SAP S016224, CENTERLINE AND EDGE STRIPING

Office of County Commissioners
Finance Department
130 Jacob's Way, Suite 302, Clarkesville, GA 30523
706-839-0200 Fax 706-839-0219
accountspayable@habershamga.com
Vendor Application Return Document Checklist (Please Initial).
Required by all vendors:
_____ Completed Vendor Application.
_____ Completed W9 Form.
_____ Vendor Affidavit Agreement (E-Verify).
*If not legally required to participate in the E-Verify Program, the following are
required.
_____ Private Employer Affidavit.
_____ Copy of state issued photo identification (Driver's License, Passport, etc.).
Insurance Requirements:
_____ Copy of your Company's most recent Insurance Certificate(s) (Must be kept
current, see attached explanation of insurance requirements).
Optional Forms:
_____ Completed ACH Payment Approval Form (Optional, fill out if you wish to receive
vendor payments through automated fund transfer).
_____ Bidder List Application (This is help us contact you directly for future bidding
opportunities).
**If any required forms are returned incomplete, Active
Vendor status will not be granted, and subsequent payments
may be delayed. Please remember that documents requesting
notary verification must be notarized to be considered
complete. **

W-9
Request for Taxpayer
Form Give form to the
(Rev. March 2024) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Go to www.irs.gov/FormW9 for instructions and the latest information.
Internal Revenue Service
Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.
.epyt
ro
tnirP
.3
egap
no
snoitcurtsnI
cificepS
eeS
1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner's name on line 1, and enter the business/disregarded
entity's name on line 2.)
2 Business name/disregarded entity name, if different from above.
3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check 4 Exemptions (codes apply only to
only one of the following seven boxes. certain entities, not individuals;
see instructions on page 3):
Individual/sole proprietor C corporation S corporation Partnership Trust/estate
LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) . . . . Exempt payee code (if any)
Note: Check the "LLC" box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax
classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate Exemption from Foreign Account Tax
box for the tax classification of its owner. Compliance Act (FATCA) reporting
Other (see instructions) code (if any)
3b If on line 3a you checked "Partnership" or "Trust/estate," or checked "LLC" and entered "P" as its tax classification,
(Applies to accounts maintained
and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check
outside the United States.)
this box if you have any foreign partners, owners, or beneficiaries. See instructions . . . . . . . . .
5 Address (number, street, and apt. or suite no.). See instructions. Requester's name and address (optional)
6 City, state, and ZIP code
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Social security number
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 I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
or
TIN, later.
Employer identification number
Note: If the account is in more than one name, see the instructions for line 1. See also What Name and
Number To Give the Requester for guidelines on whose number to enter. -
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
Signature of
Here U.S. person Date
General Instructions New line 3b has been added to this form. A flow-through entity is
required to complete this line to indicate that it has direct or indirect
Section references are to the Internal Revenue Code unless otherwise foreign partners, owners, or beneficiaries when it provides the Form W-9
noted. to another flow-through entity in which it has an ownership interest. This
Future developments. For the latest information about developments change is intended to provide a flow-through entity with information
related to Form W-9 and its instructions, such as legislation enacted regarding the status of its indirect foreign partners, owners, or
after they were published, go to www.irs.gov/FormW9. beneficiaries, so that it can satisfy any applicable reporting
requirements. For example, a partnership that has any indirect foreign
What's New partners may be required to complete Schedules K-2 and K-3. See the
Partnership Instructions for Schedules K-2 and K-3 (Form 1065).
Line 3a has been modified to clarify how a disregarded entity completes
this line. An LLC that is a disregarded entity should check the Purpose of Form
appropriate box for the tax classification of its owner. Otherwise, it
should check the "LLC" box and enter its appropriate tax classification. An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS is giving you this form because they
Cat. No. 10231X Form W-9 (Rev. 3-2024)

