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					                   University of Connecticut Health Center
                   Purchasing Services Department



To Whom It May Concern,


In order to conduct business with the University of Connecticut Health Center the attached new
vendor package must be completed and returned as soon as possible. Failure to return the
package fully completed will prevent us from doing business with your organization.
Included in the attached new vendor package are as follows:

        State Ethics Policy Memorandum from Governor M. Jodi Rell dated September 28, 2004
        Vendor Application Form
        W-9
        Non-Discrimination Certification (please complete the form applicable to your business)

Prior to conducting business with the State of Connecticut all vendors must provide taxation
identification information pursuant to Connecticut General Statutes § 4a-80.

According to Connecticut General Statutes § 4a-60 (a)(1) and § 4a-60a (a)(1) the contractor
agrees and warrants that in the performance of the contract such contractor will not discriminate
or permit discrimination against any person or group of persons on the grounds of sexual
orientation, race, color, religious creed, age, marital status, national origin, ancestry, sex, mental
retardation or physical disability, including, but not limited to, blindness, unless it is shown by
such contractor that such disability prevents performance of the work involved, in any manner
prohibited by the laws of the United States or of the state of Connecticut, and that employees are
treated when employed without regard to their sexual orientation

If your principal place of business is located in the State of Connecticut and is qualified as a
small business in conformity with Connecticut General Statutes § 4a-60g please contact our
Supplier Diversity & Compliance Coordinator Nicole Smith at nrsmith@uchc.edu or 860-679-
2244.


Thank You



Purchasing Services Department
                                                                             An Equal Opportunity Employer
                                                                            263 Farmington Avenue MC 4036
                                                                         Farmington, Connecticut 06032-4306
                                                                                  Telephone: (860) 679-2408
                                                                                   Facsimile: (860) 679-2508
Effective 1/2009
VENDOR APPLICATION FORM                                                                                                                                  VEND-03 Form
                                                                                                                                      Rev. 7/09, 5/09, 4/09 Created 12/08




                                           STATE OF CONNECTICUT
                                             UNIVERSITY OF CONNECTICUT HEALTH CENTER

                                                      PURCHASING SERVICES DEPARTMENT
                                                        263 Farmington Avenue, MC4036
                                                          Farmington, CT 06032-4036




      IMPORTANT: ALL pages of this form, Sections 1 through 5, must be completed, signed and returned. Failure to complete
      and submit all pages of this form may constitute grounds for rejection of your application. By completing this application
      the Vendor agrees that it is in compliance with all applicable UCHC policies and procedures, federal, state, and local laws
      and regulations, including but not limited to Connecticut General Statutes Sections 10a-151a and 10a-151b, 4a-60 and 4a-
      60a.

                                                     SECTION 1 of 5: VENDOR INFORMATION
      COMPLETE LEGAL BUSINESS NAME:                                                              TAXPAYER ID # (TIN):                SSN         FEIN


      P RI NT /T YPE LE GAL BUS I NE S S NAM E   A BOVE                                           P RI NT /T YPE   SSN/FEIN A BOVE
      BUSINESS NAME, TRADE NAME, DOING BUSINESS AS (IF DIFFERENT FROM ABOVE):



      PRINCIPAL PLACE OF BUSINESS (IF DIFFERENT FROM ABOVE):


      BUSINESS ENTITY:               LLC                  NON-PROFIT           PARTNERSHIP             INDIVIDUAL/SOLE PROPRIETORSHIP


                                      CORPORATION                TYPE OF CORPORATION:                                        STATE ORGANIZED IN:

      NOTE: IF INDIVIDUAL/SOLE PROPRIETOR, INDIVIDUAL’NAME MUST APPEAR IN THE LEGAL BUSINESS NAME BLOCK ABOVE.
                                                     S

      NOTE: IF YOUR BUSINESS IS A PARTNERSHIP, YOU MUST ATTACH THE NAMES AND TITLES OF ALL PARTNERS
      BUSINESS TYPE:            A. SALE OF COMMODITIES                 B. MEDICAL SERVICES       C. LEGAL SERVICES            D. RENTAL OF PROPERTY
                                                                                                                             (REAL ESTATE OR EQUIPMENT)
      E. NON-MEDICAL PROFESSIONAL SERVICES                             F. OTHER (DESCRIBE IN DETAIL)


      UNDER THIS TIN, WHAT IS THE PRIMARY TYPE OF BUSINESS YOU PROVIDE TO THE STATE?                               (ENTER LETTER ABOVE)
      UNDER THIS TIN, WHAT OTHER TYPES OF BUSINESS MIGHT YOU PROVIDE TO THE STATE?                             (ENTER LETTER ABOVE)
                                                          BUSINESS ADDRESS:                                          REMITTANCE ADDRESS:
      ADDRESS:

      CITY, STATE, ZIP CODE:

      WEBSITE:

      IS YOUR BUSINESS CURRENTLY A DAS CERTIFIED SMALL BUSINESS ENTERPRISE?                                YES (Attach a copy of Certificate)            NO

      IF SO PLEASE INDICATE WHAT TYPE OF SMALL BUSINESS ENTERPRISE?


