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HomeMy WebLinkAboutState of California Department of General Services 2018-02-05CAL -Card @ Request to Participate Form AGENCY INFORMATION: (24P-, OF ak_z 1VH Legal Name of California Tax Funded Agency 1" l g,r 7lit17 a&6,12— Name &6,12' Name of Contact Person at Agency Mailing Address Litt-, Iitht 04 95 8� City, State, Zip Code �0 Estimated number of Cards REQUIRED DOCUMENTS: Tax ID Number 1 3c? (mob Date %07 — Zj — (o 7— Phone Email Address Estimated monthly spend State agencies: Complete and submit the following to U.S. Bank: • This Request to Participate form. • Completed State Agency Subscription Agreement (formatted Std. 213). • Completed W-9 form (Note: Complete Sections 1 and 4 only. Do not complete Section 2.) Local agencies (cities, counties, special districts, schools districts and other non -state agencies): Complete and submit the following to U.S. Bank: • This Request to Participate form. • Signed Local Agency Subscription Agreement; Include signed Certificate of Authority (if applicable). • Completed W-9 form (Note: Complete Sections 1 and 4. Section 2 is optional.) • Three years of audited financial statements; check one box to indicate how financials will be provided. Paper copy mailed with original documents 1X_ PDF copy emailed to cpsmidmarketsalescoordinatora-usbank.com Documents available online at: provide web address To ensure all documents are completed properly, please check for the following: • Legal names must be used, documents with abbreviated legal names cannot be processed. • All documents must be dated and titles must be consistent throughout. SUBMITTAL INSTRUCTIONS: Please send required documentation (listed above) to the CAL -Card Sales Coordinator at: Email (preferred): cpsmidmarketsalescoordinatorCg.usbank.com U.S. Mail (optional): U.S. Bank 901 Marquette Avenue, EP-MN-A17S Minneapolis, MN 55402 NOTE: Submit W-9 as directed therein. U.S. Bank will contact you to confirm receipt of this Request to Participate Form. After U.S. Bank's review is complete, an implementation manager will contact you to set up your program. QUESTIONS? Email us at: cpsmidmarketsalescoordinator(cDUSbank.com For U.S .Bank Internal Use Only Date Submitted Circle one: <$5MM> $5MM Banker's Employee ID IPM Treasury Management Employee ID RM AM MMWR: 55631 Page 1 of 1 R 10.1.2014 CMbank. serving you C,OCA- No, 0 060(,0 State of California Participating Addendum No. 7-14-99-22 Local Agency Subscription Agreement This Local Agency Subscription Agreement ("Local Agency Subscription Agreement") constitutes an agreement to participate under the terms and conditions of the Purchase Card Services Participating Addendum No. 7-14-99-22 ("Participating Addendum") signed September 29, 2014 and entered into by U.S. Bank National Association ("U.S. Bank") and the State of California, Department of General Services ("State"). This Local Agency Subscription Agreement is entered into by U.S. Bank and the "Local Governmental Agency" identified herein, and shall become effective upon signing by U.S. Bank ("Effective Date"). RECITALS A. The State has entered into the Participating Addendum for the purpose of making available a Purchase Card Program as described in the Participating Addendum for use by State of California state agencies and local governmental agencies; B. The State is willing to permit Local Governmental Agency to participate in the Purchase Card Program provided that Local Governmental Agency assumes all responsibility and liability for Local Governmental Agency's performance of the terms and conditions of the Participating Addendum as if Local Governmental Agency was the entity signing the Participating Addendum, but Local Governmental Agency shall not be liable for the acts and omissions of the State under the Participating Addendum or this Local Agency Subscription Agreement. The State shall not bear liability or responsibility for Local Governmental Agency under the Participating Addendum or this Local Agency Subscription Agreement; and C. Local Governmental Agency has received a copy of the Participating Addendum from the State, and after a thorough review of the Participating Addendum, desires to participate as a Local Governmental Agency under the Participating Addendum. Participating Addendum No. 7-14-99-22 is incorporated into this Local Agency Subscription Agreement in its entirety and all terms and conditions of the Participating Addendum apply to the Local Governmental Agency. AGREEMENT Now therefore, in consideration of the foregoing Recitals, the mutual premises and covenants set forth in the Participating Addendum, which are incorporated herein by reference, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, all parties agree as follows: 1. Local Governmental Agency Responsibility. Local Governmental Agency agrees to accept and perform all duties, responsibilities and obligations required of Participating Agencies as set forth in the Participating Addendum. 