Common use of Privacy Act Notice Clause in Contracts

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an XXX, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Appendix F CERTIFICATION REGARDING DEBARMENT Certification Regarding Debarment, Suspension and Ineligibility As is required by the Federal Regulations Implementing Executive Order 12549, Debarment and Suspension, 45 CFR Part 76, Government-wide Debarment and Suspension, the applicant certifies, to the best of his or her knowledge and belief, that both it and its principals:

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an XXX, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Appendix F CERTIFICATION REGARDING DEBARMENT Certification Regarding DebarmentObtain User ID and Password Keeping information current (ie. contacts, Suspension services, etc.) will be the responsibility of the transloader. To access and Ineligibility As is required by edit profile information, each individual who will be working with UPDS, and the Federal Regulations Implementing Executive Order 12549profile, Debarment needs to obtain an active User ID and SuspensionPassword. UPDS encourages transloaders to update their information on a regular basis. If after eighteen (18) months, 45 CFR Part 76no changes are made, Government-wide Debarment and Suspension, the applicant certifies, to the best of his or her knowledge and belief, that both it and its principals:your information will be deactivated in our database.

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an XXXIRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Appendix F CERTIFICATION REGARDING DEBARMENT Certification Regarding DebarmentBTI - CARRIER MASTER AGREEMENT 03-20-17 MASTER AGREEMENT This Agreement (the “Agreement”) is between, Suspension XXXXXXXX TRANSPORTATION, INC., PO Box 4340, Fort Worth, TX 76164, hereinafter referred to as “BTI”, and Ineligibility As hereinafter referred to as “CARRIER”, whose address is required by the Federal Regulations Implementing Executive Order 12549, Debarment and Suspension, 45 CFR Part 76, Government-wide Debarment and Suspension, the applicant certifies, to the best of his or her knowledge and belief, that both it and its principals:.

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an XXXIRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Appendix F CERTIFICATION REGARDING DEBARMENT Certification Regarding DebarmentXxxxxxx Pet Food, Suspension Inc. Vendor Indemnification Agreement This Agreement is made and Ineligibility As is required entered into this day of , 20 , by and between (Vendor, Contractor or Subcontractor) and Xxxxxxx Pet Food, Inc. its Affiliates and Subsidiaries hereafter (Xxxxxxx). In consideration of the Federal Regulations Implementing Executive Order 12549, Debarment mutual promises and Suspension, 45 CFR Part 76, Government-wide Debarment and Suspensioncovenants contained herein, the applicant certifies, to the best of his or her knowledge and belief, that both it and its principalsparties agree as follows:

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an XXX, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Appendix F CERTIFICATION REGARDING DEBARMENT Certification Regarding DebarmentATTACHMENT 2 AFFIDAVIT OF MEDICA R E BENEFICIARY STATUS In connection with 42 U.S.C. 1395y(b) STATE OF ) ) SS: COUNTY OF ---- ) I, Suspension , being duly sworn, depose and Ineligibility As is required by the Federal Regulations Implementing Executive Order 12549, Debarment and Suspension, 45 CFR Part 76, Government-wide Debarment and Suspension, the applicant certifies, to the best of his or her knowledge and belief, that both it and its principalsaffirm:

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an XXX, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Appendix F CERTIFICATION REGARDING DEBARMENT Certification Regarding Debarment, Suspension and Ineligibility As Advance Commission Agreement This Advance Commission Agreement is required by the Federal Regulations Implementing Executive Order 12549, Debarment and Suspension, 45 CFR Part 76, Government-wide Debarment and Suspension, the applicant certifies, an addendum to the best Producer Agreement by and among Security Life Insurance Company of his or her knowledge and belief, that both it America and its principalssister company, Security Health Insurance Company of America, New York, Inc. (hereinafter individually and collectively referred to as the “Company”), and the writing Producer (hereinafter referred to as the “Producer”, “you” or “your”) named below. It is understood and agreed as follows:

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an XXX, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Appendix F CERTIFICATION REGARDING DEBARMENT Certification Regarding DebarmentForm W-4 (2015) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, Suspension complete only lines 1, 2, 3, 4, and Ineligibility As is required by 7 and sign the Federal Regulations Implementing Executive Order 12549form to validate it. Your exemption for 2015 expires February 16, Debarment 2016. See Pub. 505, Tax Withholding and Suspension, 45 CFR Part 76, Government-wide Debarment and Suspension, the applicant certifies, to the best of his or her knowledge and belief, that both it and its principals:Estimated Tax.

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an XXX, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Appendix F CERTIFICATION REGARDING DEBARMENT Certification Regarding DebarmentATTACHMENT 2 XxXXXXXX & ENGLISH, Suspension and Ineligibility As is required by the Federal Regulations Implementing Executive Order 12549LLP‌ Four Gateway Center 000 Xxxxxxxx Xxxxxx X.X. Xxx 000 Xxxxxx, Debarment and Suspension, 45 CFR Part 76, GovernmentXxx Xxxxxx 00000-wide Debarment and Suspension, the applicant certifies, to the best of his or her knowledge and belief, that both it and its principals:0000 (000) 000-0000 (000) 000-0000 (FAX) Attorneys for Defendants

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an XXXIRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions territories for use in administering their laws. The information may also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers payors must generally withhold a percentage of taxable interest, dividenddividends, and certain other payments to a payee who does not give a TIN to the payerpayor. Certain penalties may also apply for providing false or fraudulent information. Appendix F CERTIFICATION REGARDING DEBARMENT Certification Regarding DebarmentVEHICLE TITLING ADDENDUM Master Tax-Exempt Lease/Purchase Agreement dated April 30, Suspension 2024 and Ineligibility As is required by the Federal Regulations Implementing Executive Order 12549related Property Schedule No. 1 dated April 30, Debarment 2024, between Ouray County as Lessee and SuspensionU.S. Bancorp Government Leasing and Finance, 45 CFR Part 76, Government-wide Debarment and Suspension, the applicant certifies, to the best of his or her knowledge and belief, that both it and its principals:Inc. as Lessor.

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an XXXIRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Appendix F CERTIFICATION REGARDING DEBARMENT Certification Regarding DebarmentAMERITAS LIFE INSURANCE CORP. WRITING AGENT AGREEMENT For Use With Sales of Ameritas’ Edge­Series Insurance Products Ameritas Life Insurance Corp. ("Ameritas"), Suspension and Ineligibility As is required by the Federal Regulations Implementing Executive Order 12549______________________________________ ("Writing Agent"), Debarment hereby acknowledge and Suspension, 45 CFR Part 76, Government-wide Debarment and Suspension, the applicant certifies, to the best of his or her knowledge and belief, that both it and its principalsagree as follows:

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an XXXIRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Appendix F CERTIFICATION REGARDING DEBARMENT Certification Regarding DebarmentAttachment 4: Lewis County Procurement Policy LEWIS COUNTY PROCUREMENT POLICY Effective August 1, Suspension and Ineligibility As is required by the Federal Regulations Implementing Executive Order 125492023 Lewis County Procurement Policy Table of Contents 1. PURPOSE 2 2. SCOPE 2 3. CODE OF ETHICS 2 4. APPROVAL, Debarment and SuspensionSIGNATURE AUTHORITY, 45 CFR Part 76CONTRACTS, Government-wide Debarment and Suspension, the applicant certifies, to the best of his or her knowledge and belief, that both it and its principals:AND CHANGE ORDERS 3