      IS YOUR COMPANY REGISTERED WITH THE STATE OF CONNECTICUT SECRETARY OF THE STATE’OFFICE TO DO BUSINESS IN THE
                                                                                     S
      STATE OF CT?       YES            NO


                                                                              Page 1 of 9
VENDOR APPLICATION FORM                                                                                                                          VEND-03 Form
                                                                                                                              Rev. 7/09, 5/09, 4/09 Created 12/08

      IF YOU ARE A CURRENT OR PREVIOUS STATE EMPLOYEE, INDICATE YOUR POSITION, AGENCY, AND AGENCY ADDRESS:




      FOR PURCHASE ORDER DISTRIBUTION :                 1) CHECK ONLY ONE BOX BELOW          2) INPUT E-MAIL ADDRESS OR FAX# (IF CHECKED)

          E-MAIL                                                              FAX

      CONTACT NAME:

      E-MAIL ADDRESS:

      TELEPHONE NUMBER :

      TOLL FREE PHONE:

      FAX NUMBER:

      ADD FURTHER BUSINESS ADDRESS, E-MAIL, & CONTACT INFORMATION BELOW IF REQUIRED:




      SIGNATURE OF PERSON AUTHORIZED TO SIGN ON BEHALF OF THE ABOVE NAMED BUSINESS:                                         DATE EXECUTED:
       SIGN HERE
      NAME OF AUTHORIZED PERSON:                                        TITLE OF AUTHORIZED PERSON:


      P RI NT /T YPE NAME OF AUT HO RI ZE D P E RS ON                   P RI NT /T YPE TI T LE OF AUT HORI ZE D P E RS ON




                                                                     Page 2 of 9
VENDOR APPLICATION FORM                                                                                                               VEND-03 Form
                                                                                                                   Rev. 7/09, 5/09, 4/09 Created 12/08




                SECTION 2 of 5: HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 (HIPAA)


        UNIVERSITY OF CONNECTICUT HEALTH CENTER BUSINESS ASSOCIATE AGREEMENT

             nh sco o t edr plao F r V no”so em se r d o s C n at ”
                i i      e         i i               i    fr          r o.
Please Note: I t s et n fh V no A p ct n om“ edr ism t e r e e t a “ ot c r