2. Authority. The representations, warranties and recitals of Local Governmental Agency set forth in this Local Agency Subscription Agreement and the Participating Addendum constitute valid, binding and enforceable agreements of Local Governmental Agency. All extensions of credit made to Local Governmental Agency pursuant to this Local Agency Subscription Agreement and the Participating Addendum will be valid and enforceable obligations of Local Governmental Agency and Local Governmental Agency shall pay to U.S. Bank all Debts incurred by Local Governmental Agency in accordance with the terms of the Participating Addendum and this Local Agency Subscription Agreement. The execution of this Local Agency Subscription Agreement and the performance of the obligations hereunder and under the Participating Addendum are within the power of Local Governmental Agency, have been authorized by all necessary action and do not constitute a breach of any contract to which Local Governmental Agency is a party or is bound. 3. Purpose of Card Use. Local Governmental Agency declares that cards shall be used for official Local Governmental Agency purchases only, and shall not be used for individual consumer purchases or to incur consumer debt. Local Governmental Agency warrants that it possesses the financial capacity to perform all of its obligations under the Participating Addendum and this Local Agency Subscription Agreement. 4. The notice address for Local Governmental Agency is: CITY OF UKIAH 300 SEMINARY AVENUE UKIAH, CALIFORNIA 95482 Attn: MARY HORGER 5. Rebate Payment. To receive payment, Local Governmental Agency must register in the manner prescribed by U.S. Bank. U.S. Bank will not make any payments until Local Governmental Agency has registered. If Local Governmental Agency fails to register by the end of the first Addendum Year, Local Governmental Agency forfeits any payments for that Addendum Year and any subsequent Addendum Years in which Local Governmental Agency fails to register. Local Governmental Agency designates the following person to register Local Governmental Agency. Authorized Person's Name MARY HORGER Authorized Person's Email Address mhorger@cityofukiah.com CPS 1700042 Page 1 of 5 R 5/2017 cot, wo. 111 Q, [l o 6. Billing Statements. Local Governmental Agency may choose to have Statements for all Accounts with Central Billing (1) delivered by U.S. mail ("Paper Statements"); (2) made available electronically ("Electronic Statement(s)") for Local Governmental Agency to access on its own through the account management system or (3) both delivered as Paper Statements and made available as Electronic Statements. If Local Governmental Agency chooses Electronic Statements only, that is, option (2) herein, U.S. Bank will suppress delivery of Paper Statements. 7. Authorization. Local Governmental Agency certifies to U.S. Bank that the person executing this Local Agency Subscription Agreement is authorized by Local Governmental Agency in accordance with its organization rules and applicable law to bind Local Governmental Agency to the terms and conditions of this Local Agency Subscription Agreement, including the authority to incur Debt in the name of Local Governmental Agency. 8. Execution. By signing below, the individual(s) signing this Local Agency Subscription Agreement is/are acting in his or her capacity as an authorized signing officer of Local Governmental Agency and not in his or her personal capacity, and certifies and warrants that (1) all action required by Local Governmental Agency organizational documents to authorize the signer(s) to act on behalf of Local Governmental Agency in all actions taken under this Local Agency Subscription Agreement, including but not limited to, the authority to incur Debt on behalf of Local Governmental Agency, has been taken, (2) each signer is empowered in the name of and on behalf of Local Governmental Agency to enter into all transactions contemplated in this Local Agency Subscription Agreement, and (3) the signatures appearing on all supporting documents of authority, if any, are authentic. 9. Reliance. Local Governmental Agency has read, understands and agrees to all terms and conditions in this Local Agency Subscription Agreement and the Participating Addendum, and U.S. Bank is entitled to act in reliance upon the authorizations and certifications set forth herein. IN WITNESS WHEREOF, the parties have, by their authorized representatives, executed this Local Agency Subscription Agreement. Dated this --A day ofkb�, 20A By Local Governmental Agency: CITY OF UKIAH (Name) (Sig turd ­of Au zed Signer) SAGE SANGIACOMO (Printed Name of Authorized Signer) CITY MANAGER (Printed Title of Authorized Signer) Approved, sto rm: tZ �2,, f �9� (Sig ature tto ney for-1-6cal doverfimenfal Agency) DAVID RAPPORT (Printed Name of Attorney) Dated this day of , 20_ By U.S. Bank: U.S. Bank National Association (Signature of Authorized Signer) Michael