Girl Scouts of Southeast Florida, Inc. ❑ MAIL CHECK TO VENDOR RI RETURN CHECK TO DEPT. ❑ INCLUDE BACK-UP W/ CHECK
CITY OF BOYNTON BEACH
DIRECT PAYMENT REQUISITION
Please issue a check in the amount of $250.00
VENDOR #:
TO: Girl Scouts of Southeast Florida, Inc.
6944 Lake Worth Road
Lake Worth, Fl 33467
FOR: Community Support Funds
Vice Mayor Romelus
Girl Scouts of Southeast Florida, Inc,
Requested By: Queenester Nieves Date: February 6, 2019
FUND DEPT BASIC ELE OBJ AMOUNT
Approvals: 001 1110 511 95 47 250.00
Div Head qui.4 A l/ 4
Finance Dept.
City Manager
250.00
R15-055
EXHIBIT "A"
COMMUNITY SUPPORT FUNDS
REQUEST FORM
Part I - Summary of Request (to be completed by City Clerk)
Date of Request: /JioJ/
Requested by Mayor/Commissioner: M, �X11 e 44 5
Amount Requested: $ a6-1).
Recipient/Payee: 114dam.
Description of project, program, or activity to be funded: Ui( St�.r, s
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Part II - Availability of funds
The annual appropriation of funds available to the requesting Member of the
Commission listed above is $ � rye .
The balance of funds available for the requesting Member of the Commission is
$ /, IWO .
Accordingly:
• There are funds available as requested
There are insufficient funds available as requested
Dated: 99 By:
"City Clerk
Part III-Eligibility Evaluation
❑ Public funds will not be used to improve private property unless there is a clear
public need, purpose and benefit
❑ The recipient/payee provides services within the City
❑ The public purpose is beneficial to the entire communi -d by such donation
Dated: By: OAP
Requesting Me -ter of the City Commission
S:\CC\WP\COMMUNITY INVESTMENT FUNDS\Community_Support_Funs_Policy.2015.doc
Form
W�9 Request for Taxpayer Give Form to the
(Rev,October 2018) Identification Number and Certification requester.Do not
Department of the Treasury send to the IRS.
Internal Revenue Service ►Go to www.irs.gov/FormW9 for instructions and the latest information.
1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank.
Girl Scouts of Southeast Florida,Inc
2 Business name/disregarded entity name,if different from above
M3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions(codes apply only to
mfollowing seven boxes, certain entities,not individuals;see
a instructions on page 3):
o ❑ Individual/sole proprietor or d❑ C Corporation ❑ S Corporation ❑ Partnership ❑Trust/estate
H single-member LLC Exempt payee code(if any) 501 C
n o
4.i ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)►
`o 2 Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting
Z w LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is codeIf an
.` another LLC that is not disregarded from the owner for U.S.federal tax purposes Otherwise,a single-member LLC that code(if
a 0 is disregarded from the owner should check the appropriate box for the tax classification of its owner.
dB ElOther(see instructions)... (Applies to accounrsmenwned outside me US)
y 5 Address(number,street,and apt.or suite no.)See instructions. Requester's name and address(optional)
2 6944 Lake Worth Road
6 City,state,and ZIP code
Gill
Lake Worth, FL 33467
7 List account number(s)here(optional)
Taxpayer Identification Number(TIN) __
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding.For individuals,this is generally your social security number(SSN).However,for a -f
resident alien,sole proprietor,or disregarded entity,see the instructions for Part I,later. For other -
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a l
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 identification number
Number To Give the Requester for guidelines on whose number to enter. '
5 9 - 0 6 5 7 3 2 7
Part II Certification
Under penalties of perjury,I certify that:
1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2. I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3. I am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,
acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments
other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
instructions� for Part II,later.
Sign Siature
Here u,s personf► (V Date► 0 I 1061 ( Ot_D) q
General Instructions •Form 1099-DIV(dividends,including those from stocks or mutual
funds)
Section references are to the Internal Revenue Code unless otherwise •Form 1099-MISC(various types of income,prizes,awards,or gross
noted. proceeds)
Future developments.For the latest information about developments •Form 1099-8(stock or mutual fund sales and certain other
related to Form W-9 and its instructions,such as legislation enacted transactions by brokers)
after they were published,go to www.irs.gov/FormW9.
•Form 1099-S(proceeds from real estate transactions)
Purpose of Form •Form 1099-K(merchant card and third party network transactions)
An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(student loan interest),
information return with the IRS must obtain your correct taxpayer 1098-T(tuition)
identification number(TIN)which may be your social security number •Form 1099-C(canceled debt)
(SSN),individual taxpayer identification number(ITIN),adoption •Form 1099-A(acquisition or abandonment of secured property)
taxpayer identification number(ATIN),or employer identification number
(EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S.person(including a resident
amount reportable on an information return.Examples of information alien),to provide your correct TIN.
returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might
•Form 1099-INT(interest earned or paid) be subject to backup withholding.See What is backup withholding,
later.
Cat.No.10231X Form W-9(Rev 10-2018)