Mayor Grant - Peggy Adams Animal Rescue League❑ MAIL CHECK TO VENDOR 0 RETURN CHECK TO DEPU INCLUDE BACK-UP W/ CHECK
CITY OF BOYNTON BEACH
DIRECT PAYMENT REQUISITION
Please issue a check in the amount of $200.00
TO: Peggy Adams Animal Rescue League
3200 N. Military Trail, Suite 3100
West Palm Beach, FI 33409
FOR: Community Investment Funds
Mayor Grant Community Investment Funds
Requested By: Queenester Nieves
Approvals:
�7
Div Head (/'z i /✓
Finance Dept.
City Manager
VENDOR #:
Date: February 12, 2020
FUND
DEPT BASIC
ELE
OBJ
AMOUNT
001
1110 511
95
47
200.00
1 200.00
R15-055
EXHIBIT "A"
COMMUNITY SUPPORT FUNDS
REQUEST FORM
Part I - Summary of Request (to be completed by City Clerk)
Date of Request: 2/05/2020
Requested by Mayor/Commissioner: Mayor Steven B. Grant
Amount Requested: $ 200.00
Recipient/Payee: Peggy Adams Animal Rescue League
Description of project, program, or activity to be funded: The Peggy Adams Animal
Rescue League provides shelter to lost, homeless and unwanted animals, provides
spay, neuter and other medical services for companion animals and advocates for
animal welfare, community involvement and education to further the bond between
people and animals. Funding supports programs and services to help animals in need.
Part II - Availability of funds
The annual appropriation of funds available to the requesting Member of the
Commission listed above is $ 2,000.00 .
The balance of funds available for the requesting Member of the Commission is
$ 800.00
Accordingly:
There are funds available as requested
❑ There are insufficient funds available as requested
Dated: By:
City Clerk
Part III -Eligibility Evaluation
C� 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
GK -The public purpose is beneficial to the ent'r6co mun' y served by such donation
Dated: By:
Requesting Member of the City Commission
Form
W-9
Request for Taxpayer
Give Form to the
(Rev. December 2014)
Identification Number and Certification
requester- not
Department oithe Treawry
Send t0 the IRS.
Internal Rrve^ue Service
1 Name (as shown on your income tax return). Name :s required on th s fine: do not leave this line blank.
Peggy Adams Animal Rescue League of the Palm Beaches, Inc
l 2 Bus -nm name/d:sregarded entity name. if different from above
m
c
m
CL
3 Check avtimpnate box for federal tax classification; check only one of the following seven boxes:
4 Exemptions (codes apply only to
°
a
Indwidual/sole proprietor or C Corporatron
❑ p p ❑ ❑ S Corporation ❑ Partnership ❑ Trust/estate
certa-n entiVes, not individua!s: see
instructions on page 3):
m c
,—,
I single -member LLC
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) 11 -
Exempt payee code (f any)
Note.
Note. For a s,ng!e-member LLC that is d sregarded, do not check LLC; check the appropriate box in the line above for
Exwrot,on from FATCA repo ting
m
the tax classification of the single -member owner.
code (if any)
C
a u
❑ other flee instruct'ons) ► Non-profit
USI
0
5 Address (number, street. and apt. or suite no.)
Requester's name and address (ootiarttl
3100-3200 N Military Trail
y
m
6 C ty, state. and ZIP code
West Palm Beach, FL 33409
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 (SSM. However, }ora
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other L I I SWI {
entities, It is your employer identification number (EIM. If you do not have a number, see How to get a
T1N on page 3. or
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for I Employer Identification number 1
guidelines on whose number to enter.
5 9 -I0 6 3 7 8 1 1
Under penalties of perjury, 1 certify that:
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 (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 (it any) indicating that 1 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 on page 3. r �
,tyrt U.S person ef l � f ,��li �J Date ► U . I —T
Here
General Instructions
Section references are to the Internal Revenue a unl s otherwise noted.
Future developments. Information about devN.opmne affecting Form W-9 (such
as legislation enacted after we release it) is at www.irs.gov/Av9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to fife an information
return with the IRS must obtain your correct taxpayer identification number (TIN)
which may be your social security number (SSM, individual taxpayer identification
number (TIM, adoption taxpayer identification number (ATIN), or employer
identihcabon number (EIM, to report on an information return the amount pa,d 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 (-nterest earned or paid)
• Form 1099 -DIV (dividends, including those from stocks or mutual funds)
• Form 1099-MISC (var oars 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 transactional
• Form 1099-K (mecnant card and thrd party network transactions)
• Form 1098 (home mortgage Interest), 1098-E (student loan interest), 1098-T
(tuition)
• Form 1099-C (canceled debt)
• Form 1099-A facquisa on or abandonment of secure 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 wifhholdirrg? on page 2.
By vgninq the Wed -out form, you:
1. Certify that the TIN you are giving is correct for you are wa,t:ng for a number
to be issued),
2. Certify that you are not subsea to backup withholding, or
3. Claim exemption from backup wdnholdtmg if you are a U.S. exempt payee. tf
applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership income from a U.S. trade or business is not subject to the
withholding tax on foreign partners' share of effectively connected income, and
4. Certify that FATCA code(s) entered on th!s form lif any) ind,cabng that you are
exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
page 2 for further information.
Cnt. No. 10231X Foran W-9 (Rev. 12-2014)
R15-055
EXHIBIT "A"
COMMUNITY SUPPORT FUNDS ohm
1"C296M�
REQUEST FORM
Part I - Summary of Request (to be completed by City Clerk)
Date of Request: 2/05/2020
Requested by Mayor/Commissioner: Mayor Steven B. Grant
Amount Requested: $ 200.00
Recipient/Payee: Peggy Adams Animal Rescue League
Description of project, program, or activity to be funded: The Peggy Adams Animal
Rescue League provides shelter to lost, homeless and unwanted animals, provides
spay, neuter and other medical services for companion animals and advocates for
animal welfare, community involvement and education to further the bond between
people and animals. Funding supports programs and services to help animals in need.
Part II - Availability of funds
The annual appropriation of funds available to the requesting Member of the
Commission listed above is $ 2,000.00 .
The balance of funds available for the requesting Member of the Commission is
$ 900.00
Accordingly:
/There are funds available as requested
There are insufficient funds available as requested
Dated: 2) By: L4
City Clerk
Part III -Eligibility Evaluation
C" 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 ent' OF mun' y served by such donation
Dated: By:
Requesting Member of the City Commission
❑ MAIL CHECK TO VENDOR El RETURN CHECK TO DEPT] INCLUDE BACK-UP W/ CHECK
CITY OF BOYNTON BEACH
DIRECT PAYMENT REQUISITION
Please issue a check in the amount of $200.00
TO: Peggy Adams Animal Rescue League
3200 N. Military Trail, Suite 3100
West Palm Beach. FI 33409
FOR: Communitv Investment Funds
Mavor Grant Communitv Investment Funds
Requested By: Queenester Nieves
Approvals:
Div Head
Finance Dept.
City Manager
VENDOR #:
Date: February 12, 2020
FUND
DEPT BASIC
ELE
OBJ
AMOUNT
001
1110 511
95
47
200.00
200.00