resource Development Program Grant Application for Mines of Spain Timeline Exhibit DATE: April 28, 2010 Planning Services Manager Laura Carstens recommends City Council approval of a Resolution and a $20,500 grant application to the State Historical Society of Iowa for Historic Resource Development Program (HRDP) grant funds for the Mines of Spain Interactive Multi -Media Timeline Exhibit. The local match of $20,000 will come from a $150,000 federal grant the City has received for the Mines of Spain Exhibit and Education Program. I concur with the recommendation and respectfully request Mayor and City Council approval. MCVM:jh Attachment cc: Barry Lindahl, City Attorney Cindy Steinhauser, Assistant City Manager Laura Carstens, Planning Services Manager Michael C. Van Milligen Masterpiece on the Mississippi TO: Michael Van Milligen, City Manager FROM: Laura Carstens, Planning Services Manager 'i SUBJECT: HRDP Grant Application for Mines of Spain Timeline Exhibit DATE: April 27, 2010 Dubuque kiftd All-America lfty I 2007 Introduction This memo transmits a resolution and a grant application to the State Historical Society of Iowa for Historic Resource Development Program (HRDP) grant funds for the Mines of Spain Interactive Multi -Media Timeline Exhibit, for City Council approval. The exhibit will be installed in the expanded E.B. Lyons Interpretive Center at the Mines of Spain. Discussion The Mines of Spain is owned and managed by the Iowa DNR. The E.B. Lyons Interpretive Center, owned by the City of Dubuque, serves as a visitor information center and park office. The Interpretive Center has artifacts on display interpreting the park's historical sites of farming, prairies, lead mining, Native Americans and wildlife. These displays are being updated in 2010. The Interactive Multi -Media Timeline will provide a dynamic exhibit that conveys the geology and human occupation of the Mines of Spain. This dual timeline will trace the geologic course of the park on one side, and cultural history on the other side. The exhibit will include a clear acrylic case with artifacts from prehistoric people, Native Americans, lead mining, early settlement, and the park today. Four interactive touch screens on each side will allow the visitor to learn more about the objects in the case, and the history of the Mines of Spain. Budget Impact The estimated project cost is $40,500. The HRDP grant request is for $20,500. The local match of $20,000 will come from a $150,000 federal grant the City has received for the Mines of Spain Exhibit and Education Program. Recommendation I recommend that the City Council approve the enclosed resolution and HRDP grant application, and authorize the Mayor to sign them on behalf of the City of Dubuque. Enclosures F: \USERS \LCARSTEN \WP\Mines of Spain \HRDP Mines of Spain Exhibits \HRDP Grant MOS Exhibits Memo MVM.doc Prepared by: Laura Carstens, City Planner Address: City Hall, 50 W. 13th Street Telephone: 589 -4210 RESOLUTION NO. 125-10 RESOLUTION AUTHORIZING GRANT APPLICATION FOR HRDP FUNDS FOR MINES OF SPAIN INTERACTIVE MULTI -MEDIA TIMELINE EXHIBIT Whereas, the State Historical Society of Iowa has Historic Resource Development Program (HRDP) grant funds available for the preservation and interpretation of Iowa's historic and cultural resources; and Whereas, the City of Dubuque has an adopted Comprehensive Plan with goals and objectives for the preservation and interpretation of the community's historic and cultural resources; and Whereas, the City of Dubuque owns the E. B. Lyons Interpretive Center at the Mines of Spain, which includes exhibits for interpretation of the park's historic and cultural resources. NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF DUBUQUE, IOWA: Section 1. That the Mayor is hereby authorized to sign the grant application for HRDP funds to create the Mines of Spain Interactive Multi -Media Timeline Exhibit. Section 2. That the City of Dubuque agrees to abide by all local, state, and federal requirements applicable to the proposed project. Attest: Passed, approved and adopted this 3rd day of May, 201 . �, /ice_ eanne F. Schneider, City Clerk F: \USERS \LCARSTEN \WP\Mines of Spain \HRDP Mines of Spain Exhibits \HRDP MOS Exhibits Res.doc G Roy D. Buol, Mayor STATE HISTORICAL SOCIETY OF IOWA FY2011 REAP /HRDP Grants Documentary Collections Part 1: Application Cover Sheet Applicant Section Name of Applicant: Individual Business House: 27 & 28 City of Dubuque Name & Title of Contact Person: Laura Carstens, Planning Services Manager Address: Planning Services Department, 50 W. 13 St. City : Dubuque State: I� A� Zip: 52001 Email Address: _ Icarsten(a citvofdubuque.orq Telephone (daytime) : _(563) 589 - 4210 Type of Applicant: Nonprofit corporation; unit of government; or American Indian tribe Applicant Profile: The city of Dubuque is located on the Mississippi River in northeastern Iowa. The city is approximately 30 square miles in area, with a population of approximately 60,000 persons. The City's annual operating and capital budget is nearly $100 million and funds a full range of services, including historic preservation and arts & culture. The City owns the E.B. Lyons Interpretive Center at the Mines of Spain. Project Section Project Title: