AG 21-062 - UKRAINIAN COMMUNITY OF WASHINGTONBrittany Julius
253-326-.1227
CITY OF FEDERAL WAY LAW DEPARTMENT ROUTING FORM
1. ORIGINATING DEPT./DIV: CD/cs
2. ORIGINATING STAFF PERSON: Brittany Julius EXT: 253-326-1277 3. DATE REQ. BY:
PE
4., TYPE OF DOCUMENT (CHECK ONE)-.
El CONTRACTOR SELECTION DOCUMENT (E.G., RFB, RFP, RFQ)
r-1 PUBLIC WORKS CONTRACT El SMALL OR LIMITED PUBLIC WORKS CONTRACT
X PROFESSIONAL SERVICE AGREEMENT
El GOODS AND SERVICE AGREEMENT
❑ REAL ESTATE DOCUMENT
o ORDINANCE
❑ CONTRACT AMENDMENT (AG#) 4o
n nTPT P
5. PROJECT NAME: Russian Ukrainian Refugee Assistance Program
El MAINTENANCE AGREEMENT
[!I HUMAN SERVICES/ CDBG
❑ SECURITY DOCUMENT E.G. BOND RELATED DOCUMENTS)
El RESOLUTION
❑ INTERLOCAL
6. NAME OF CONTRACTOR. Ukrainian Community Center of Washington
ADDRESS: 17701 108tn Ave se, 336, Renton WA 98055 TELEPHONE (425) 430-8229
E-MAIL: FAX:
SIGNATURE NAME: Qlea PVC1Cia TITLE
7. EXHIBITS AND ATTACHMENTS: A SCOPE, WORK OR SERVICES 0 COMPENSATION A INSURANCE REQUIREMENTS/CERTIFICATE A ALL
OTHER REFERENCED EXHIBITS 0 PROOF OF AUTHORITY TO SIGN El REQUIRED LICENSES 1:1 PRIOR CONTRACT/AMENDMENTS
8. TERM: COMMENCEMENT DATE: January 1, 2021 COMPLETION DATE: December 31,2022
9. TOTAL COMPENSATION $ 10,000-00 (INCLUDE EXPENSES AND SALES TAX, IF ANY)
QF CALCULATED ONUf-URLY LABOR CHARGE - ATTAru cCuFnUL-Pq. OF EMPLOYEES TITLES AND HOLIDAY RATES)
REIMBURSABLE EXPENSE: DYES
IS SALES TAX OWED i0YES
YES, MAXIMUM DOLLAR AMOUNT.' S -.-- .. -.-. ..- - - . ... -
ID NO IF YES, $ PAID BY: El CONTRACTOR ❑ CITY
RETAINAGE: RETAINAGE AMOUNT: El RETAINAGE AGREEMENT (SEE CONTRACT) OR El RETAINAGE BOND PROVIDEE
ONO
❑ PURCHASING-. PLEASE CHARGE TO,* 001-7300..083..562-10-410
10. DOCUMENT/CONTRACT REVIEW
El PROJECT MANAGER
El DIRECTOR
❑ RISKMANAGEMENT (IFAPPLICABLE)
I!t LAW
I I . COUNCIL APPROVAL (IF APPLICABLE)
12. CONTRACT SIGNATURE ROUTING
INITIAL / DATE REVIEWED
sus 02/17/2021
DK 03-03-2021
COMMITTEE APPROVAL DATE: 11110/2020
INITIAL / DATE APPROVED
M
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 / D E SIGNED
El LAW DEPARTMENT
[&OWGNATORY (MAYOR OR DIRECTOR)
❑ CITY CLERK
❑ ASSIGNED AG# AG'r
COMMENTS:
cIrr OF
'��... Federa
Way
CITY HALL
33325 Sth Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
www c0uifea`erenwnV c007
HUMAN SERVICES AGREEMENT
FOR
RUSSIAN UKRAINIAN REFUGEE ASSISTANCE PROGRAM
This Human Services Agreement ("Agreement") is made between the City of Federal Way, a Washington
municipal corporation ("City"), and Ukrainian Community Center of Washington, a Washington nonprofit
corporation ("Agency"). The City and Agency (together "Parties") are located and do business at the below
addresses which shall bc valid for any notice required under this Agreement:
UKRAINIAN COMMUNITY CENTER OF
WAS INGTON.0
Oleg Pynda
17701 108th Ave SE, 336
Renton, WA 98055
(425) 430-8229 (telephone)
ov1vnda(&,uccwa.ora
The Parties agree as follows:
CITY OF FEDERAL WAY,
Brittany Julius
33325 8th Ave. S.