Contractor Affidavit under O.C.G.A. 13-10-91(b)(1)
By executing this affidavit, the undersigned, who is the duly elected/appointed
_________________ <insert title> of ____________________________, <name of
entity> the contractor, and is duly authorized to make this Affidavit on behalf of the
contractor, verifies its compliance with O.C.G.A. 13-10-91, stating affirmatively that
the individual, firm or corporation which is engaged in the physical performance of
services on behalf of Habersham County, Georgia has registered with, is authorized to
use and uses the federal work authorization program commonly known as E-Verify, or
any subsequent replacement program, in accordance with the applicable provisions and
deadlines established in O.C.G.A. 13-10-91. Furthermore, the undersigned
contractor will continue to use the federal work authorization program throughout the
contract period and the undersigned contractor will contract for the physical
performance of services in satisfaction of such contract only with subcontractors who
present an affidavit to the contractor with the information required by O.C.G.A.
13-10-91(b). Contractor hereby attests that its federal work authorization user
identification number and date of authorization are as follows:
_________________________________
Federal Work Authorization User Identification Number (E-Verify Number)
_________________________________
Date of Authorization
_________________________________
Name of Contractor
_________________________________
Name of Project
_________________________________
Name of Public Employer
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on ______, ___, 20___ in ______________________(city), ______(state).
_________________________________
Signature of Authorized Officer or Agent
_______________________________
Printed Name and Title of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE ______ DAY OF ______________,202__.
_________________________________
NOTARY PUBLIC
My Commission Expires:
_________________________________

Private Employer Affidavit Pursuant To O.C.G.A. 36-60-6(d)
By executing this affidavit under oath, the undersigned private employer verifies one of the
following with respect to its application for a business license, occupational tax certificate, or other
document required to operate a business as referenced in O.C.G.A. 36-60-6(d):
Section 1. Please check only one:
(A) ________ On January 1st of the below-signed year, the individual, firm, or
corporation employed more than ten (10) employees1.
*** If you select Section 1(A), please fill out Section 2 and then execute below.
(B)________ On January 1st of the below-signed year, the individual, firm, or
corporation employed ten (10) or fewer employees.
*** If you select Section 1(B), please skip Section 2 and execute below.
Section 2.
The employer has registered with and utilizes the federal work authorization program in
accordance with the applicable provisions and deadlines established in O.C.G.A. 36-60-6. The
undersigned private employer also attests that its federal work authorization user identification
number and date of authorization are as follows:
__________________________________
Name of Private Employer
__________________________________
Federal Work Authorization User Identification Number
__________________________________
Date of Authorization
---------------------------------------------------------------------------------------------------------------------
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on ______, ___, 20___ in _______________________ (city), _____ (state).
__________________________________
Signature of Authorized Officer or Agent
__________________________________
Printed Name and Title of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE ______ DAY OF ______________, 20___.
_______________________________________________
NOTARY PUBLIC
My Commission Expires: __________________________
1
To determine the number of employees for purposes of this affidavit, a business must count its total number of
employees company-wide, regardless of the city, state, or country in which they are based, working at least 35 hours
a week.

Vendor ACH/Direct Deposit Authorization Form
Habersham County Board of Commissioners
1.Please Check One:
NEW Direct Deposit CHANGE Direct Deposit CANCEL Direct Deposit
2.Vendor/Payee Information
Name:
Address:
Contact Person's Name (if other than payee):
Telephone Number:
Email Address:
3.Financial Institution Information
Bank Name:
Bank Address:
Name on Bank Account:
Bank Phone Number:
Bank Account Number:
Nine-Digit Bank Routing/Transit Number (ABA):
Type of Account: Checking Savings
4. Approvals/Authorizations - I certify that the information provided on this form is correct, and I hereby authorize Habersham County Accounts
Payable to electronically deposit payments to the bank account designated above. It is my responsibility to notify AP (accountspayable@habershamga.com or
706-839-0200) immediately if I believe there is a discrepancy between the amount deposited to my bank account and the amount of the invoice(s) paid. I
understand that I must notify Habersham County AP in writing immediately of any changes in status or banking information. I understand that this authorization
will remain in full force and
effect until AP has received written notification requesting a change or cancellation and has had reasonable opportunity to act on it, which
should take no longer than seven (7) to ten (10) business days.
Print Name: Signature: Date: _
Important Information
Please return completed form via email: accountspayable@habershamga.com
For Office of Accounts Payable Use Only Date Stamp - Received
Entered by:____________
Reviewed by:__________