HomeMy WebLinkAboutAG 21-061 - CRISIS CONNECTIONSRETURN TO: Brittany Julius EXT: 253-326-1227
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
ORIGINATING DEPT./DIV: CD/CS
2. ORIGINATING STAFF PERSON: Brittany Julius
EXT: 253-326-1227 3. DATE REQ. BY:
TYPE OF DOCUMENT (CHECK ONE):
❑ CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ)
❑ PUBLIC WORKS CONTRACT ❑ SMALL OR LIMITED PUBLIC WORKS CONTRACT
A PROFESSIONAL SERVICE AGREEMENT ❑ MAINTENANCE AGREEMENT
❑ GOODS AND SERVICE AGREEMENT A HUMAN SERVICES / CDBG
❑ REAL ESTATE DOCUMENT ❑ SECURITY DOCUMENT (E.G. BOND RELATED DOCUMENTS)
❑ ORDINANCE ❑ RESOLUTION
❑ CONTRACT AMENDMENT (AG#): ❑ INTERLOCAL
❑ OTHER
5. PROJECT NAME: King county 2-1-1
6. NAME OF CONTRACTOR: Crisis Connections
ADDRESS: 2901 3rd Avenue, Ste 100, Seattle, WA 98121
TELEPHONE (206) 333-8720
FAX:
SIGNATURE NAME: Lauren Rlgalt TITLE
EXHIBITS AND ATTACHMENTS: A SCOPE, WORK OR SERVICES A COMPENSATION X INSURANCE REQUIREMENTS/CERTIFICATE m ALL
OTHER REFERENCED EXHIBITS N PROOF OF AUTHORITY TO SIGN ❑ REQUIRED LICENSES ❑ PRIOR CONTRACT/AMENDMENTS
8, TERM: COMMENCEMENT DATE: January 1, 2021
COMPLETION DATE: December 31, 2022
9. TOTAL COMPENSATION $ 8,000.00 (INCLUDE EXPENSES AND SALES TAX, IF ANY)
(IF CALCULATED ON HOURLY LABOR CHARGE - ATTACH SCHEDULES OF EMPLOYEES TITLES AND HOLIDAY RATES)
REIMBURSABLE EXPENSE: ❑ YES ❑ NO IF YES, MAXIMUM DOLLAR AMOUNT: $
IS SALES TAX OWED ®YES ONO IF YES, $ PAID BY: ❑ CONTRACTOR ❑ CITY
RETAINAGE: RETAINAGE AMOUNT:
❑ RETAINAGE AGREEMENT (SEE CONTRACT) OR ❑ RETAINAGE BOND PROVIDED
❑ PURCHASING: PLEASE CHARGE TO: 001-7300-083-562-10-410
10. DOCUMENT/CONTRACT REVIEW
❑ PROJECTMANAGER
❑ DIRECTOR
❑ RISK MANAGEMENT (IF APPLICABLE)
® LAW
11. COUNCIL APPROVAL (IF APPLICABLE)
12.
CONTRACT SIGNATURE ROUTING
INITIAL / DATE REVIEWED
SJB 03/04/2021
DK 02-22-2021
COMMITTEE APPROVAL DATE: 11/10/2020
INITIAL / DATE APPROVED
COUNCIL APPROVAL DATE: 11/17/2020
❑ SENT TO VENDOR/CONTRACTOR DATE SENT: DATE REC'D:
❑ ATTACH: SIGNATURE AUTHORITY, INSURANCE CERTIFICATE, LICENSES, EXHIBITS
❑ CREATE ELECTRONIC REMINDER/NOTIFICATION FOR 1 MONTH PRIOR TO EXPIRATION DATE
(Include dept. support staff if necessary and feel free to set notification more than a month in advance if council approval is needed.)
INITIAL / DATE SIGNED
t�AADEPARTMENT y 13 2IATORY (MAYOR OR DIRECTOR)
fXCITY CLERK
❑ ASSIGNED AG# Ala# w"
COMMENTS:
DK: Performance measure should be specified up front, if possible.
-T,
CITY OF CITY HALL
Federal Wa Feder 8th Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
wwwWyoflederahmy com
HUMAN SERVICES AGREEMENT
FOR
KING COUNTY — 2-1-1
This Human Services Agreement ("Agreement") is made between the City of Federal Way, a Washington
municipal corporation ("City"), and Crisis Connections, Washington public benefit corporation ("Agency"). The
City and Agency (together "Parties") are located and do business at the below addresses which shall be valid for
any notice required under this Agreement:
CRISIS CONNECTIONS:
Lauren Rigert
2901 Yd Avenue, Ste 100
Seattle, WA 98121
(206) 333-8720 (telephone)
The Parties agree as follows:
CITY OF FEDERAL WAY:
Brittany Julius
33325 8th Ave. S.
Federal Way, WA 98003-6325
(253) 835-2651 (telephone)
.com
1. TERM. The term of this Agreement shall be for a period commencing on January 1, 2021 and terminating on
December 31, 2022 ("Term"). Funding for the second year of the Agreement is contingent upon satisfactory Agreement
performance during the first year of the Agreement term and upon funding availability. This Agreement may be extended
for additional periods of time upon the mutual written agreement of the City and the Agency.
2. SERVICES. The Agency shall perform the services more specifically described in Exhibit A, attached hereto and
incorporated by this reference ("Services"), in a manner consistent with the accepted professional practices for other similar
services within the Puget Sound region in effect at the time those services are performed to the City's satisfaction, within
the time period prescribed by the City and pursuant to the direction of the Mayor or his or her designee. The Agency warrants
that it has the requisite training, skill, and experience necessary to provide the Services and is appropriately accredited and
licensed by all applicable agencies and governmental entities, including but not limited to obtaining a City of Federal Way
business registration. Services shall begin immediately upon the effective date of this Agreement. Services shall be subject,
at all times, to inspection by and approval of the City, but the making (or failure or delay in making) such inspection or
approval shall not relieve the Agency of responsibility for performance of the Services in accordance with this Agreement,
notwithstanding the City's knowledge of defective or non -complying performance, its substantiality or the ease of its
discovery.
