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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />J R SMITH CLERK <br />STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION ' 575-030-27 <br />REQUEST FOR TAXPAYER IDENTIFICATION NUMBER RIGHT OF WAY <br />10/16 <br />Indian River County Solid Waste Disposal District ITEM/SEGMENT NO.: 4130482 <br />Attn: Himanshu H. Mehta, Managing Director MANAGING DISTRICT <br />1801 271h Street F.A.P. NO.: <br />Vero Beach, FL 32960 STATE ROAD NO.: <br />COUNTY: <br />PARCEL NO.: <br />D417 092 B <br />CR 606 (Oslo Road / 91" St. SW) <br />Indian River <br />109/702 <br />The Florida Department of Transportation will be acquiring, or has acquired property owned by you for a transportation project or will be <br />processing a payment to you related to the above referenced parcel. Federal regulations require that we report this transaction to the <br />Internal Revenue Service (IRS), therefore we must obtain your correct Taxpayer Identification Number (TIN). <br />If you fail to furnish your correct TIN you may be subject to an IRS penalty. Willfully falsifying certifications or affirmations may subject you <br />to criminal penalties including fines and/or imprisonment. <br />See the attached instruction for how to enter names and TINS. If you have any questions please let us know. <br />Name <br />Phone Number <br />i <br />Business Name, if different from above <br />Phone Number <br />Board of County Commissioners - Indian River Count <br />(772) 226-1427 <br />Address (number, street, and apt. or suite no.) <br />OWNERSHIP INTEREST <br />1801 27th Street <br />A( Sole Owner <br />❑ Part Owner with % interest <br />City, State, and ZIP Code <br />Vero Beach, Florida 32960 <br />❑ Not Applicable (Vendor Only) <br />TAXPAYER IDENTIFICATION NUMBER (TIN) <br />For individuals, this is your social security number (SSN): <br />For other entities, it is your employer identification number (EIN) 5 9 - 6 0 0 0 6 7 4 <br />If you do not have a TIN, see attached instructions for How to get a TIN. <br />Below, choose one number that accurately describes the business or the individual. <br />❑ 1 -CORPORATION, PROFESSIONAL ASSOCIATION OR PROFESSIONAL CORPORATION <br />(A corporation formed under the laws of any state within the United states.) <br />❑ 2 -NOT FOR PROFIT CORPORATION(Section 501 (c)(3) Internal Revenue Code) FF=t3t11LAS T� FOAr <br />, <br />❑ 3 -PARTNERSHIP, JOINT VENTURE, ESTATE, TRUST OR MULTIPLE MEMBER LLC A -!lD LEU -AL SUFFICIENCY <br />❑ 4 - INDIVIDUAL, SOLE PROPRIETOR, SELF EMPLOYED OR SINGLE MEMBER LLC <br />BY <br />❑ 5 - NONCORPORATE RENTAL AGENT � <br />to j E1C1i��a.��_I� <br />6 - GOVERNMENTAL ENTITY (City, County, State or U.S. Government) CC3iN 1 Y :\TT0RNEV <br />❑ 7 - FOREIGN CORPORATION OR ENTITY (A foreign entity formed under the laws of a country ofg �effrey R. Smith, Clerk of <br />the United States.) If YES is marked below, complete and attach Form W-8EC1. ircuit Court and Comptroller <br />Is income effectively connected with business in the United" est; [:]YES ❑NO <br />❑ 8 -NONRESIDENT ALIEN (An individual temporarily iotie U.S who i 'riatU.S. citizen or resid,) <br />CERTIFICATION _;<..-,„ <br />Do lark <br />Under penalties of perjury, I certify that the nurhber shAwn, <br />on this:form is my correct taxpayer identification <br />number (or I am waiting for umber to be issiiiii#_to MO. ";� <br />Sign Here, ql-�I Date October 19, 2021 <br />Title <br />J e E. Flescher, Chairman L-A <br />