C. Leppones (Printed Name of Authorized Signer) Vice President (Printed Title of Authorized Signer) CPS 1700042 Page 2 of 5 R 5/2017 EXAMPLES TO Signing Instructions for Certificate of Authority (C Of A) EXAMPLE 1: Cow Nn . nIB 11(0 1. One (1) person is required to sign legal documents, and 2. Local Governmental Agency has more than two (2) authorized signatories who can attest to signatures of other signatories. Local Agency Subscription Agreement: Person A signs C of A Section 2: Person A completes and signs. C of A Section 3: First box is checked. C of A Section 5: Person B (preferably the Secretary) signs attesting to the signature of Person A AND Person C signs attesting to Person B's authority and signature. EXAMPLE 2: 1. Two (2) people are required to sign legal documents, and 2. Local Governmental Agency has more than two (2) authorized signatories who can attest to signatures of other signatories. Local Agency Subscription Agreement: Persons A and B sign C of A Section 2: Persons A and B complete and sign. C of A Section 3: Second box is checked. C of A Section 5: Person C (preferably the Secretary) signs attesting to the signatures of Persons A and B AND Person D signs attesting to Person C's authority and signature. EXAMPLE 3: 1. One (1) person is required to sign legal documents, and 2. Local Governmental Agency has only one (1) other authorized signatory who can attest to signatures of other signatories. Local Agency Subscription Agreement: Person A signs C of A Section 2: Person A completes and signs. C of A Section 3: First box is checked. C of A Section 5: Person B (preferably the Secretary) signs attesting to the signature of Person A. NOTE: If the Secretary can sign the C of A, than they cannot be Person A; they must be Person B. AND Person A signs attesting to Person B's authority and signature. EXAMPLE 4: 1. Two (2) people are required to sign legal documents, and 2. Local Governmental Agency has only one (1) other authorized signatory who can attest to signatures of other signatories. Local Agency Subscription Agreement: Persons A and B sign. C of A Section 2: Persons A and B complete and sign. C of A Section 3: Second box is checked. C of A Section 5: Either Person A or B (preferably the Secretary) signs attesting to the signature of Persons A and B. NOTE: If the Secretary can sign the C of A, than they must sign in Section 4 and the other person must sign in Section 5 AND the Person who did not sign Section 4 signs attesting to the signing authority and signature of the person who did sign in Section 4, subject to the note above. CPS 1700042 Page 4 of 5 R 5/2017 Cow No• 11161?0 CERTIFICATE OF AUTHORITY 'INSTRUCTIONS' Before completing the Certificate of Authority, please read: If the Local Agency Subscription Agreement being signed was "approved as to form" by an attorney, it is not necessary to complete the attached Certificate of Authority (C of A). If the Local Agency Subscription Agreement was not "approved as to form" by an attorney, please complete the attached C of A (page 7). Be sure to date all documents upon signing. Undated documents cannot be accepted and will be returned for dating. Signing Instructions for Certificate of Authority Note that three (3) different individuals must sign and date the C of A. If the Local Governmental Agency does not have three individuals who are authorized to sign on behalf of the Local Governmental Agency, please refer to page 6. Section 1 Organizational Information- Enter the legal Local Governmental Agency name and the tax ID number on the C of A. Note: The legal name of the Local Governmental Agency name is required. The legal name is usually the name on the Local Governmental Agency's financial statements. Section 2 Authorized Persons - The individual who signed the Local Agency Subscription Agreement must complete and sign in Section 2. Section 3 Execution Requirement - Check only one box in Section 3 to indicate how many individuals (either 1 or 2) that the Local Governmental Agency requires to sign legal documents on behalf of the Local Governmental Agency. Section 4 Execution - No action required. Section 5 Certification - Two (2) individuals must sign and date Section 5 as well as insert their names and titles. Note: The individual(s) who signed in Section 2 cannot sign in Section 5 or this document is invalid. • An officer of the Local Governmental Agency ("Officer One") is required to sign the top area of Section 5 attesting to the signatures in Section 2. • One other officer of the Local Governmental Agency ("Officer Two") must sign the bottom area of Section 5 attesting to the signature of Officer One. Please see examples below: 5. Certification. I certify that I am the Secretary and I am acting in my official capacity as an authorized officer who has been given the authority by the Local Governmental Agency to certify that the Authorized Person(s) has/have the full power and authority under applicable law and the governance rules