Mines of Spain Interactive Multi -Media Timeline Project Category Documentary Collections Project Summary: The project is to develop an educational and interpretive program using a dynamic interactive timeline exhibit that conveys the geology and human occupation of the Mines of Spain. This dual timeline will trace the geologic course of the park on one side, and cultural history on the other side. County where project is located: Dubuque Iowa General Assembly /Legislative District Numbers: U.S. Congressional District: 1 Senate: 14 Ownership Section Does the Applicant own the historic resource? x Yes No If the applicant does not own the historic resource, the following information is required: Name of Owner: Address: City: State: Zip: Email Address: Telephone (daytime): I give my permission for the applicant to carry out the project described in this REAP /HRDP grant application. Signature of Owner: Date: Public Access Does the public have access to the historical resource? x Yes No If yes, how is the historical resource made accessible to the public? (what are your hours of operation? Is it visible from a public street? Is it available to view by appointment?)_ The Mines of Spain is open year- round, from 4 a.m. to 10:30 p.m. The E.B. Lyons Interpretive Center is open year- round. It is open Monday - Friday from October - April with limited hours. During the summer season, April — October, the center is open 7 days a week. Summer hours are 8 a.m. to 4 p.m. Monday - Friday and noon to 4:30 p.m. on weekends. If no, how do you plan to make the historical resource accessible to the public to meet our guidelines? Is there a reason that the historical resource cannot be made accessible to the public? STATE HISTORICAL SOCIETY OF IOWA FY2011 REAP /HRDP Grants PART 2: Project Description and Specific Project Scope of Work Project Description: Within your discussion, be sure to (1) specifically identify the historical resource and state its significance; (2) provide an overview of the activities you will complete; and (3) explain how the proposed actions will assist the historical resource. Describe how the project will have an impact on the local community (neighborhood, town, region, or however you choose to define that community). Historical Resource & Significance: The Mines of Spain State Recreation Area consists of 1,387 acres of forest and prairie along the Mississippi River in Dubuque County near the city of Dubuque that is owned and managed by the Iowa DNR. The E.B. Lyons Interpretive Center serves as a visitor information center and park office. The Interpretive Center, which is owned by the City of Dubuque, has displays on the park's historical sites of farming, prairies, lead mining, Native Americans and wildlife. These displays are being updated in conjunction with an expansion of the Interpretive Center. Trails connect visitors to a farm site, forests, prairies, archeological sites, and wetlands. The Mines of Spain Area Rural Community Archeological District, Lead Mining Community Archeological District, and Prehistoric District, and the Dubuque Trading Post -- Village of Kettle Chief Archeological District were listed in the National Register of Historic Places in 1988. In 1993, the Mines of Spain was designated as a National Historic Landmark. The Mines of Spain Recreation Area was designated in 2005 as a Silos and Smokestacks National Heritage Area site. The Julien Dubuque Monument, built in 1897 on the site where Dubuque was buried, sits high above the Mississippi River and provides the "landmark" for the Mines of Spain. The Julien Dubuque Monument, owned by the State of Iowa, was listed in the National Register in 1988. It was protected as a City Landmark in 1993. Project Overview: The Interactive Multi -Media Timeline project will provide an educational and interpretive program using a dynamic interactive timeline exhibit that conveys the geology and human occupation of the Mines of Spain. It will offer visitors an interpretive media and object -based exhibit that is both engaging and educational. This dual timeline will trace the geologic course of the park on one side, and cultural history on the other side. The exhibit will include a clear acrylic case with artifacts from prehistoric people, Native Americans, lead mining, early settlement, and the park today. Four interactive touch screens on each side will allow the visitor to learn more about the objects in the case, and the history of the Mines of Spain. Lighting will be used to highlight the artifacts, and interactive media programming will aid in telling the story of the area. It's imagined as an exhibit that conveys high -end interpretation of the Mines of Spain and the local region by using an installation of objects that are evocative of the rich cultural, geological, and natural history alongside a four - screen, touch - activated dynamic media experience. There, visitors can "drill down" and discover the content and educational storyline, all of which is tied to a chronological interpretation of the region. Artifacts from the Mines of Spain collection will be used in the Interactive Multi -Media Timeline. Project Impact: There is no exhibit or facility in the local or regional museums or interpretive centers