3. TERMINATION. Either party may terminate this Agreement, with or without cause, upon providing the other
party thirty (30) days' written notice at its address set forth above. The City may terminate this Agreement immediately if
the Agency fails to maintain required insurance, breaches confidentiality, or materially violates Section 12, and such may
result in ineligibility for further City agreements.
4. COMPENSATION.
4.1 Amount. In return for the Services, the City shall pay the Agency an amount not to exceed a maximum
amount and according to a rate or method as delineated in Exhibit B, attached hereto and incorporated by this reference.
The City shall reimburse the Agency only for the approved activities and in accordance with the procedures as specified in
Exhibit B. The Agency shall be solely responsible for the payment of any taxes imposed by any lawful jurisdiction resulting
from this Agreement.
4.2 Method of Payment. On a quarterly basis, the Agency shall submit to the City an invoice for payment on a
form provided by the City and all reports as required by this Agreement. Payment shall be made on a quarterly basis by the
HUMAN SERVICES AGREEMENT - 1 - 12/2020
CITY of CITY HALL
Federal Way Feder 8th Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
www. cityoffedera/way com
City only after the Services have been performed and within forty-five (45) days after the City's receipt and approval of a
complete and correct invoice and reports. The City will use the quantity of Services actually delivered, as reported on the
Agency's reports, as a measure of satisfactory performance under this Agreement. The City shall review the Agency's
reports to monitor compliance with the performance measures set forth in Exhibit A. Should the Agency fail to meet the
performance measures for each quarter, the City reserves the right to adjust payments on a pro rata basis at any time during
the term of this Agreement. Exceptions may be made at the discretion of the City's Human Services Manager in cases where
circumstances beyond the Agency's control impact its ability to meet its service unit goals and the Agency has shown
reasonable efforts to overcome these circumstances to meet its goals. If the City objects to all or any portion of the invoice,
it shall notify the Agency and reserves the option to pay only that portion of the invoice not in dispute. In that event, the
Parties will immediately make every effort to settle the disputed portion.
4.3 Final Invoice. The Agency shall submit its final invoice by the date indicated on Exhibit B. If the Agency's
final invoice and reports are not submitted by the last date specified in Exhibit B, the City shall be relieved of all liability
for payment to the Agency of the amounts set forth in said invoice or any subsequent invoice; provided, however, that the
City may elect to pay any invoice that is not submitted in a timely manner.
4.4 Non-Agprapriation of Funds. If sufficient funds are not appropriated or allocated for payment under this
Agreement for any future fiscal period, the City will not be obligated to make payments for Services or amounts incurred
after the end of the current fiscal period, and this Agreement will terminate upon the completion of all remaining Services
for which funds are allocated. No penalty or expense shall accrue to the City in the event this provision applies.
5. INDEMNIFICATION.
5.1 Agency Indemnification. The Agency agrees to release, indemnify, defend, and hold the City, its elected
officials, officers, employees, agents, representatives, insurers, attorneys, and volunteers harmless from any and all claims,
demands, actions, suits, causes of action, arbitrations, mediations, proceedings, judgments, awards, injuries, damages,
liabilities, taxes, losses, fines, fees, penalties expenses, attorney's fees, costs, and/or litigation expenses to or by any and all
persons or entities, including, without limitation, their respective agents, licensees, or representatives arising from, resulting
from, or in connection with this Agreement or the performance of this Agreement, except for that portion of the claims
caused by the City's sole negligence. Should a court of competent jurisdiction determine that this Agreement is subject to
RCW 4.24.115, then, in the event of liability for damages arising out of bodily injury to persons or damages to property
caused by or resulting from the concurrent negligence of the Agency and the City, the Agency's liability hereunder shall be
only to the extent of the Agency's negligence. Agency shall ensure that each subcontractor shall agree to defend and
indemnify the City, its elected officials, officers, employees, agents, representatives, insurers, attorneys, and volunteers to
the extent and on the same terms and conditions as the Agency pursuant to this paragraph. The City's inspection or
acceptance of any of Agency's work when completed shall not be grounds to avoid any of these covenants of
indemnification.
5.2 Industrial Insurance Act Waiver. It is specifically and expressly understood that the Agency waives any
immunity that may be granted to it under the Washington State industrial insurance act, Title 51 RCW, solely for the
purposes of this indemnification. Agency's indemnification shall not be limited in any way by any limitation on the amount
of damages, compensation or benefits payable to or by any third party under workers' compensation acts, disability benefit
acts or any other benefits acts or programs. The Parties further acknowledge that they have mutually negotiated this waiver.
5.3 City Indemnification. The City agrees to release, indemnify, defend and hold the Agency, its officers,
directors, shareholders, partners, employees, agents, representatives, and subcontractors harmless from any and all claims,
demands, actions, suits, causes of action, arbitrations, mediations, proceedings, judgments, awards, injuries, damages,
liabilities, losses, fines, fees, penalties expenses, attorney's fees, costs, and/or litigation expenses to or by any and all persons
or entities, including without limitation, their respective agents, licensees, or representatives, arising from, resulting from
or connected with this Agreement to the extent solely caused by the negligent acts, errors, or omissions of the City.
5.4 Survival. The provisions of this Section shall survive the expiration or termination of this Agreement with
respect to any event occurring prior to such expiration or termination.