relating to the Local Governmental Agency to execute and deliver to U.S. Bank, on behalf of the Local Governmental Agency, and to bind the Local Governmental Agency under, the Documents for the purpose of establishing and extending the Services. I also certify that the name(s) and title(s) of the Authorized Person(s) set forth above are correct and that the signature appearing beside each name is a true and genuine specimen of his/her signature. JOHN DOE n PRINTED NAME OF THE SECRETARY OF THE LOCAL GOVERNMENTAL AGENCY i (CANNOT BE AN AUTHORIZED PERSON LISTED IN SECTION 2) Signature of the Secretary of the Local Governmental Agency DATE I certify that I am an officer of the Local Governmental Agency, and as such, I certify that the above-named Secretary is acting in such capacity on behalf of the Local Governmental Agency, the signature below is my genuine signature and the signature above is the genuine signature of such Secretary. JANE SMITH, TREASURER n PRINTED NAME & TITLE OF INDIVIDUAL SIGNING BELOW i (CANNOT BE AN AUTHORIZED PERSON LISTED IN SECTION 2) Signature n Attested by One (1) Other Individual of the Local Governmental Agency DATE CPS 1700042 Page 3 of 5 R 5/2017 C,Qw No. nt8 n6 CERTIFICATE OF AUTHORITY 1. Organizational Information. This Certificate of Authority has been completed on behalf of the following Local Governmental Agency (the "Local Governmental Agency"): Local Governmental Agency Legal Name: Federal Tax Identification Number: 2. Authorized Persons. In accordance with the governance rules relating to the Local Governmental Agency, the following individuals (the "Authorized Person(s)") are authorized, on behalf of the Local Governmental Agency, to execute and deliver to U.S. Bank National Association ("U.S. Bank") and/or its affiliates the applicable contract(s), any applicable addenda and/or amendments thereto and any other documents or writings required by U.S. Bank (collectively, the "Documents") for the purpose of establishing one (1) or more card programs, extending credit and providing related services to the Local Governmental Agency with U.S. Bank in the United States (collectively, the "Services"): Name Title Signature 3. Execution Requirements. The governance rules relating to the Local Governmental Agency require the following number of Authorized Persons to sign the Documents for the Services (choose only one box): ❑ One (1) Authorized Person ❑ Two (2) Authorized Persons 4. Execution. By signing the Documents, each individual signing in his or her capacity as an authorized signing officer of the Local Governmental Agency and not in his or her personal capacity, certifies and warrants that (a) all action required by Local Governmental Agency's organizational documents to authorize the signer(s) to act on behalf of the Local Governmental Agency in all actions taken under the Documents, including but not limited to, the authority to incur debt on behalf of the Local Governmental Agency, has been taken, (b) each signer is empowered in the name of and on behalf of the Local Governmental Agency to enter into all transactions and Services contemplated in the Documents, and (c) the signatures appearing on all supporting documents of authority are authentic. 5. Certification. I certify that I am the and I am acting in my official capacity as an authorized officer who has been given the authority by the Local Governmental Agency to certify that the Authorized Person(s) has/have the full power and authority under applicable law and the governance rules relating to the Local Governmental Agency to execute and deliver to U.S. Bank, on behalf of the Local Governmental Agency, and to bind the Local Governmental Agency under, the Documents for the purpose of establishing and extending the Services. I also certify that the name(s) and title(s) of the Authorized Person(s) set forth above are correct and that the signature appearing beside each name is a true and genuine specimen of his/her signature. Printed Name of the of the Local Governmental Age Signature of the of the Local Governmental (Cannot be an Authorized Person listed in Section 2) Date I certify that I am an officer of the Local Governmental Agency, and as such, I certify that the above-named is acting in such capacity on behalf of the Local Governmental Agency, the signature below is my genuine signature and the signature above is the genuine signature of such Printed Name & Title of Individual Signing Below 11 (Cannot be an Authorized Person listed in Section 2) Signature n Attested by One (1) Other Individual of the Local Governmental Agency Date CPS 1700042 Page 5 of 5 R 5/2017 cov— No- 111$1-1to bank. U.S. Bank W-9 & Related Information Form instructions Vendor Number: To be completed by U.S. Bank's Corporate Payables department Section 1: W-9 information U.S. Bank requires your taxpayer identification number and filing information in the case that we must file an information return to the IRS to report income paid to