that tells this story of where Iowa's history began. This Interactive Multi -Media Timeline exhibit will help people understand the unique geologic history of this area and the complex cultural history of the Mines of Spain. Its unique interactive storylines about Dubuque's natural and cultural history will be accessible to visitors of all ages. The exhibit will be open free to the public when the park's Interpretive Center is open throughout the year. The exhibit will allow us to increase the number and kind of programs that are provided to the public and to schools and other youth organizations about the geologic and cultural history of the Dubuque area. The grant would also increase the number of schools utilizing the park for field trips since we will be able to provide new and higher level of interpretation and education for them. More and different programs would also increase the park's visitation and attendance to the center. Using this same format, continue on additional sheets as necessary. Specific Project Scope of Work: This section is a critical part of the application. Provide a step -by- step description of how the project will be carried out. Each major work element should clearly relate to budget line items. Include a timeline for each major work element. Interpretive displays about the Mines of Spain's natural, historic, and cultural resources are being updated in conjunction with an expansion of the E.B. Lyons Interpretive Center at the Mines of Spain. Experience Design, out of Boston, Massachusetts, is the exhibit design firm hired to update these displays and develop the new exhibit and educational program at the Mines of Spain. Experience Design has created exhibits at museums and interpretive centers across the country. Experience Design has indicated that development of the Interactive Multi -Media Timeline Exhibit involves the following steps: 1. Media design July 2010 2. Media production August 2010 3. Media hardware September 2010 4. Case October 2010 5. Exhibit cabinetry November 2010 Experience Design will install the Interactive Multi -Media Timeline Exhibit. Artifacts from the Mines of Spain collection will be used in the Interactive Multi -Media Timeline. Using this same format, attach additional sheets as necessary. STATE HISTORICAL SOCIETY OF IOWA FY2011 REAP /HRDP Grants PART 2, continued: Digitization Projects If your project involves digitization or scanning, please consider and answer the following questions. If your project does not involve digitization or scanning, please move on to Part 3: Budget Form. 1. What standards are being followed for digitization? 2. How will the digital masters be protected and preserved? 3. How have you provided for long -term enduring access to the digital files and metadata? Possibilities include a combination of refreshing the data, migrating it to a new environment, and replication. Using this same format, continue on additional sheets as necessary. PROJECTED COSTS REAP /HRDP GRANT REQUEST APPLICANT'S MATCH CASH IN -KIND ROW TOTALS Media design $ 1,500 $ 1,500 $ 3,000 Media production $ 5,000 $ 5,000 $10,000 Media hardware $ 7,500 $ 7,500 $15,000 Case $ 3,500 $ 3,500 $ 7,000 Exhibit cabinetry $ 2,500 $ 2,500 $ 5,000 TAN* $500 $500 STATE HISTORICAL SOCIETY OF IOWA FY2011 REAP /HRDP Grants Part 3: Budget Form $20,500 REAP /HRDP GRANT Cash In -Kind $20,000 $ APPLICANT MATCH $40,500 TOTAL PROJECT COST *A $500 line is provided for TAN (Technical Advisory Network). It is included as part of your grant, should the need for technical assistance arise during the project. If the $500 is not used for TAN during the project, the $500 reverts to the State Historical Society and shall not be used to fund another portion of your project. Please include this line and document match for it even if you do not foresee using it. Matching requirements for each one dollar of grant request are as follows: Units of govt., tribes, & non - profit corporations — fifty cents, of which at least twenty -five cents must be in cash. Individuals — seventy -five cents, of which at least fifty cents must be in cash. Businesses — one dollar, of which at least seventy -five cents must be in cash. For further explanation please see MATCHING FUNDS in the grant guidelines. Part 3, continued: Budget Explanation Part 4: Photographs Attach Labeled Photographs on Separate Sheet Part 5: Minority Impact Statement Pursuant to 2008 Iowa Acts, HF 2393, Iowa Code Section 8.11, all grant applications submitted to the State of Iowa which are due beginning January 1, 2009 shall include a Minority Impact Statement. This is the state's mechanism to require grant applicants to consider the potential impact of the grant project's proposed programs or policies on minority groups. See the following page for definitions. Please choose the statement(s) that pertains to this grant application. Complete all the information requested for the chosen statement(s). x The proposed grant project programs or policies could have a disproportionate or unique positive impact on minority persons. Describe the positive impact expected from this project: Name: Title: Indicate which group is impacted: Women x Persons with a Disability Blacks Latinos Asians Pacific Islanders American Indians