HUMAN SERVICES AGREEMENT - 2 - 12/2020
CITY OF
�� Federal Way
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
www otyoffederalway com
6. INSURANCE. The Agency agrees to carry insurance for liability which may arise from or in connection with the
performance of the services or work by the Agency, their agents, representatives, employees or subcontractors for the
duration of the Agreement and thereafter with respect to any event occurring prior to such expiration or termination as
follows:
6.1. Minimum Limits. The Agency agrees to carry as a minimum, the following insurance, in such forms and
with such carriers who have a rating that is satisfactory to the City:
a. Commercial general liability insurance covering liability arising from premises, operations,
independent contractors, products -completed operations, stop gap liability, personal injury, bodily injury, death, property
damage, products liability, advertising injury, and liability assumed under an insured contract with limits no less than
$1,000,000 for each occurrence and $2,000,000 general aggregate.
b. Workers' compensation and employer's liability insurance in amounts sufficient pursuant to the
laws of the State of Washington;
C. Automobile liability insurance covering all owned, non -owned, hired and leased vehicles with a
minimum combined single limits in the minimum amounts required to drive under Washington State law per accident for
bodily injury, including personal injury or death, and property damage.
6.2. No Limit of Liability. Agency's maintenance of insurance as required by the agreement shall not be
construed to limit the liability of the Agency to the coverage provided by such insurance, or otherwise limit the City's
recourse to any remedy available at law or in equity. The Agency's insurance coverage shall be primary insurance as
respect the City. Any insurance, self-insurance, or insurance pool coverage maintained by the City shall be excess of the
Agency's insurance and shall not contribute with it.
6.3. Additional Insured, Verification. The City shall be named as additional insured on all commercial general
liability insurance policies. Concurrent with the execution of this Agreement, Agency shall provide certificates of
insurance for all commercial general liability policies attached hereto as Exhibit C and incorporated by this reference. At
the City's request, Agency shall furnish the City with copies of all insurance policies and with evidence of payment of
premiums or fees of such policies. If Agency's insurance policies are "claims made," Agency shall be required to
maintain tail coverage for a minimum period of three (3) years from the date this Agreement is actually terminated or
upon project completion and acceptance by the City.
6.4 Survival. The provisions of this Section shall survive the expiration or termination of this Agreement.
7. CONFIDENTIALITY. All information regarding the City obtained by Agency in performance of this Agreement
shall be considered confidential subject to applicable laws. Breach of confidentiality by the Agency may be grounds for
immediate termination. All records submitted by the City to the Agency will be safeguarded by the Agency. The Agency
will fully cooperate with the City in identifying, assembling, and providing records in case of any public records disclosure
request.
8. WORK PRODUCT. All originals and copies of work product, including plans, sketches, layouts, designs, design
specifications, records, files, computer disks, magnetic media or material which may be produced or modified by Agency
while performing the Services shall belong to the City upon delivery. The Agency shall make such data, documents, and
files available to the City and shall deliver all needed or contracted for work product upon the City's request. At the
expiration or termination of this Agreement all originals and copies of any such work product remaining in the possession
of Agency shall be delivered to the City.
9. BOOKS AND RECORDS. The Agency agrees to maintain books, records, and documents which sufficiently and
properly reflect all direct and indirect costs related to the performance of the Services and maintain such accounting
procedures and practices as may be deemed necessary by the City to assure proper accounting of all funds paid pursuant to
this Agreement. These records shall be maintained for a period of six (6) years after the termination of this Agreement and
may be subject, at all reasonable times, to inspection, review or audit by the City, its authorized representative, the State
Auditor, or other governmental officials authorized by law to monitor this Agreement.
HUMAN SERVICES AGREEMENT - 3 - 12/2020
CITY OF CITY HALL
41111111 Federal Way Feder l Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
www ciryoffederelway com
10. INDEPENDENT CONTRACTOR. The Parties intend that the Agency shall be an independent contractor and
that the Agency has the ability to control and direct the performance and details of its work, the City being interested only
in the results obtained under this Agreement. The City shall be neither liable nor obligated to pay Agency sick leave, vacation
pay or any other benefit of employment, nor to pay any social security or other tax which may arise as an incident of
employment. Agency shall take all necessary precautions and shall be responsible for the safety of its employees, agents,
and subcontractors in the performance of the Services and work and shall utilize all protection necessary for that purpose.
All work shall be done at Agency's own risk, and Agency shall be responsible for any loss of or damage to materials, tools,
or other articles used or held for use in connection with the work. The Agency shall pay all income and other taxes due
except as specifically provided in Section 4. Industrial or any other insurance that is purchased for the benefit of the City,
regardless of whether such may provide a secondary or incidental benefit to the Agency, shall not be deemed to convert this
Agreement to an employment contract.
11. CONFLICT OF INTEREST. It is recognized that Agency may or will be performing services during the Term
for other parties; however, such performance of other services shall not conflict with or interfere with Agency's ability to
perform the Services. Agency agrees to resolve any such conflicts of interest in favor of the City. Agency confirms that
Agency does not have a business interest or a close family relationship with any City officer or employee who was, is, or
will be involved in the Agency's selection, negotiation, drafting, signing, administration, or evaluating the Agency's
performance.
12. EOUAL OPPORTUNITY EMPLOYER. In all services, programs, activities, hiring, and employment made
possible by or resulting from this Agreement or any subcontract, there shall be no discrimination by Agency or its
subcontractors of any level, or any of those entities' employees, agents, sub -agencies, or representatives against any person
because of sex, age (except minimum age and retirement provisions), race, color, religion, creed, national origin, marital
status, or the presence of any disability, including sensory, mental or physical handicaps, unless based upon a bona fide
occupational qualification in relationship to hiring and employment. This requirement shall apply to, but not be limited to,
the following: employment, advertising, layoff or termination, rates of pay or other forms of compensation, and selection
for training, including apprenticeship. Agency shall comply with and shall not violate any of the terms of Chapter 49.60
RCW, Title VI of the Civil Rights Act of 1964, the Americans With Disabilities Act, Section 504 of the Rehabilitation Act
of 1973, 49 CFR Part 21, 21.5 and 26, or any other applicable federal, state, or local law or regulation regarding non-
discrimination.