you. Please complete Section 1 in its entirety. Section 2: Automated Clearing House (ACH) ACH is U.S. Bank's preferred payment method. Signing up for ACH will allow U.S. Bank to pay you (vendor) through an automated electronic deposit into your preferred checking account. ACH eliminates mail delivery time and funds are credited to your account within 1-2 business days of the payment date for U.S. Bank account holders and 3-5 business days for non -U.S. Bank account holders. A remittance advice detailing the invoice number(s), date and dollar amount will be sent to you via e-mail if an e-mail address is provided or mail when the payment has been sent electronically to your account. Please acquire your routing number and account number from a check (not from a deposit slip) Section 3: Minority and Women Owned Business Enterprises (MWBEs) U. S. Bank is committed to building relationships with certified MWBEs, defined as companies that are at least 51 percent owned, controlled and managed by one or more of the following categories - African American, Hispanic American, Asian Pacific American, Asian Indian American, Native American, Woman. Please include a copy of the company's certification from a regional council of the National Minority Supplier Development Council (NMSDC); the Women's Business Enterprise National Council (WBENC); the National Women Business Owners Corporation (NWBOC); or a federal, state or local government affiliate. Section 4: Signature and Submission Please submit the signed and completed form to: Mail: Rebates 901 Marquette Ave S EP-MN-A18S Minneapolis, MN 55402 Email: cps.rebates@usbank.com Foreign and Sole Proprietor If you are a sole proprietor, please complete and submit a W-9 form or Form 8233 from the IRS. For all other legal structures for foreign vendors, please complete a W-8BEN form or W-8EC1 form. Corporate Payment Systems, EP -MN -Al 8S Minneapolis, MN 55402 © 2013 U.S. Bank National Association. Rev (01/14) Coin, No . 1'118 k-1 to bank. U.S. Bank W-9 & Related Information Return completed form to cps.rebates@usbank.com or US Postal Mail as indicated on the instruction page. Vendor Number (to be completed by U. S. Bank): I Section I: W-9 Must be completed and returned for payments to be processed. CITY OF UKIAH Legal Name Trade Name 300 SEMINARY AVENUE UKIAH CA 95482 Address City Staie ZIP 707-463-6233 707-463-6204 94-6000446 Phone Fax Federal Tax ID/Social Security Number* *MUST match the person/entity listed above Legal Structure ❑ Sole Proprietorship If LLC, please select one of the following: ❑ Corporation ❑ LLC Corporation ❑ Partnership ❑ LLC Partnership ❑ Tax Exempt Organization ❑ LLC Sole Proprietorship (legal name and SSN required) ❑o Government Agency Legal Name ❑ Other, please specify SSN Section 2: Automated Clearing House (Direct Deposit) U.S. Bank's preferred payment method. ❑■ Authorization Agreement for Automatic Deposits (ACH Credits) I (We) hereby authorize U.S. Bank, on behalf of any affiliate for which it processes payments, hereinafter called COMPANY, to initiate credit entries to my (our) account indicated below and the depository/financial institution named below, hereinafter called BANK, to credit the same to such account. Ihalvorsen a@cityofukiah.com cps rebates(a_)usbank.com E-mail address (to receive electronic remittance advices) Checking Account Information (Please attach a voided check or copy of a check with MICR coding) 1220-00496 7020022285 MUFG UNION BANK N.A. Routinq/ABA Number Account Number Bank Name Branch SAN FRANCISCO CALIFORNIA City State 94104 800.322.2778 ZIP Phone This authority is to remain in full force and effect until COMPANY has received written notification from me (us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonably opportunity to act on it. Section 3: Minority and Women Owned Business Enterprises (MWBEs) U. S. Bank is committed to building relationships with certified Minority and Women Owned Business Enterprises (MWBEs), defined as companies that are at least 51 percent owned, controlled and managed by one or more of the following categories - African American, Hispanic American, Asian Pacific American, Asian Indian American, Native American, Woman Is your company certified as a minority/ woman owned business? ❑ No ❑Yes (if yes, a copy of your minority/woman owned certification MUST BE INCLUDED) MWBE Business Status (check all that apply): ❑ African American ❑ Asian Pacific American ❑ Hispanic American ❑ Asian Indian American Native American Woman This will certify to U.S. Bank that I have read the requirements cited on this form, and the company classification (s) I have selected above are true and correct. I will advise U.S. Bank if our classification should change. Section 4: Signature (required) Name (Print): SAGE SANGIACOMO Title: CITY MANAGER Signature S Date Corporate Payment Systems, EP-MN-A18S Minneapolis, MN 55402 @ 2013 U.S. Bank National Association. Rev (01/14) — +sem — % It— For Internal Use Only: DUNs#