(a) If the Contractor is a Business Associate under the requirements of the Health Insurance Portability and Accountability Act of 1996
     “ P A ) h ot c r uto p i l e s n cnio o t s et n fh
      H          ,e        r o
    ( IA ” t C n at m scm l wt a t m ad od i s fh Sco o t Vendor Application Form. If the Contractor is
                                             y h lr                    tn         i     i        e
    not a Business Associate under HIPAA, this Section of the Vendor Application Form does not apply to the Contractor.
(b) The Contractor is required to safeguard the use, publication and disclosure of information on all applicants for, and all clients who receive,
    services provided by the Contractor in accordance with all applicable federal and state law regarding confidentiality, which includes but is
    not limited to HIPAA, more specifically with the Privacy and Security Rules at 45 C.F.R. part 160 and part 164, subparts A, C, and E; and
                                                                                              hr n t t D pr et ia cvr n t
                                                                                                 e ae e
(c) The State of Connecticut Agency named on page 1 of this Vendor Application Form (e i f rh “ ea m n )s “oe dety t ”                  e i”
    as that term is defined in 45 C.F.R. §160.103; and
                           ea fh ea m n e om fnt n t i l h s r i l ue f i i d l d ti l el
                                f      e       t , f
(d) The Contractor, on bhlo t D pr etpr r s ucos htno et ueo d c sr o “ d i ayi n f b hah
                                                                     i      a vv e                  so            n v u l e ia e                t
     n r ao, sh t m s e nd n 5 ...10 0;n
      f       i ”       a r           i
    i om t n a t te idf e i4 CFR §6. 3ad                     1
      h C n at ia bs es s ie fh ea m n a t t
               r o             n       o a”        e       t , a
(e) T e ot c rs “ui s asc t o t D pr et shterm is defined in 45 C.F.R. §160.103; and
(f) The Contractor and the Department agree to the following in order to secure compliance with HIPAA, the requirements of Subtitle D of
    the Health Information Technology for Economic and Clinical Health Act (hereinafter the HITECH Act) (Pub. L. 111-5, sections 13400 to
    13423), and more specifically with the Privacy and Security Rules at 45 C.F.R. part 160 and part 164, subparts A, C, and E.
(g) Definitions.
               Be h sa aeh a e en g sh e s e n
                   a        l        e             n       e r         i
         (1) “ r c” hlhv t sm m ai a t t midf ed in section 13400 of the HITECH Act (42 U.S.C. §17921(1)).
               B s es s ie hl enh ot c r
                    n        o a” l
         (2) “ ui s A sc t sa m a t C n at .      e      r o
               C vr E ty hl en h ea m no t te f onccta e o pg 1 fh Vendor Application Form.
                     e      i” l
         (3) “ oe d n t sa m a t D pr et fh Sa o C netunm d n ae o t s
                                              e       t          e t               i                         i
               D s nt R cr St hl aeh a e en g sh e ds nt r r st n 5 ...14 0.
                    g e                ” l           e
         (4) “ ei a d eod e sa hv t sm m ai a t t m“ei a d eod e i4 CFR §6. 1
                                                                   n      e r          g e c           ”                    5
               Ee r i el R cr” hl ae h a e en g sh e s e nd n et n 30 fh IE H c (2 ...
                   co c        t               l
         (5) “ l t n H ah eod sa hv t sm m ai a t t m idf e i sco 140o t H T C A t4 USC
                                                         e            n       e r          i          i               e
              §17921(5)).
               I i d l hl aeh a e en g sh e i i d l n 5 ...10 0 ad hl n u a e o w o uli
                nvu” l                   e             n
         (6) “ d i a sa hv t sm m ai a t t m “ d i a i 4 CFR §6. 3 n sa i l e pr n h qaf s
                                                              e r n vu”                             1            l cd            s           ie
              as a personal representative as defined in 45 C.F.R. §164.502(g).
               Pi c u ” hl en h t a fr r ay fni d l dn f ble
                  v         e
         (7) “r ayR l sa m a t Sadrs o Pi c o Id i ayIeti Health Information at 45 C.F.R. part 160 and
                                   l         e n d              v            vul           ia
              parts 164, subparts A and E.
               Po c d el nom t n o “H ” hl ae h a e en g sh e po c d el n r ao” n 5 ...
                    ee         t           i                  l
         (8) “rt t H ahIfr ao” r P I sa hv t sm m ai a t t m “rt t hahi om t n i 4 CFR
                                                                       e             n        e r        ee        t f          i
              §160.103, limited to information created or received by the Business Associate from or on behalf of the Covered Entity.
               R qi d y a ” sa aeh a e en g sh e r u e b l i4 CFR §6. 3
                     r                  l
         (9) “ eu e b L w ’hlhv t sm m ai a t t m “ qi d ya ”n 5 ...14 0.
                                                e             n       e r e r               w                    1
         1)Sc t y sa en h er a o t ea m n o H ah n H m n
                   er         l         e er             e      t             t
        (0 “er a ” hlm a t Sc t y fh D pr et f el ad u a Services or his designee.
         1)Moe tn n hl aeh a e en g sh e m r si n n 5 ...10 0.
                      rg ” l                e             n
        (1 “ r si etsa hv t sm m ai a t t m“ oe tneti 4 CFR §6. 2e r             rg ”                       2
         1)T i    s                                           r e o h IA rv i s t e i n h r n r y
                                                                fs e
        (2 “ h Section of the Vendor Application Form” e rt t H P APoioste hr nit iete . sn ad e, e                    it
              “eui Ic et hl aeh a e en g sh e scryn d t n 5
                     t      d ” l              e            n       e r
        (13)Scry ni n sa hv t sm m ai a t t m“eui i i n i 4 C.F.R. §164.304.      t ce”
         1) Scry u ” hl en h eui Sa a frh rt t n f l r i rt t H ah nom t n t 5 .
                     t      e      l
        (4 “eui R l sa m a t Scry t drso t Po co o Eet n Po c d el Ifr ao a4 CF.R. part
                                            e        t n d             e ei                co c e e             t            i
              160 and parts 164, subparts A and C.
         1)U scr rt t hah n r ao” hl aeh a e en g sh e s e nd n et n 30() ( o
                        d ee             t f        i        l
        (5 “ neue po c d el i om t n sa hv t sm m ai a t t ma df e isco 142h() ) f
                                                                     e             n       e r         i          i               1A
              HITECH Act (42 U.S.C. §17932(h)(1)(A)).
(h) Obligations and Activities of Business Associates.
         (1) Business Associate agrees not to use or disclose PHI other than as permitted or required by this Section of the Vendor Application
              Form or as Required by Law.
         (2) Business Associate agrees to use appropriate safeguards to prevent use or disclosure of PHI other than as provided for in this
              Section of the Vendor Application Form.
         (3) Business Associate agrees to use administrative, physical and technical safeguards that reasonably and appropriately protect the
              confidentiality, integrity, and availability of electronic protected health information that it creates, receives, maintains, or
              transmits on behalf of the Covered Entity.
         (4) Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to the Business Associate of a
              use or disclosure of PHI by Business Associate in violation of this Section of the Vendor Application Form.
         (5) Business Associate agrees to report to Covered Entity any use or disclosure of PHI not provided for by this Section of the Vendor
              Application Form or any security incident of which it becomes aware.
         (6) Business Associate agrees to insure that any agent, including a subcontractor, to whom it provides PHI received from, or created
                                                                    Page 3 of 9
VENDOR APPLICATION FORM                                                                                                              VEND-03 Form
                                                                                                                  Rev. 7/09, 5/09, 4/09 Created 12/08