13. GENERAL PROVISIONS.
13.1 lnterpretation and Modification. This Agreement, together with any attached Exhibits, contains all of the
agreements of the Parties with respect to any matter covered or mentioned in this Agreement and no prior statements or
agreements, whether oral or written, shall be effective for any purpose. Should any language in any Exhibits to this
Agreement conflict with any language in this Agreement, the terms of this Agreement shall prevail. The respective captions
of the Sections of this Agreement are inserted for convenience of reference only and shall not be deemed to modify or
otherwise affect any of the provisions of this Agreement. Any provision of this Agreement that is declared invalid,
inoperative, null and void, or illegal shall in no way affect or invalidate any other provision hereof and such other provisions
shall remain in full force and effect. Any act done by either Party prior to the effective date of the Agreement that is
consistent with the authority of the Agreement and compliant with the terms of the Agreement, is hereby ratified as having
been performed under the Agreement. No provision of this Agreement, including this provision, may be amended, waived,
or modified except by written agreement signed by duly authorized representatives of the Parties.
13.2 Assignment and Beneficiaries. Neither the Agency nor the City shall have the right to transfer or assign, in
whole or in part, any or all of its obligations and rights hereunder without the prior written consent of the other Party. If the
non -assigning party gives its consent to any assignment, the terms of this Agreement shall continue in full force and effect
and no further assignment shall be made without additional written consent. Subject to the foregoing, the rights and
obligations of the Parties shall inure to the benefit of and be binding upon their respective successors in interest, heirs and
assigns. This Agreement is made and entered into for the sole protection and benefit of the Parties hereto. No other person
or entity shall have any right of action or interest in this Agreement based on any provision set forth herein.
HUMAN SERVICES AGREEMENT - 4 - 12/2020
CITY OF CITY HALL
Federa I Way Feder 8th Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
www cityoffederelpmy com
13.3 Compliance with Laws. The Agency shall comply with and perform the Services in accordance with all
applicable federal, state, local, and city laws including, without limitation, all City codes, ordinances, resolutions,
regulations, rules, standards and policies, as now existing or hereafter amended, adopted, or made effective. If a violation
of the City's Ethics Resolution No. 91-54, as amended, occurs as a result of the formation or performance of this Agreement,
this Agreement may be rendered null and void, at the City's option.
13.4 Enforcement. Time is of the essence in this Agreement and each and all of its provisions in which
performance is a factor. Adherence to completion dates set forth in the description of the Services is essential to the Agency's
performance of this Agreement. Any notices required to be given by the Parties shall be delivered at the addresses set forth
at the beginning of this Agreement. Any notices may be delivered personally to the addressee of the notice or may be
deposited in the United States mail, postage prepaid, to the address set forth above. Any notice so posted in the United States
mail shall be deemed received three (3) days after the date of mailing. Any remedies provided for under the terms of this
Agreement are not intended to be exclusive, but shall be cumulative with all other remedies available to the City at law, in
equity or by statute. The failure of the City to insist upon strict performance of any of the covenants and agreements
contained in this Agreement, or to exercise any option conferred by this Agreement in one or more instances shall not be
construed to be a waiver or relinquishment of those covenants, agreements or options, and the same shall be and remain in
full force and effect. Failure or delay of the City to declare any breach or default immediately upon occurrence shall not
waive such breach or default. Failure of the City to declare one breach or default does not act as a waiver of the City's right
to declare another breach or default. This Agreement shall be made in, governed by, and interpreted in accordance with the
laws of the State of Washington. If the Parties are unable to settle any dispute, difference or claim arising from this
Agreement, the exclusive means of resolving that dispute, difference, or claim, shall be by filing suit under the venue, rules
and jurisdiction of the King County Superior Court, King County, Washington, unless the parties agree in writing to an
alternative process. If the King County Superior Court does not have jurisdiction over such a suit, then suit may be filed in
any other appropriate court in King County, Washington. Each party consents to the personal jurisdiction of the state and
federal courts in King County, Washington and waives any objection that such courts are an inconvenient forum. If either
Party brings any claim or lawsuit arising from this Agreement, each Party shall pay all its legal costs and attorney's fees
and expenses incurred in defending or bringing such claim or lawsuit, including all appeals, in addition
to any other recovery or award provided by law; provided, however, however nothing in this paragraph shall be construed
to limit the Parties' rights to indemnification under Section 5 of this Agreement.
13.5 Execution. Each individual executing this Agreement on behalf of the City and Agency represents and
warrants that such individual is duly authorized to execute and deliver this Agreement. This Agreement may be executed in
any number of counterparts, each of which shall be deemed an original and with the same effect as if all Parties hereto had
signed the same document. All such counterparts shall be construed together and shall constitute one instrument, but in
making proof hereof it shall only be necessary to produce one such counterpart. The signature and acknowledgment pages
from such counterparts may be assembled together to form a single instrument comprised of all pages of this Agreement
and a complete set of all signature and acknowledgment pages. The date upon which the last of all of the Parties have
executed a counterpart of this Agreement shall be the "date of mutual execution" hereof.
[Signature page follows]
HUMAN SERVICES AGREEMENT - 5 - 12/2020
`Federal Wa CITY HALL
33325 8th Avenue South
Federal Way, WA 98003-6325
vAi� (253) 835-7000
www. cdWflederahmy. com
IN WITNESS, the Parties execute this Agreement below, effective the last date written below.
CITY OF FEDERAL WAY:
Jim
DATE:
CRISIS CONNECTIONS:
By: 1�
Printed Name:
Title: 5 D i r- 67 LGI�V �t-
DATE: ( []Z
STATE OF WASHINGTON )
ss.