Alaskan Native Americans Other ❑ The proposed grant project programs or policies could have a disproportionate or unique negative impact on minority persons. Describe the negative impact expected from this project: Present the rationale for the existence of the proposed program or Policy: Provide evidence of consultation of representatives of the minority groups impacted Indicate which group is impacted: Women Persons with a Disability Blacks Latinos Asians Pacific Islanders American Indians Alaskan Native Americans Other ❑ The proposed grant project programs or policies are not expected to have a disproportionate or unique impact on minority persons. Present the rationale for determining no impact. I hereby certify that the information on this form is complete and accurate, to the best of my knowledge: Minority Impact Questionnaire Definitions "Minority Persons ", as defined in Iowa Code Section 8.11, mean individuals who are women, persons with a disability, Blacks, Latinos, Asians or Pacific Islanders, American Indians, and Alaskan Native Americans. "Disability ", as defined in Iowa Code Section 15.102, subsection 5, paragraph "b ", subparagraph (1): b. As used in this subsection: (1) "Disability" means, with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities of the individual, a record of physical or mental impairment that substantially limits one or more of the major life activities of the individual, or being regarded as an individual with a physical or mental impairment that substantially limits one or more of the major life activities of the individual. "Disability" does not include any of the following: (a) Homosexuality or bisexuality. (b) Transvestism, transsexualism, pedophilia, exhibitionism, voyeurism, gender identity disorders not resulting from physical impairments or other sexual behavior disorders. (c) Compulsive gambling, kleptomania, or pyromania. (d) Psychoactive substance abuse disorders resulting from current illegal use of drugs. "State Agency ", as defined in Iowa Code Section 8.11, means a department, board, bureau, commission, or other agency or authority of the State of Iowa. Part 6: Contract The contract appears on the next five pages. Fill in the highlighted areas and print two copies. Then have the legally- authorized representative of the applicant sign and date both copies. We need two contracts with original signatures included with the application submittal. Contract Number: Agency: Grant Recipient: Grant Amount: Effective Dates: HISTORICAL RESOURCE DEVELOPMENT PROGRAM STATE HISTORICAL SOCIETY OF IOWA GRANT PROJECT FUNDED THROUGH THE RESOURCE ENHANCEMENT AND PROTECTION PROGRAM ACT [Number to be assigned by State]. STATE HISTORICAL SOCIETY OF IOWA City of Dubuque $ 20,500 JULY 1, 2010 — NOVEMBER 30, 2012 IDENTIFICATION OF PARTIES (Article 1.0) • This contract is entered into by and between the State Historical Society of Iowa (hereafter referred to as "State" or "SHSI ") and City of Dubuque (hereafter referred to as "Grantee "). • The SHSI Public Trust administrator or designee is the State official designated to execute any changes in the terms or conditions specified in this contract. • The Planning Services Manager is designated to execute any changes in the terms or conditions specified in this contract, on behalf of the Grantee. • "HRDP" means Historical Resource Development Program as defined in Iowa Code Chapter 303.16, and Iowa Administrative Code [223] Chapter 49. STATEMENT OF PURPOSE (Article 2.0) • The purpose of the Historical Resource Development Program is to provide grants to preserve, conserve, interpret, educate the public about and enhance the historical resources of the state. • SHSI has been designated by the Iowa General Assembly to administer REAP /HRDP, and the grantee has been approved for funding. CONTRACTUAL REQUIREMENTS (Article 3.0) • REAP /HRDP monies are to be expended according to Iowa Administrative Code [223] Chapter 49 and FY2011 grant guidelines (version published January 2010). • The Grantee must: • Give preference to Iowans and Iowa products and services in carrying out this grant. • Refrain from using REAP /HRDP funds to influence legislation or for any lobbying function. • Follow all local, state, and federal laws which bar discrimination against any employee, applicant for employment, or any person participating in a sponsored program, on the basis of race, creed, color, national origin, religion, sex, age, or physical or mental disability, and require compensation for employment at no less than minimum wage requirements, and provide safe and sanitary working conditions. These laws include, but are not limited to, Title VI and VII of the Civil Rights Act of 1964, as amended, and the Rehabilitation Act of 1973, as amended. • Comply with applicable Americans with Disabilities Act (ADA) provisions. ADA is a civil rights law that prohibits discrimination on the basis of physical or mental impairment (the definition of disability). The project must comply with ADA, unless (1) the property is a religious entity, a private club or private residence and not used as a place of public accommodation; (2) the property is an owner - occupied bed -and- breakfast with five or fewer rooms; or (3) the repair work is