Federal Way, WA 98003-6325
(253) 835m2651 (telephone)
brittanv.]*ul'ius(&,,,Citvoffederalwav com
1. TERM. The term of this Agreement shall be for a period commencing on January 1, 2021 and terminating on
December 31'P
, 2022 ("Term"). Funding for the second year oef thAgreement is contingent upon satisfactorygAreement
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 Cl'ty'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 ies
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 is 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.
310 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 m.tterminate-ne 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-a COMPENSATION.
401 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 andi"n 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.
HUMAN SERVICES AGREEMENT — 1 no 12/2020
receipt and approval
vered, all���i reported on
review the Agency's
h the performance measures set forth I*n Exhl'bl*t A. Should the Agency fail to mee
F%.Iformance measures for each quarter, the City reserves the right io adjust payments on a pro rats basis at any
during the term ot- this Agreement. Exceptions may be made at the discretion of the City's Human Services Manager in
Federal Way
33325 8th Avenue South
Federal Way. WA 98003r-6325
(253-) 835-7000
bwv4v rlNotfe,derah
COrr,
the City only after the Services have been performed and within forty-five (45) days after the City's
oi a complete and correct invoice and
the Agency's re -ports, as a measure of
reports to monitor compliance wit
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
reports. The City will use the quantity of Services actually deli
satisfactory performance under this Agreement. The City shall
cases where circumstances beyond the Agency's
t the
time
�v►ILruI 1111PacL ins aviiity to meet its service unit goals and the Agenev
CITY
HALL 1
waV
has shown reasonable efforts to overcomethese circumstances to meet 1*ts goals. If the City objoecthe invoice, it shall notify the Agency and
event, the Parties will immediately make every effort to settle the disputed portion.
A______ ts tn all or any portion of
eserves the option to pay only that portion oi the invoice not in dispute. In that
4.3 Final Invoice. The Agency shall submit its final invoice by the date indicated on E�ibit B. If the
Agency's final invoice and reports are not submitted by the last date specified in E�ibit 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; providedhowever, that the City may elect to pay any invoice that is not submitted in a timely manner.
4.4 Non-A��ro�riation of Funds. If sufficient funds are not appropriated or allocated for payment under this
Agreement for any future ftscal 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 Agencv Indemnification. The Agency agrees to release, indemnify, defend, and hold the City, its elected
officials, officers, employeesagents, representatives, insurers, attorneys, and volunteers harmless from any and all claims,demands, actions, suits, causes of action, arbitrations, mediations, proceedings, judgments, awards, injuries, damagesliabilities, taxes, losses, fines, fees, penalties expenses, attorneys fees, costs, and/or litigation expenses to ar 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 Ageement 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 paragaph. 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 ganted 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 agees to release, indemnify, defend and hold the Agency, its officers,
directors, shareholders, partners, employees, agents, representatives, and subcontractors harmless from any and all claims,
HUMAN SERVICES AGREEMENT - 2 - 12/2020
r
CITY OF
�4!!,, Federa
Vay
CITY HALL
33325 Sth Avenue South
Federal Way, WA 98003-6325
{253} 835-7000
ww4v. clNeffedera7wn v coJ73
demands, actions, suits, causes of action, arbitrations, mediations, proceedings, judgments, awards., injuries, damages,
liabilities, losses, fines, fees, penalties expenses, attorneys fees, costs, and/or litigation expenses to or by any and a
persons or entities, including without limitation,, their respective agents, licensees, or representatives, arising from,
resulting from or connected w
the City.
respec
J1
ith this Agreement to the extent solely caused by the negligent acts,
errors, or omissions of
504 Survival. The provisions of this Section shall survive the expiration or termination of this Agreement with
t to any event occurring prior to such expiration or termination.