COUNTY OF ,n }
ATTEST:
, 1 1
nCeyC C, City Cllv� k� " 61�A ,
erk OV
TO FORM:
f v r-, E-L- 9 ".
J. Ryan Call, City Attorney
-`0, STRY
c P]� go..
�1.
,;
J
On this day personally a peared before me Lut�'n /� i '..r-• to me known to be the
Cy,c � ;,« f c that executed the foregoing
instrument, and ackn� d the said instrument to be the free and voluntary act and deed of said corporation,
for the uses and purposes therein mentioned, and on oath stated that he/she was authorized to execute said
instrument and that the seal affixed, if any, is the corporate seal of said corporation.
GIVEN my hand and official seal this _ _ day of
Notary's signature
Notary's printed name
Notary Public in and for the StAte of Washington.
My commission expires 09 " 13 _Z3
HUMAN SERVICES AGREEMENT - 6 - 12/2020
CITY OF
Federal
Project Summary
CITY HALL
Way 33325 8th Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
www ct" federalway com
EXHIBIT A
SERVICES
The City of Federal Way, along with the cities of Burien, Des Moines, Renton, and Tukwila, have entered into a
Memorandum of Understanding to make the most efficient use of their resources by cooperating to provide joint
application and funding for human services. It is the City's responsibility to enter into an agreement with the
Agency on behalf of the cities which are party to said Memorandum of Understanding.
The Agency shall connect residents to available resources and services in the community by referring them to
various organizations for the cities listed below. The Agency shall ensure that services provided with funding
under this Agreement are made available to the participating cities' residents.
Performance Measures
A. Number Served
The Agency agrees to serve, at minimum, the following unduplicated number of residents by city with Human
Services funds annually:
QUARTER
1st
2nd
3rd
41
Annual
Total
-City of Burien: Number of unduplicated Clients
86
86
87
87
346
QUARTER
1st
2nd
3rd
4th
Annual
Total
-City of Des Moines: Number of unduplicated Clients
38
38
39
39
154
QUARTER
1st
2nd
3ra
4th
Annual
Total
City of Federal Way: Number of unduplicated Clients
77
77
77
77
308
QUARTER
1st
2"d
3rd
4th
Annual
Total
-City of Renton: Number of unduplicated Clients
96
96
96
1 97
385
QUARTER
1st
2"d
3rd
4th
Annual
Total
City of Tukwila: Number of unduplicated Clients
191
19
19
J 20
77
HUMAN SERVICES AGREEMENT - 7 - 12/2020
CITY OF
44 Federal
CITY HALL
Way 33325 8th Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
wwwci"ffedera/way com
B. Units of Service
The Agency agrees to provide, at minimum, the following units of service by quarter:
QUARTER
of Burien Performance Measures
1st
2nd
3rd
41
Annual
Total
-City
1.Information/Referral
86
86
87
87
346
QUARTER
of Des Moines Performance Measures
1st
2nd
3rd
4'
Annual
Total
-City
1. hiformation/Referral
38
38
39
39
154
QUARTER
of Federal Way Performance Measures
1st
2"a
3rd
4th
Annual
Total
-City
1. Infon nation/Referral
77
77
77
77
308
QUARTER
Cityof Renton Performance Measures
1st
2nd
3rd
4th
Annual
Total
1.Information/Referral
96
96
96
97
385
QUARTER
of Tukwila Performance Measures
1st
2nd
3rd
411
Annual
Total
-City
1.Information/Referral
19
19
19
20
77
C. Definition of Services
1. Information/Referral: A service unit is defined as one incoming phone call, email, or chat inquiry.
D. Performance Measure(s)
Outcome(s) to be reported:
1. 90% of callers report receiving new information.
2. 90% of callers intend to contact the agencies that were referred.
Records
A. Project Files
The Agency shall maintain files for this project containing the following items:
1. Notice of Grant Award.
2. Motions, resolutions, or minutes documenting Board or Council actions.
3. A copy of this Agreement with the Scope of Services.
4. Correspondence regarding budget revision requests.
5. Copies of all invoices and reports submitted to the City for this project.
6. Bills for payment with supporting documentation.
7. Copies of approved invoices and warrants.
8. Documentation of client address; residency verified via King County Parcel Viewer.
HUMAN SERVICES AGREEMENT - 8 - 12/2020
,ACITY OF
� Federal
CITY HALL
Way 33325 8th Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
www cityoffederalway com
9. Documentation of client income. The Agency agrees to use the HUD Income Guidelines to report
income of clients served under this Agreement. Income guidelines may be adjusted periodically by
HUD.
King County FY 2020 Income Limits Summary
Median
FY 2020
Income
Income
1
2 3
4
5
6
7
8
King
Limit
Person
Persons Persons
Persons
Persons
Persons
Persons
Persons
County
Category
Extremely
Low
(30%)
$25,100
$28,650
$32,250
$35,800
$38,700
$41,550
$44,400
$47,300
Income
Limits
Very Low
$113,300
(50%)
Income
$41,800
$47,800
$53,750
$59,700
$64,500
$69,300
$74,050
$78,850
Limits
Low
(80%)
$66,700
$76,200
$85,750
$95,250
$102,900
$110,500
$118,150
$125,750
Income
Limits
The Agency agrees to use updated Income Guidelines which will be provided by the City.
Reports and Reporting Schedule
The Agency shall collect and report client information to the City quarterly and annually on a Service Unit
Report to be provided by the City in the format requested by the City.
The Agency shall submit an Annual Demographic Data Report. The agency shall collect and retain the data
requested on this form from the persons served through this contract. Data should be tracked in an ongoing
manner and submitted annually no later than January 15 in the format requested by the City.