something like reroofing, masonry repointing, painting or wallpapering, or changes to mechanical and electrical systems that do not affect the usability of the property. If you can make minor adjustments in your project that would eliminate barriers in a way that meets the Secretary of the Interior's Standards and Guidelines for Archeology and Historic Preservation, you should do so. If your proposed work is an alteration that affects the "primary function area" of your property, ADA accessibility standards also apply to the path from accessible parking to and through an entrance. Building owners are not required to spend more than 20%% of the total cost of altering the primary function area to make the path of travel to that area accessible. (There are also alternative requirements for those historic properties that cannot be made accessible without threatening or destroying their significance. Contact the State Historical Society if you believe this is your situation.) • Consult with the State Historical Society if your project involves any disturbance of the ground including, but not limited to, moving in any large equipment or uprooting plants. After you have consulted with the State Historical Society and the Society has given written permission for you to proceed, make sure that any excavation work at your project is carefully observed by you or your contractors. If, during construction, the project work uncovers an item or items which might be of archaeological, historical, or architectural interest - -or if important new archaeological, historical, or architectural data come to light in the project area, you must stop work immediately and notify the State Historical Society. Make reasonable efforts to avoid or minimize harm to the materials until the significance of the discovery can be determined by a professionally - qualified archaeologist. Contact the State Historical Society with any questions and for instructions. • Include the following statement in any printed lists of contributors, and in any promotions, publicity, or advertising: "This project is supported in part by the State Historical Society of Iowa, Historical Resource Development Program." • Post signs provided by the State in a conspicuous place at the project area where grant funds are used. The sign must remain in place for no less than 36 months after the contract has been completed. • Write your state legislators within thirty (30) days of receiving your signed contract to tell them about the project. Copies of the letters must be sent to Grants Manager, State Historical Society of Iowa, 600 East Locust Street, Des Moines, Iowa 50319 -0290. FINANCIAL RECORDS • Retain all financial records, reporting documents, and all other records pertinent to the HRDP program for a period of three calendar years beyond the end of the grant contract. • Provide, at no charge, and make accessible to the State and to the State Auditor's office, all books, documents, account information, facilities, 12 or other property belonging to or in use by the Grantee concerning the receipt of funds under this program. COPYRIGHT • Choose to copyright any books, publications, films, or other material developed because of grant activities, unless otherwise specified in the award notice or scope of work. The State reserves the right to borrow or use, without payment of a royalty fee, any materials developed through grant projects. PROFESSIONAL STANDARDS • Comply with all applicable federal and state laws, regulations, guidelines, and technical standards, including nationally accepted documentary collection and museum standards and the Secretary of the Interior's Standards and Guidelines for Archeology and Historic Preservation. The Secretary of the Interior's Standards and Guidelines for Archeology and Historic Preservation were published in the Federal Register on September 29, 1983, and revised in 1990. • If your project includes work on real property that is listed on or eligible for the National Register of Historic Places, you must include the following clause in all construction contracts and project specifications: "All work on this project will be done in accordance with the recommended practices as stated in the 1990 edition of The Secretary of Interior's Standards for Rehabilitating Historic Buildings." SCOPE OF WORK AND BUDGET • Follow the Scope of Work and Budget as presented in the Grant Application and as approved by the State Historical Society. DAMAGES • Hold the State harmless from damages in any action arising from the performance of work described in this contract. PHOTOGRAPHS • Provide photographs of the project work. Photographs must be taken at the beginning of the project, at various stages during work, and at the project's conclusion to document the nature of the work. Good quality, original, photographs should be mounted or printed on 8 x 11" paper. If digital photographs are submitted, please include a CD or DVD containing the images, as well as the printed copies. Along with the final report and request for reimbursement, the Grantee must provide at least five (5) color photographs of the project from its beginning to its end. FINDING OF NON - COMPLIANCE (Article 4.0) • The State may, for cause, find that the