INSURANCE,. The Agency agrees t
performance of the services or
the Agreement and
duration of
followsdp
work by
thereafte
o carry insurance for
the Agency
r with respect to any event occurring prior
1, tneir agents, representatives,
liability which may arise from or in connection with the
' employees or subcontractors for the
to such expiration or termination as
6*1e 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 i*s 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
advertising injury, and liability assumed under an insured contract with limits no less than
ence and $2,000,000 general aggreaate.
damage, products liability,
$1,000,000 for each occurr
b. Workers' compensation and employer
laws of the State of Washington;
's liability insurance in amounts sufficient pursuant to the
ce Automobile liability insurance covering all owned, non -owned, hired and leased vehicles with a
minimum combined single limits I*n the minimum amounts required to drive under Washington State law per accident for
bod1*1yi"nj*ury, including personal injury or death, and property damage.
6.62* No.Ll*ml*t 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 i"n 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.
6e3w 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 Cl*ty'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 i*s actually terminated or
upon project completion and acceptance by the City.
6.04 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 confident iality 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
HUMAN SERVICES AGREEMENT - 3 - 12/2020
CITY HALL
333'sZ5.5 8th Avenue South
Federal Way. WA 98003-6325
(253) 835-7000
wrvw. crtvah`ederaiwm� rat
needed or contracted for work product upon the C I'ty's request. At the
ng of all funds paid pursuant
to this Agreement. These r perioa (o) years arter the termination "
and may be subject, at allreasonable ,its authorized r
StateAuditor, or other governmental officials authorized by law to monitor this Agreement.
files avail
IF IF 0 0 a
expiration or termination ot this Agreement all originals and copies ot any such work product remaining in the possession
of Agency shall be delivered to the City.
!Oe BOOKS AND RECORDS. The Agency agrees to maAl
intain books, records,, and documen
and properly reflect all direct and indirect costs related to the performance of the Services and maintain
procedures and practices as may be deemed necessary by the City to assure proper accounti
ecordsshallbemamtamedfora
times, to inspection, review or audit the City
FederalWay
abletotheCityandshalldeliverall
Its which sufficiently
thisAgreement
epresentative,the
ll
ty
10.INDEPENDENTCNTRCTORThePrtiesintendthattheAgencyshallbeanindependentcontractorand
thattheAgencyhastheabilitytocontrolanddirecttheperformanceanddetailsofitswork,theCitybeinginterestedonly
intheresultsobtainedunderthisAgreement.TheCity shallbe neitherliablenorobligated topayAgency sickleave,
vacationpayoranyotherbenefitofemployment,nortopayanysocialsecurityorothertaxwhichmayariseasan
incidentofemployment.Agencyshall takeall necessary precautionsand shall beresponsible forthesafetyof its
employees,agents,andsubcontractorsintheperforanceoftheServicesandworkandshallutilizeallprotection
necessaryforthatpurpose.All worksha
bedone atAgency'sown risk,and Agency shall beresponsiblefor any lossof
ordamagetomaterials,tools,orotherarticlesusedarheldforuseinconnectionwiththework.TheAgencyshallpayall
incomeandothertaxesdueexceptasspecificallyprovidedinSection4.Industrialaranyotherinsurancethatispurchased
forthebenefitoftheCity,regardlessofwhethersuchmayprovideasecondaryorincidentalbenefittotheAgency,shall
notbedeemedtoconvertthisAgreementtoanemploymentcontract.
rt
11.CONFLICTOFINTEREST.ItisrecognizedthatAgencymayorwillbeperformingservicesduringtheTerm
forotherparties;however, such performanceof other servicesshallnotconflictwith or interfere withAgency'sabilityto
performtheServices.Agencyagreestoresolveanysuchconflicts ofinterest in favorof theCi
.Agency confirs that
AgencydoesnothaveabusinessinterestoracloseamilyrelationshipwithanyCityofficeroremployeewhowas,is,or
willbeinvolvedintheAgency'sselection,negotiation,drafting,signing,administration,orevaluatingtheAgency's
performance.
12.EQUALOPPORTUNITYEMPLOYER.Inallservices,programs,activities,hiring,andemploymentmade
possiblebyorresultingfromthisAgreementoranysubcontract,thereshallbenodiscriminationbyAgencyorits
subcontractorsofanylevel,oranyofthoseentities'employees,agents,sub-agencies,orrepresentativesagainstany
personbecauseofsex,age(exceptminimuageandretirementprovisions),race,color,religion,creed,nationalorigin,
maritalstatus,orthepresenceofanydisability,includingsensory,mentalorphysicalhandicaps,unlessbaseduponabona
fideoccupationalqualification inrelationship tohiringand employment.Thisrequirement shall apply to,but not be
limitedto,thefollowing:employment,adve
ising, layoff ortermination, rates ofpayorotherforms ofcompensation,and
selectionfortraining,includingapprenticeship.Agencyshallcoplywithandshallnotviolateanyofthetermsof
Chapter49.60RCW,TitleVIoftheCivilRightsActof1964,theAmericansWithDisabilitiesAct,Section504ofthe
RehabilitationActof197349CFRPart2121.5and26oranyotherapplicablefederalstateorlocallaworregulation
regardingnon-discrimination.
gr
13.GENERALPROVISIONS.