The Agency shall implement and track at least one measurable outcome for the program as presented in the
application. Changes to the outcome presented in the application must be approved by the City prior to
implementation. The Agency shall report the results of its outcome measure(s) annually on the Annual Outcome
Data Report to be submitted by January 15 in the format requested by the City.
Public Information
In all news releases and other public notices related to projects funded under this Agreement, the Agency will
include information identifying the source of funds as the City of Federal Way Human Services General Fund
Program.
HUMAN SERVICES AGREEMENT - 9 - 12/2020
CITY OF
.� Federal Way
EXHIBIT B
COMPENSATION
Project B_ udgct
CITY HALL
33325 8th Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
wwwv. ci"ffederaiway com
The Agency shall apply the following funds to the project in accordance with the Line Item Budget Summary,
detailed below. The total amount of reimbursement pursuant to this Agreement shall not exceed Sixty -Six
Thousand and 00/100 Dollars ($66,000.00).
Annual Budget and Expenses detailed for each benefitted City:
City of Burien $9,000.00
City of Des Moines $4,000.00
City of Federal Way $8,000.00
City of Renton $10,000.00
City of Tukwila $2,000.00
Total: $33,000.00
Reimbursement Requests and Service Unit Report forms shall be submitted no less frequently than quarterly
and are due on the following dates:
1st Quarter: April 15 or within 10 days of notice to proceed, whichever is later;
2nd Quarter: July 15;
3rd Quarter: October 15; and
4th Quarter: Final Reimbursement Request and Service Unit Report forms due January 6; Demographic Data
Report and Annual Outcome Data Report with supporting documentation due January 15.
The Agency shall submit Reimbursement Requests in the format requested by the City. Reimbursement
Requests Invoices shall include a copy of the Service Unit Report and any supporting documents for the billing
period.
HUMAN SERVICES AGREEMENT - 10 - 12/2020
CITY OF
Federal
Estimated Quarterly Payments:
2021
1st Qtr
$8,250.00
2nd Qtr
$8,250.00
3rd Qtr
$8,250.00
4th Qtr
$8,250.00
2022
1 st Qtr $8,250.00
2nd Qtr $8,250.00
3rd Qtr $8,250.00
4t' Qtr $8,250.00
CITY HALL
Way 33325 8th Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
www cityoffederaWay com
Quarterly payment requests shall not exceed the estimated payment without prior written approval from the
City. Estimated quarterly payments are contingent upon meeting or exceeding the above performance
measure(s) for the corresponding quarter. This requirement may be waived at the sole discretion of the City
with satisfactory explanation of how the performance measure will be met by year-end on the Service Unit
Report.
HUMAN SERVICES AGREEMENT - 11 - 12/2020
Aca►�o� CERTIFICATE OF LIABILITY INSURANCE
DATE IMMID D/YYYY)
03/24/2021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER WA#877030 1-206-343-2323 COME: Kareena Beckner
NAME:
AssuredPartners of Washington, LLC PHONE FAX
925-952-2681 -5910
AssuredPartners of Wash. Ins. Agency, LLC CA Lic OK61066 E-MAIL
1325 Fourth Avenue, Suite 2100 ADDRE : kareena.beckner@assuredpartnere.com
Seattle, WA 98101
INSURED
Crisis Connections
INSURERA : GREAT AMER INS CO
INSURER B :
2901 3rd Avenue, Suite 100 INSURERD:
INSURER E : j+
Seattle, WA 98121 INSURERF: I
rnvoown_oc d`C071CI^ATC A111MQC0- 61700R31 RFV131AN NIIMRFR-
16691
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN:M D RR POLICYEFF POLICYEFP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER DD MM/DD
A
X
COMMERCIAL GENERAL LIABILITY
X
PAC4296835
07/01/20
07/01/21
EACH OCCURRENCE
$ 1,000,000
—
CLAIMS -MADE T OCCUR
15MAUE TO RENTED
PRgml S Ea urren-i
$ 1,000,000
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 3,000,000
PRODUCTS - COMP/OPAGG
$ 3,000,000
POLICY PRO ❑ LOC
X JECT
$
OTHER:
A
AUTOMOBILE LIABILITY
PAC4296835
07/01/20
07/01/21
Maacciden!dentl GLELIMIT
Ea
$ 1,000,000
BODILY INJURY (Per person)
$
ANY AUTO
OWNED SCHEDULED
BODILY INJURY (Per accident)
$
AUTOS ONLY AUTOS
PROPERTY DAMAGE
Per acalden
$
X HIRED X NON -OWNED
AUTOS ONLY AUTOS ONLY
A
LIAB
X
OCCUR
UMB4296836
07/01/20
07/01/21
EACH OCCURRENCE
$ 4,000,000
kJUMBRELLA
EXCESS LIAB
CLAIMS -MADE
AGGREGATE
$ 4,000,000
DED I X I RETENTION $ 101000
$
A
WORKERS COMPENSATION
PAC4296835
07/01/20
07/01/21
STATUTE ERH
AND EMPLOYERS' LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N
+IN/A
E.L. EACH ACCIDENT
$ 1,000,000
E.L. DISEASE - EA EMPLOYE
$ 1,000,000
OFFICER/MEMBEREXCLUDED?
(Mandatory in NH)
I
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
A
Professional Liability
PAC4296835
07/01/20
07/01/21
Agg Limit
3,000,000
A
Professional Liab cont
PAC4296835
07/01/20
07/01/21
Each Act/Error Omm
1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space is required)
Certificate holder is an additional insured per insured form #GC8970 11 14 but only with respects to operations of the
named insured. Excess Policy follows General Liability ***10 days notice of cancellation for non payment of premium***
f:FRTIFIf:ATF Ht1I nFR CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Federal Way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 9718 AUTHORIZED REPRESENTATIVE
Federal Way, WA 98063yr_
i USA
U 19SS-2U15 AGURD GURPUKA 11UN. All rlgnTs reservea.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Kareenabeckner
Crisis Connections Board of Trustees Meeting Minutes
Wednesday, July 15, 2020
6:00 PM
Mission: Our passion is caring and listening, helping people to make positive life changes. We do this
through connections between people and critical resources.
