Contract - TexasTERM - 4/9/2015 • ERM NEW INVESTOR APPL/CAT/ON
PRIOR Questions?Call 1-866-839-8376
Instructions: Complete this application to become a new investor in TexasTERMI. This application must be included with all other required documentation
and certifications in order to be accepted and processed by TexasTERM. Please fax or mail this completed application to your account representative at the
fax number or address listed at the bottom of this application.
INVESTOR INFORMATION: (All fields in this section must contain Investor information ONLY.)
Investor Name: City of Round Rock TIN# 74 - 6017485
(Name to appear on Pool records) (Taxpayer Identification Number)
Legal Name: Phone#: (512)218-3297
(Name as filed with the IRS,if different from above)
Street Address: 221 E Main Street Fax#: (512)218-5442
Street Address(A P.O.Box is not acceptable)
Round Rock TX 78664 Entity Type: City
city State Zip (City,County,School District,etc.)
Mailing Address: Fiscal Year End: 09/30
(If different from Street Address) Mailing Address(If different from Street Address) (Month and Day)
Contact Name: Joan Sharp
city State Zip 0 Mr. ❑r Ms. 0 Mrs.
INVESTOR CERTIFICATION: (A representative of the Investor should read,complete,sign and date this section.)
I. The undersigned represents and warrants that he/she has the full power and authority to make investments on behalf of the Investor listed above.
II. The undersigned certifies that the Investor named on this application adopted or enacted the attached Ordinance/Resolution at a duly convened
meeting of the governing body of the Investor held on the day of . 20. and that such
Ordinance/Resolution is in full force and effect on the date of this application,and that such Ordinance/Resolution has not been modified,amended
or rescinded since its adoption or enactment. (Please attach the Ordinance/Resolution to this document.)
III. The undersigned further certifies that the Investor has received a copy of the Pool's Information Statement, and agrees that the Investor will be
bound by the terms of such documents.
IV. The establishment of an account is subject to acceptance by the Pool and is subject to the conditions under the provisions contained in the
Information Statement.
V. Under penalty of perjury,the undersigned below certifies that the tax identification number provided for this Investor is true,correct and complete.
VI. The information,authorizations, and certifications set forth in or attached to this New Investor Application shall remain in full force and effect until
the Pool receives written notification of change.
X CT R C 2 a I I . \ �. \ 1_� Seal: �pWAD RO
Authorized Signature Date
Susan Morgan Chief Financial Officer O ,�
Print or Type Name of Authorized Signatory Title/Position }
r
REQUIRED , ,
•W-9(Name on W-9 must match IRS records) • Ordinance/Resolution • Investment Policy
POOL USE ONLY: (Please fax or mail this document to your account representative for their signature below.)
X X
TexasTERM Account Representative Signature Date Principal Approval Signature Date
Any document received by email will not be accepted. Please send byfax or mail. POOL USE ONLY
FAX TO: TexasTERM Client Services Group MAIL TO: TexasTERM Client Services Group v2014.10 Dare wmaLs
1-800-252-9551 P.O.Box 11760 Processed
Harrisburg,PA 17108-1760 Confirmed
Form W-9 Request for Taxpayer Give Form to the
(Rev.December 2014) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service
1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank.
City of Round Rock
N 2 Business name/disregarded entity name,if different from above
to
rn
to
°- 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to
C: certain entities,not individuals;see
° ❑Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑Trust/estate instructions on page 3):
ar c single-member LLC Exempt payee code([f any)
4.1° ° Limited liability company.Enter the tax classification C=C corporation,S=S corporation,P=partnership)►
0 ❑ tY P Y• ( rP P P P)
o 2 Note.For a single-member LLC that is disregarded,do not check LLC;check the appropriate box in the line above for Exemption from FATCA reporting
= y the tax classification of the single-member owner. code(if any)
nc
— ❑✓ Other(see instructions)0- Municipal Government (Apples(o accounts maintained outside the U.S.)
U
5 Address(number,street,and apt.or suite no.) Requester's name and address(optional)
a 221 E Main Street
rn
m 6 City,state,and ZIP code
u) Round Rock,TX 78664
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(page However,for a -m -
resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN 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 Employer identification number
guidelines on whose number to enter.
M4 - 6 1 0 1 1 1 7 1 4 8 5
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(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. 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,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.
Sign Signature of
Here U.S.person► l� Date► //,s—
General Instructions •Form 1098(home mortgage interest),1098-E(student loan interest),1098-T
(tuition)
Section references are to the Internal Revenue Code unless otherwise noted. •Form 1099-C(canceled debt)
Future developments.Information about developments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property)
as legislation enacted after we release it)is at www.irs.gov/fW9.
Use Form W-9 only if you are a U.S.person(including a resident alien),to
Purpose of Form provide your correct TIN.
An individual or entity(Form W-9 requester)who is required to file an information If you do not return Form W-9 to the requester with a TIN,you might be subject
return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What is backup withholding?on page 2.
which may be your social security number(SSN),individual taxpayer identification By signing the filled-out form,you:
number([TIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number
identification number(EIN),to report on an information return the amount paid to to be issued),
you,or other amount reportable on an information return.Examples of information
returns include,but are not limited to,the following: 2.Certify that you are not subject to backup withholding,or
•Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding if you are a U.S.exempt payee.If
•Form 1099-DIV(dividends,including those from stocks or mutual funds) 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
•Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and
•Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are
brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on
•Form 1099-S(proceeds from real estate transactions) page 2 for further information.
•Form 1099-K(merchant card and third party network transactions)
Cat.No.10231X Form W-9(Rev.12-2014)