13.1InterpretationandModification.ThisAgeement,togetherwithanyattachedExhibits,containsallofthe
agreementsofthePartieswithrespecttoanymattercoveredormentioned in thisAgreement and noprior statementsaragreements,whetheroralorwritten,shallbe effective for anypurpose.Shouldany languageinany E�chibitsto this
AgreementconflictwithanylanguageinthisAgeement,thetermsofthisAgreementshallprevail.Therespective
captionsoftheSectionsoftsAgreementareinsertedforconvenience ofreferenceonlyand shallnotbe deemed to
modifyorotherwiseaffectanyoftheprovisionsofthisAgreement.AnyprovisionofthisA
eement thatisdeclared
HUMANSERVICESAGREEMENT4 -12/2020
CITY OF
CITY OF
Federal Way
CITY HALL
33325 8th Avenue South
Federal Way, OVA 98003-6325
(253) 835-7000
tatvw crtVuffe'dern!wawcn;r,
invalid, inoperative, null and void, orilleval shall in no way affect or invalidate any other nrov
provisions shall remain in full force and effect. Any act done by either Party prior to the effective date of the Agreemen
inai is consistent with the autnori
having been performed under the Agreement. No provision of this Agreement, including this provision, may be amended
ty of the Agreement and compliant with the terms of the Agreemen
on hereof and such other
t
S
t, is hereby ratified a
waived, or modified except by written agreement signed by duly authorized representatives of the Parties.
Assignment and Benefici*a ries,
n whole or in part, any or all of its obligati*
10 10
Neit
ons and rights hereunder without the t)ri"o
•
her the Agency nor the City shall
r
have the right to transfer or assign,
written consent of the other Party . If
11
c null-as�i�nm� LURV Jjives us consent to anv assignment _ the terms of this Agreement shall rnntin"a in full fnrrlm a,,A
effect and no further assignment shall be made without additional written consent. Subject tn the fnrp.rightsnmlgoing, the
obligations of the Parties shall inure to the benefit of and be binding upon their respective successors
assigns. This Agreement is made and entered into for the sole protection and benefit of the Parties heretoa M. No other person
or entity shall have any right of action or interest in this Agreement based on any provision set forth herein.
in interest, heirs and
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 anisst 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 Agree ent 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 filingilng suit under the venue, rules and jurisdiction of the King County Superior Court, King County, Washington,
unless the parties agree in writing to an alteiatve 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 attorneys fees and expenses incurred in defending :1)r 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
HUMAN SERVICES AGREEMENT - 5 - 12/2020
13*2
CITY OF
Federal Way
CIrY HALL
$3325 8th Avenue South
Federal Way, WA 98003-6325
(253) 835-7000
mw w, ci t vo ffede ra Wo v co i i
Pages from such counterparts may be assembled together to form a single instrument comprised of all pages of this
Agreement and a complete set ot all signature and acknowledgment pages. The date upon which
45
Parties have executed a counterpart of this Agreement shall be the "date of mutual execution" hereof
[Signature page follows]
1P
HUMAN SERVICES AGREEMENT - 6 - 12/2020
the last of all of the
CITY OF
Fe d e ra
I Vay
CITY HALL
33325 8th Avenue South
Federal Way., WA 98003-6325
(253) 835-7000
o-vww. crtvotfec7eraiemv cn�n
IN WITNESS, the Parties execute this Agreement below, effective the last date written below.
CITY OF FEDERAL WAY:
DATE:
UKRAINIAN COMMUNITY CENTER
OF WASHINGTON.9
By-*
Printed Name: Oleg "Pylida
Title:
DATE:
Executive Director
March 04, 2021
STATE OF WASHINGTON )
King ) SS.