Present: Angela Cronin, Clif Curry, David Dickinson, John Engber, Katie Simmons, Mike Nielsen,
Ursula Whiteside, Pam Mandel, Kim Gunning
Staff and Guests: Allie Franklin, Robbi Kay Norman, Russ Davies
I. Call to Order and Welcome: Mike Nielsen, President (6:00)
Welcome and introduction of members.
H. Motion 1: To Approve the Minutes of May 2020 Meeting Approve (6:01)
Motion carried and accepted.
III. Finance Committee Report Approve (6:02)
■ KC CAP has no update. Request from Provisional to CAP was rejected. Provisional
extended to 30 days.
• Audit is on hold.
• Year to date revenue is ahead of budget over 1 million.
■ 119,000 private contracts ahead due to COVID-19 funding.
• Crisis Connections is currently understaffed.
• IT, interpreter, and telephone costs are over budget.
• Landlord is delayed in reimbursing us.
• Accounts Payable has gone down.
IV. Motion 2: Remove past ELT members and two new ELT members Approve (6:12)
Motion carried and accepted.
V. Motion 3: Delegate Lauren Rigert to fulfill CEO Administrative duties until Interim
CEO is named (signed checks, contracts, etc.) Approve (6:13)
Motion carried and accepted.
VII. Philanthropy Chair Report Inform (6:14)
• A virtual event is likely to happen.
• List of potential sponsors will be sent in the next few weeks.
• Possible food delivery or packages could be implemented.
• Most of the event can be pre-recorded and there might be some live events. This would
include an auction.
• Angela Cronin requests the board help fill virtual tables.
VIII. CEO Report Inform (6:24)
0 Update, FEMA rollout on July 161h at l lam.
Crisis Connections Board of Trustees Meeting Minutes
Wednesday, July 15, 2020
6:00 PM
Mission: Our passion is caring and listening, helping people to make positive life changes. We do this
through connections between people and critical resources.
Present: Angela Cronin, Clif Curry, David Dickinson, John Engber, Katie Simmons, Mike Nielsen,
Ursula Whiteside, Pam Mandel, Kim Gunning
Staff and Guests: Allie Franklin, Robbi Kay Norman, Russ Davies
I. Call to Order and Welcome: Mike Nielsen, President (6:00)
Welcome and introduction of members.
H. Motion 1: To Approve the Minutes of May 2020 Meeting Approve (6:01)
Motion carried and accepted.
III. Finance Committee Report Approve (6:02)
■ KC CAP has no update. Request from Provisional to CAP was rejected. Provisional
extended to 30 days.
• Audit is on hold.
• Year to date revenue is ahead of budget over 1 million.
• 119,000 private contracts ahead due to COVID-19 funding.
• Crisis Connections is currently understaffed.
• IT, interpreter, and telephone costs are over budget.
• Landlord is delayed in reimbursing us.
• Accounts Payable has gone down.
IV. Motion 2: Remove past ELT members and two new ELT members Approve (6:12)
Motion carried and accepted.
V. Motion 3: Delegate Lauren Rigert to fulfill CEO Administrative duties until Interim
CEO is named (signed checks, contracts, etc.) Approve (6:13)
Motion carried and accepted.
VII. Philanthropy Chair Report Inform (6:14)
• A virtual event is likely to happen.
• List of potential sponsors will be sent in the next few weeks.
• Possible food delivery or packages could be implemented.
• Most of the event can be pre-recorded and there might be some live events. This would
include an auction.
• Angela Cronin requests the board help fill virtual tables.
VIII. CEO Report Inform (6:24)
0 Update, FEMA rollout on July 16t" at 11 am.
4/12/2021 Corporations and Charities System
BUSINESS INFORMATION
Business Name:
CRISIS CONNECTIONS
UBI Number:
600 578 099
Business Type:
WA PUBLIC BENEFIT CORPORATION
Business Status:
ACTIVE
Principal Office Street Address:
2901 3RD AVE STE 100, SEATTLE, WA, 98121-1037, UNITED STATES
Principal Office Mailing Address:
2901 3RD AVE STE 100, SEATTLE, WA, 98121-1037, UNITED STATES
Expiration Date:
02/28/2022
Jurisdiction:
UNITED STATES, WASHINGTON
Formation/ Registration Date:
02/27/1964
Period of Duration:
PERPETUAL
Inactive Date:
Nature of Business:
CHARITABLE
REGISTERED AGENT INFORMATION
Registered Agent Name:
DIRECTOR OF DEVELOPEMENT
Street Address:
2901 3RD AVE STE 100, SEATTLE, WA, 98121-1037, UNITED STATES
Mailing Address:
2901 3RD AVE STE 100, SEATTLE, WA, 98121-1037, UNITED STATES
GOVERNORS
Title
GOVERNOR
GOVERNOR
Governors Type
INDIVIDUAL
INDIVIDUAL
Entity Name First Name
LAUREN
AUNDREA
Last Name
RIGERT
JACKSON
https://ccfs.sos.wa.gov/#/BusinessSearch/Businessinformation 1/1
CITY of CITY HALL
Federal Way Feder l a Avenue South
Federal W WA 98003-6325
(253) 835-7000
wWW01yoffedernhvWcom
City of Federal Way
Human Services Contract for 2021-2022 General Fund
Authorized Signatures for Invoices
I authorize the following individuals to sign invoices and quarterly reports on behalf of:
(Contracting Agency), for
the following: 1 �s (Program Title).