Grantee is not in compliance with the requirements of the HRDP program or the terms of this contract pursuant to Iowa Code 303.16, Iowa Administrative Code [223] Chapter 49, and published grant guidelines. At the State's discretion, remedies for non - compliance include suspension or return of HRDP grant funds. CANCELLATION DUE TO NON - APPROPRIATION (Article 5.0) • If funds anticipated for the continued fulfillment of this contract are at any time cancelled or insufficient either through the failure of the State of Iowa to appropriate funds, or through discontinuance or material alteration of the program for which funds were provided, the State shall have the right to cancel this contract without penalty by giving written notice of not less than 13 thirty (30) days documenting the lack of funding, discontinuance or program alteration. In the event of termination of this contract due to non - appropriation, discontinuance, or program alteration, the exclusive, sole, and complete remedy of the Grantee shall be payment for services rendered prior to the termination. PAYMENT (Article 6.0) • The State will issue a payment for fifty percent (50 %) of the grant at the time of award. • At the conclusion of the project, the grantee must submit documentation of all project work and all expenditures to the State. Upon approval of all project work and all documentation, the State will provide final payment of grant funds. The grantee's request for reimbursement must be submitted with documentation proving project completion, documentation of expenditure of grant funds, and documentation of cash and in -kind match, as outlined in the contract budget. • The final report provided by the Grantee must include photographs of work completed and an explanation of how the work meets the standards established in the museum, historic preservation, or documentary collections category. The final report must be made on forms supplied by the State Historical Society, and must include all information and documentation as outlined on the form. CHANGES IN OWNERSHIP (Article 7.0) If a change of ownership completion of the grant, the State. • If a change of ownership the grant, fifty (50) percent of the grant shall be • when the • of real property occurs within 24 months after the the entire amount of the grant shall be returned to occurs within 25 to 60 months after the completion of returned to the State. If the Grantee i g is a government unit or a non - profit organization, the sale of property is exempt from payback provisions sale places the property on tax rolls. • In the event of death of an individual owner, this provision shall not apply. TIME OF PERFORMANCE (Article 7.0) • All claims for HRDP funds shall be received by November 30, 2012. 14 SIGNATURES • Grant Applicants must sign and date two copies of this document as part of the REAP /HRDP FY2011 grant application process. This document becomes a legally - binding contract upon signature by the State Historical Society of Iowa's authorized representative. For the Grantee: Signature of Grant Applicant's Legally Authorized Representative Roy D. Buol, Mayor Typed Name and Title of Above Representative May 3, 2010 Date Signed by Grantee For the State: Jerome Thompson, Administrator, State Historical Society of Iowa Date Signed by State 15 Part 7: SUBSTITUTE W 9/VENDOR UPDATE FORM (Please print or type except for signature) In order for the State of Iowa to pay you the amount that is due to you and to comply with the IRS regulations on reporting these payments, we are requesting the following information. Failure to provide this information will result in withholding of payment. Box A Are you/Your Business YES NO Individual [ I ] Or Sole Proprietor [ S ] Phone 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Fax If the answer to both was no, please complete Box B If you answeredYes to either item, please provide your Social Security number (Sole Proprietors may enter their EIN, however, the IRS prefers you use your SSN): SSN 1 1 1 1 L_LJ 1 1 1 1 1 OR EIN LJ 1 1 1 1 1 1 1 1 AND Complete the name and address below Last Name 1111111111111111 First Name 11111 11111111111 Doing Business as 11111111111111111 1 1 I I 1 1 11 Address: 1 1 1 1 i 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Address: H I I I I I I I I I I I I I I I I I I I I I H City: I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 State: Zip: J 1 1 1 1 1 1 -1 1 1 1 Box B Is your business Corporation Partnership Estate or Trust Government Other Please Explain Please provided us with your Federal Employer Identification Number: LJJ 11111111 Phone: Fax : From Dept. Contact Phone #: [C] [P1 [E] [G] AND Complete the Name and Address below: Firm: YES NO I J o m I g LJustness [ I I I as: 1 1 1 1 1 1 I I I I I 1 1 1 11 IAo IJI ess I I I I I I I I I I I I I I I I I I I I 1 try 1 : 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1111111111111111 1 1 1 . State: Zip: J 1 1 1 1 1 1 1 1 1 1 1 Certification Must Be Signed By Vendor 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 subjected 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. Signature Date For Office Use Only (Refer to Procedure 270.450 for more details) Add 0 Change (Include vendor code and changes only Delete Reason 33