COUNTY OF 1
On this day personally
Executive Director
APPROVED AS TO FORM:
J. Ryan Call., City Attorney
annearPri hefnrp. me, Oleg Pynda
lerk
me known
to be the
of u icrainian Community Uenter ot Washington that executed the foregoing
instrument', and acknowledged 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, I's the corporate
ciIVF,��1 hand and official seal this 04th day
O%Ajl
P S E L,� led
�`Ssion F+gtiG%�
%oft�mom
mom:�� �TARY w 400Wmom
4um
urm
owl Ave L�C M%W
MOO, 4Z
29
W2 *00 !,Z�
OP WAS X �NN
Notary's signature
Notary's printed nam
seal of said corporation.
y co
a 40 .0 fission expires
HUMAN SERVICES AGREEMENT - 7 - 12/2020
e Stat
ITIN IF
on.
Federal Way
EXHIBIT A
SERVICES
7-% • A
The Agency shall provide services to refugee and immigrant individuals and their families from the countries of
the former Soviet Union in the City of Federal Way. The Agenevshall ensure that
funding under this Agreement are made available to Federal Way residents.
CITY HALL
33325 8th Avenue South
Federal Way. OVA 98003-6325
(253) 835-7000
w.v4Y Citvotfeciereaiwz3Y c:ott;
services provided with
Performance Measures
A. Number Served
The Agency avrxes to serve, at minimum,, the following unduplicated number of Federal Way residents with
Human Services funds:
St 2nd 3rd 4th
Quarter Quarter Quarter Quarter Total
JAN* _ APRIL — JULY — OCT. —
MARCH JUNE SEPT. DEC.
No. of unduplicated Federal
Way, passisted in 2021 4 4 4 4 16
No. of unduplicated Federal
Wayersons assisted in 2022 4 4 4 4 16
B. Units of Service
The Agency agrees to provide, at minimum,, the following units of service by, quarter:
1st 2nd 3rd 4th
Quarter Quarter Quarter Quarter Total
JAN* — ARIL — JULY — OCT. —
MARCH JUNE SEPT. DEC.
2021
1. Case Management
4 4 4 4 16
2. Support Group
a 1 0 o i
2022
1. Case Management
4 4 4 4 16
2. Support Group
0 1 0 0 1
HUMAN SERVICES AGREEMENT - 8 - 12/2020
Federal Way
CITY HAIL
33325 8th Avenue South
Federal Way, VVA 98003-6325
t253j835-7000
swnx crtyoffeder€rfwcttl can-
C. Definition of Services
I Case Management -Consists of outreach, intake,, direct assistance and foll
2. Support Group — Consists of group sessions,,
D. Performance Measure(s)
Outcome(s) to be reported:
ow -up.
1. 90% of participants will meet their goals towards self-sufficiency as outlined in their
service plan andreport improvement in knowledge of community resources.
Records
A. Project F
ices
The Agency shall maintain files for this project containing the following items:
1.
2.
3.
4.
5.
6.0
7.0
8.9
9.0
Notice of Grant Award.
Motions, resolutions, or minutes documen
ting Board or Council actions.
A copy of this Agreement with the Scope of Services.
-9
Correspondence regarding budget revision requests.
Copies of all invoices and reports submitted to the Cl't
Bills for payment with supporting documentation.
Copies of approved invoices and warrants.
Documentation of client address;
Documentation of client income.
income of cll*
HUD.
y for this Project.
residency verified via King County Parcel Viewer.
The Agency agrees to use the HUD Income Guidelines to report
ents served under this Agreement. Income guidel1P ines may be adjusted periodically by
..... .....
King CY 2020
Median FY 2020
Income Income 1 2 3 4 5 6 7 S
King Limit Person Persons Persons Persons Persons Persons Persons Persons
County Category
Extremely
Low
(30%) $251100 $285650 $321250 $35-9800 $38,700 $41 '550 $441400 $471300 1
Income
Limits
Very Low
$113-9300 (50%)
Income $411)800 $471800 $53,750 S-5919700 $645500 $691300 $74,5050 $781�850
Limits
Low
(80%) $66,700 $7619200 $85,750 $959250 $102900 $110500 $118150,$125750
Income
Limits
The Agency agrees to use updated Income Guidelines which will be provided by the City.,
HUMAN SERVICES AGREEMENT - 9 - 12/2020
Data Report to be submitted by January 15 ion t
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 Program.