Authorizing
Signature:
(must be signed by
person who signs
the contract,
generally,
Executive Director)
Additional
Authorized
Signature:
(Printed
(Printed Name)
(Title)
(Title)
(Signature) (Date)
Additional
Authorized
Signature:
(Printed Name) (Title)
(Signature) (Date)
Note: It is the responsibility of the contractor to inform the City of Federal Way if they wish to add a
name to or delete names from this list.
Washington State Department of Revenue
License Information:
Entity name.
CRISIS CONNECTIONS
Business name.
CRISIS CONNECTIONS
Entity type:
Norpreft Corporaiior
UBI X:
6X-578-099
Business ID:
001
Location ID:
0001
Locatiolr.
Active
Location address: 2901 3RD AVE
STE 100
SEATTLE WA 98121.1037
Mailing address: 2901 AD AVE
STE 100
SEATTLE WA 98121.1037
Excise tax and reseller permit status: C CY I've
Secretary of State status: C cK here
Endorsements
Endorsements held at this lo-U— license M Count Details Status
Feder. a' Way Gerera' Bus Tess - Non. -T;%e
Res dert
Nnv searcr BacK to resu is
E.pintim date F,rst ksuance dale
Mar-31-2022 Mar-19.2021
W111111119
Request for Taxpayer
Give Form to the
Form
(Rev. October201$)
Identification Number and Certification
requester. Do not
Department df the Treasury
Intarnsl Revenue Service
M► Go to wwwire.gov/FormW9 for instructions and the latest information.
send to the IRS.
i Name (as shown on your f7rcarize tax return). Name N required on Chia line; do not leave this line blanK.
Crisis Connections
2 Business nameldisrage rded entky name, If different from above
^�
m
3 Check appropriate box for federal tax classification of the person Whose name is entered on line 1. Check only one of the
Y
4 Exem ,bons codes apply only to
P� ( Y Y
�p
following seven boxes.
certain entities, not Individuals; see
a
ElIndividual/sole proprietor or 0 C Corporation El6 Corporation ❑ Partnership ElTrust/estate
instructions an page 3):
d> in
single -member LI C
Exempt payee code (if any)
❑ Limited liability company. Fnterthetax classification (C=C corporation, 8=8 corporation, P=Partnership) I'L
`p
Noce: Check the appropriate box in the line above for the tax classification of the single -member owner. DO trot check
Exemption from FATCA reporting
cn
LLC if the LLC is classified as a singie-member LLC that is disregarded from the owner unless the owner of the LLC is
code ( if any)
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC tr+;,t
Is disregarded from the owner should check the appropriate box for the tax classification of its owner.
ri
❑ Other (see instructions) ►
t0 &CCW 7i3 MBM M ned oulabe the U.SJ
G Atltlres5 (number, street, and apt. or sulte no.) See Instructions.
AeQugS ws name and address (optional
5
2901 Third Ave, STE 100
6 City, state, and ,ZIP code
Seattle, WA 99121
7 List account numbar(s) here (ootlonat)
Taxpayer IdantifiCetion Nurnber (TIN)
Enter
yourTIN in the appropriate box. The TIN provided must match the name givers on line 1 to avoid
social security number
-
backup withholding_ For ietor, r ds, this is generally your social security number (safer However, for a
resident alien, sale proprietor, or disregarded entity, sea the instructions for Pert I, later. For other
entities, It Is your employer identification number (EIN). If you do not have a number, see Now to get a
TIN, later. or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer fdant'rfication number
Number To Give the Requester for guidelines on whose number. to enter.
7 1 7 1 3 t 1$ P7
MUM- 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. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (13) 1 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. 1 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, ttem 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 11, later
Sign Signature of
Here I U.S. person ►
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 anaoted
after they were published, go to www,frs.gov1F6rmW9.
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 correot taxpayer
Identification number (TIN) which may be your racial security number
(SSN), Individual taxpayer iderstlfIc9on numl-r (ITIN), adoptfon
taxpayer identlffoation number (ATiN), or employer identification number
(PIN), to report on an lofarMaliorl 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)
[Sate 0�
• Form 1099-DIV (dividends, including those fruit, stocks or mutual
funds)
• Form 1099-M)SC (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 I OOB (home mortgage interest), 1098-1� (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 withhofding. See What is backup withholding,
later.
Cat, No. 10231X Form YV-H (Rev. 10-2018)
CITY OF
Federal Way 33325 8" Avenue South, Federal Way, WA 98003
❑New Vendor ® Update Form
To add your business to our vendor file, or update information. Please complete this form and mail or fax it to the address/fax number
below.
Business In d n (For office use only) VN#:
Business Name: l� �'! S1Sa1►� OILS
ContactName: C12_ rl _
Location Address: A01 -R( l& SL' I U) CITY/STATE C.Rnto Zip
Mailing Address (ifdifferent): CITYISTATE Zip Code
Phone #: (Z & ): o - q qm_ Fax #: { } - E-Mail:
Buriness 7�ye-(Please Check lane)
Corporation ❑
- - - - - - - -
Federal ID # (9 digits)
Partnership ❑
- - - - - - - -
Federal ID # (9 digits)
Government Agency ❑
- - - - - - -
Federal ID # (9 digits)
Non -Profit]
] l q
- i - Q - -
Federal ID # (9 digits)
Sole Proprietor ❑
- - - - - - - -
Federal ID # (9 digits) or Social Security Number
What is the official name registered with the I.RS. for the above number?
Ifyou are not a corporation, is your Business subject to 1099 reporting? `21 Yes ❑ No
State of Washington U.B.I. # Federal Way Business License #:
Will you provide supplies or services to the City of Federal Way? ❑ Supplies Rsmiees
City of Federal Way Staff/Department Contact Name:
Signature (US Person including a Date:
US resident alien)
3 b2,Z0.t
For information call: 253.835.2525 or Fax: 253.835.2509 or E-mail: Accountspayable@cityoffederalway.com