CITY OF
Federal Way
Revorts and RelDorti*n
Schedule
CITY HALL
33325 Sth Avenue South
Federal Way, VVA 98003-6325
(253) 835-*7000
m.vw: C1tYotfederotwtiv Cool?
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 shallSU mit 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 I*n the format requested by the City.
The Agency shall implement and track at least one measurable outcome for the Drogram as presented in the.
application,, Changes to the outcome presented in the application must be approved b-% the Cit
implementation. The Agency shall report the results oi its outcome measure(s) annually on the Annual Outcome
he format requested by the City.
y prior to
the City of Federal Way Human Services General Fund
HUMAN SERVICES AGREEMENT - 10= 12/2020
Federal Way
EXHIBIT B
CITY HALL
33325 8th Avenue South
Federal Way. WA 98003-6325
(253) 835-7000
sw^nw alvotlederniwav corn
COMPENSATION
Project Budget
The Agency shall apply the following funds to the project. The total amount of compensate
Agreement shall not exceed Ten Thousand and 00/100 Dollars ($10,000.00),.
on pursuant to this
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 Quarters. Final Reimbursement Request and Service Unit
Report and Annual Outcome Data Report due January 15.
The Agency shall submit
copy of the Service Unit
Report forms due January 6; Demographic Data
do
payment requests in the format requested by the City. Payment requests shall include a
Report.
Estimated Quarterly Payments.
2021
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
2022
1 St Qtr
2 °d Qtr
3�d Qtr
4th Qtr
$1,250.00
$1925000
$1,250.00
$11250.00
Quarterly payment requests shall not exceed the estimated payment without prior written approval fromthe
City. Estimated quarterly payments are contingent upon meeting or exceeding the above performance
measure(s) for
W 0
with satisfactory explanation ol now the performance measure will be met by year-end on the Service Unit
Report.
the corresponding quarter. This requirement may be waived at the sole discretion of the City
HUMAN SERVICES AGREEMENT - I I - 12/2020
< Business Lookup
License Information:
Entity Warne:
Business name:
Entity typt,
U81 #0Is
Business ID.0
Location I C�:
Location:
Location address:
MaHing address:
UKRAINIAN COMMUNITY CENTER OF WASHINGTON
UKRAINIAN COMMUNITY CENTER OF WASHINGTON
A .
. . U
i � ` c. � c
601 -885%2058
001
0001
Active
Excise tax and reseller permit status:
Secretary of State status:
Endorsements
Endorsements held at this location
sd er a 'vl-va
Liceflse#
130'470 MART! N LUTH ER KI NG WAY S
SEATTLE WA 98178
17701 iOziTH AVE S 335
RENTON WA 98055
ere
here
f,
CITY OF
17ei(Jera
Way
CITY HALL
33325 8th Avenue South
Federal Way. WA 98003-6325
(253) 835-7000
ivww cityrp{fe+derahvqY. corTt
City of Federal Way
Human Services Contract for 2021m2022 General Fund
Authorized Signatures for Invoices
I authorize the following individuals to sign invoices and quarterly reports on behalf of:
Ukrainian Community Center of Washington
the following:
(Contracting Agency), for
Russian Ukrainian Refugee Assistance PrGIctram (Program Title)
.
Authorizing
Signature:
(must be signed by
person who signs
the contract,
generally,
Executive Director)
Oleg Pynda
Executive Director
(Printed Name) (Title)
(Signature)
03/04/2021
(Date)
i ** ■if Wi�����****i�fiii�����*f!!li������■ ii *! i �'� i� ���**■f Fi'i'iii���**fttti'i E. E. E. I%WE■■i•FFEiijp'##;i7iiiiiiiiiii777i77■aaaqiiM ■i■■■■ r■■■■■III i■■■■■■■*■■■ i■■■■■■■■ ffffii�.. i.. iiii■i,■■ii rtf*ti'i'�������i++f•i'������f�+++fi����aaa �! i ■i i ■!!ii i����
Additional
Authorized
Signature:
Additional
Authorized
Signature:
Irina P111pChuk5 IN
(Printe Name)
r
nature)
(Printed Name)
(Signature)
Program Manager
(Title)
03/04/2021
(Date)
(title)
(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.
3/9/2021
4
Corporations and Charities System
BUSINESS INFORMATION
Business Name:
UKRAINIAN COMMUNITY CENTER OF WAS INGTON
UBI Number:
601885258
Business Type:
WA NONPROFIT CORPORATION
Business Status:
ACTIVE
Principal Office Street Address:
13470 MARTIN LUTHER KING JR. WAY S, SEATT E. WA, 98178-5210, UNITED STATES
Principal Office Mailing Address:
17701 108T AVE SE, 336, RENTON, WA, 98055=6448, UNITED STATES
Expiration Date:
06/30/2021
Jurisdiction:
UNITED STATES, WASHINGTON
Formation/ Registration Date:
06/19/1998
Period of Duration:
PERPETUAL
Inactive Date*.
Nature of Business:
SOCIAL, CHARITABLE
REGISTERED AGENT INFORMATION
Registered Agent Name:
OLEG PYNDA
Street Address:
13470 MLK JR WAY S. SEATTLE
Mailing Address:
WA, 98178wOOOO, UNITED STATES
17701 108TH AVE SE # 336, RENTON, WA, 98055ow6448,, UNITED STATES
GOVERNORS
Title - — — - - - --- - - - - -
GOVERNOR
GOVERNOR
GOVERNOR
GOVERNOR
GOVERNOR
Governors Type
INDIVIDUAL
INDIVIDUAL
INDIVIDUAL
INDIVIDUAL
INDIVIDUAL
entity Name
First A ame
YURIY
PETRO
BINNI
IGOR
SVETLANA
Last tame
ILI FA # OWIVA
MARTYNYUK
THOMAS
ti-
MARCHUK
GOVERNOR
INDIVIDUAL
LILIYA
MILYAN
htt S://ccfs.sos.wa.gov/#/BusinessSearch/BusinessInformation 112
3/9/2021
Corporations and Charities System
Title
GOVERNOR
Governors Type
INDIVIDUAL
Entity Name
First Name
IRYNA
Last Name,
https:(/ccfs.sos.wa.gov/#/BusinessSearch/Businesslnformation 212
lkp --mmEmbliki.- ANrWmmi� dhd0d rmmh.._
IFI
ILI
COVERAGES
CERTIFICATE NUMBER: 60525472
REVISION NUMBER:
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.
tNSR
LTR
Y
k
CLAIMS -MADE ,/ i OCCUR
TYPE OF INSURANCE ►4DDL SUBR
INSD MD
COMMERCIAL GENERAL LIABILITY I
i
' GEN'L AGGREGATE LIMIT APPLIES PER:
r PRO -
POLICY � ❑roc
JECT
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
HIRED
AUTOS ONLY
SCHEDULED
AUTOS
NON -OWNED
AUTOS ONLY
� UMBRELLA L{AB
' OCCUR
i
EXCESS LIAR CLAIMS -MADE
DED RETENTIQN $
A WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRI ETORlPARTNERIEXECUTIV
QFFiCERfMEMBEREXCL.IJDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
I
E
r
f
A
POLICY NUMBER
BLA57738883
' BLA57738883
Y/N
E �N/A
Stop Gap
i
1
POLICY EF F
�LMMIDDIYM
POLICY
/DP
r a
4/30/2020 : 4/30/202
I
1
4/30/2020 i 4/30/2021
LIMITS
EACH OCCURRENCE
$15000,000
DAMAGE TO RENTED
� PREMISES (Ea occurrence
$ 1
;0003000
MED EXP (Any one person)
$ 15,000
PERSONAL & ADV INJURY
$ 'I
1000,000
GENERAL AGGREGATE
s 2,000,000..
1 $ 2$000;000
PRODUCTS - COMP/OP AGG
COMBINED SINGLE LIMIT
$
(Ea accident
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
$
(Per accident
3
EACH OCCURRENCE
$
AGGREGATE
$
PER A
' STATUTE ER
E.L. EACH ACCIDENT
$1,000,000
E.L. DISEASE - EA EMPLOYEE
$140004000
E.L. DISEASE - POLICY LIMIT
$ 2,0001-POO
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 701, Additional Remarks Schedule, may be attached if more space is required)
Certificate Holder is Additional insured if requir
Insured Provision.
CERTIFICATE HOLDER
City of Federal Way
33325 8th Ave S
Federal Way WA 98003
ed by written contract or written agreement subject to General Liability Blanket Additional
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE �t q
Katlyn Griffin
O 19884015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
=9 WW a
Request for Taxpayer
Form Identification Number and Certification(Rey. �cto�er �018)
Department of the Treasury
Internal Revenue Service ► Go to www.rrs.gov/FormW9 for instructions and the latest information.
1 {Name (as shown an your income tax return). Name is required on this line; do not leave this line blank.
Ukrainian Community Center of Washin
n
2 Busd,
iness name/disregarded entity name, if different from above
M
v 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.
Q
o I I Individual/sole proprietor or ❑ C Corporation ❑ S Corporation Partnership ❑ Trust/estate
� = single -member LLC
CL+ "0 Limited Habillity company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ►
4 Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check
ow H LLC if the LLC is classified as asingle-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
CL a is disregarded from the owner should check the appropriate box for the tax classification of its owner.
dr
� Q ether (see instructions) ■ Non -&Profit corporation
� 5 Address (number, street, and apt. or suite no.) See instructions.
COO 1177701 - 108th Ave SE #336
6 City, state, and ZIP code
Renton, WA 98055
7 List account number(s) here (optional)
M:M§M Taxpayer Identification Number (TIN)
Give Form to the
requester. Do not
send to the IRS.
4 Exemptions (codes apply only to
certain entities, not individuals; see
I
nstructions on page 3):
Exempt payee code cif any)
Exemption from FATCA reporting
code cif any)
(App&s to accounts maintained outside the U.S.)
Requester's name and address (optional)
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 1, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see Haw to get a
TIN, later.
Notes. 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.
edification
Social security number
or
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number for 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 J.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this firm (if any) indicating that 1 am exempt from FATCA reporting is correct.
Certification instructions. You must crass 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, contribut] o an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign t�q certificati ut ou must provide your correct TIN. See the instructions for Past II, later.
Sign Signature of
Here I U.S. person 10*
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/FormW3.
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 fallowing.
• Form I 099-INT (:interest earned or paid)
Date ■
03/04/2021
Farm 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.
Cat. No. 10231X 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 for 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 an this form cif 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 dives 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 fawn 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 an 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
day the section 1446 withholding fax. 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 an its allocable share of net income from the partnership
conducting a trade or business in the Unite! 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. granter 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 bother than a grantor trust), the U.S. trust
father 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, coo 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 an certain tykes of income. However, most tax
treaties contain a provision known as a " saving cause." Exceptions
specified in the saving clause may permit an exemption from tax to
continue for certain hypes 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 mush 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 for 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.
Pan0- 9
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 align 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 #reaty (dated APril 30P 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 world 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 dorm W-8 or Form 8233.
Backup W0 0
ithholding
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
dP subject to backup withho#ding include interest, tax-exempt interest,
dividends, broker and barter exchange transactions, ran#s, royalties,
nonemployee pay, payments made in settlement of payment card and
third party network transactions, and certain payments from fishing boat
operators. Reif estate transactions are not subject to backup
withholding.
You will not be subject to backup withholding on payments you
receive it you give the requester your correct TIN, make the proper
certifications, and report all your taxable interest and dividends an your
tax return.
Payments you receive will be subject to backup withholding ffm.
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required see the instructions for
Part !I ��r details},
3. The IRS tails 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 jade, later, and the separate Instructions for the
Requester of Firm 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 inf
tion 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 Farm 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.
CITY of
Federal Way
To add your business to our
below,
Business Information
Bus iness Name:
Contact Name.
Location Addres
Mailing Address
Phone li:
33325 8th Avenue South,, Federal Way, WA 98003
IX]New Vendor E:1 Update Form
vendor file, or update information. Please complete this form and mail or fax it t
(For office use only) VN#
Ukrainian Community Center of Washington
o the address/fax number
Oleg Pynda
13470 Martin Luther King Jr. Way S CITY/STATE Seattle/WA
f different):
425 )430.
State of Washington U.B.I. #
8229
17701 108th Ave SE #336
CITY/STATE Renton/WA
Fax #: 425 336. 2785 E-Mail: 0pynda@uccwa,org
601-885-258 Federal Way Business License #:
Will you provide supplies or services to the City of Federal Way?
City of Federal Way Staff/DepartmentContact Name.
Signature (US Person including a
US resident alien)
For information call: 253-835.2525 or Fax: 253.835.2509
El Supplies
Dade:
IN Services
03/04/2021
Code 98178
Code 98055
or E-mail: Accountspayable@�)cityoffiederalway.com
0