             or received by Business Associate, on behalf of the Covered Entity, agrees to the same restrictions and conditions that apply
             through this Section of the Vendor Application Form to Business Associate with respect to such information.
      (7)    Business Associate agrees to provide access, at the request of the Covered Entity, and in the time and manner agreed to by the
             parties, to PHI in a Designated Record Set, to Covered Entity or, as directed by Covered Entity, to an Individual in order to meet
             the requirements under 45 C.F.R. §164.524.
      (8)    Business Associate agrees to make any amendments to PHI in a Designated Record Set that the Covered Entity directs or agrees
             to pursuant to 45 C.F.R. §164.526 at the request of the Covered Entity, and in the time and manner agreed to by the parties.
      (9)    Business Associate agrees to make internal practices, books, and records, including policies and procedures and PHI, relating to
             the use and disclosure of PHI received from, or created or received by, Business Associate on behalf of Covered Entity, available
             to Covered Entity or to the Secretary in a time and manner agreed to by the parties or designated by the Secretary, for purposes of
              h er a dt m n g oe d n t cm lne i h r ay u .
               e er e i                        e      i’
             t Sc t y e r i n C vr E tys o p ac wt t Pi c R l     i        h e v             e
      (10)   Business Associate agrees to document such disclosures of PHI and information related to such disclosures as would be required
             for Covered Entity to respond to a request by an Individual for an accounting of disclosures of PHI in accordance with 45 C.F.R.
             §164.528 and section 13405 of the HITECH Act (42 U.S.C. §17935) and any regulations promulgated there under.
      (11)   Business Associate agrees to provide to Covered Entity, in a time and manner agreed to by the parties, information collected in
             accordance with clause (h)(10) of this Section of the Vendor Application Form, to permit Covered Entity to respond to a request
             by an Individual for an accounting of disclosures of PHI in accordance with 45 C.F.R. §164.528 and section 13405 of the
             HITECH Act (42 U.S.C. §17935) and any regulations promulgated there under. Business Associate agrees at the Covered
               n t d et n o rv e n con n o d c sr f H d et t a i v uln codne i 5 ... 14
                 i’ r i                  d
             E tys i co t poi a acut g f i l ue o P I i cy o n ni dai acrac wt 4 CFR §6.528
                                                       i        so s                r l           di                         h
             and section 13405 of the HITECH Act (42 U.S.C. §17935) and any regulations promulgated there under.
      (12)   Business Associate agrees to comply with any state or federal law that is more stringent than the Privacy Rule.
      (13)   Business Associate agrees to comply with the requirements of the HITECH Act relating to privacy and security that are applicable
             to the Covered Entity and with the requirements of 45 C.F.R. sections 164.504(e), 164.308, 164.310, 164.312, and 164.316.
      (14)   In the event that an individual requests that the Business Associate (a) restrict disclosures of PHI; (b) provide an accounting of
                      r fh n v ul P Io ( rv e oy fh n v ul P In n l t n el e r,h ui s
                        s       e di ’                     )
             disclosue o t i i da s H ; r c poi acp o t i i da s H i a e c oi hahr od t B s es
                                                                 d               e di ’                       er c t c                 e     n
             Associate agrees to notify the covered entity, in writing, within two business days of the request.
      (15)   Business Associate agrees that it shall not, directly or indirectly, receive any remuneration in exchange for PHI of an individual
             without (1) the written approval of the covered entity, unless receipt of remuneration in exchange for PHI is expressly authorized
             and (2) the valid authorization of the individual, except for the purposes provided under section 13405(d)(2) of the HITECH Act
             (42 U.S.C. §17935(d)(2)) and in any accompanying regulations
      (16)   Obligations in the Event of a Breach.
             A. The Business Associate agrees that, following the discovery of a breach of unsecured protected health information, it shall
                  notify the Covered Entity of such breach in accordance with the requirements of section 13402 of HITECH (42 U.S.C.
                  17932(b)) and the provisions of this Section of the Vendor Application Form.
             B. Such notification shall be provided by the Business Associate to the Covered Entity without unreasonable delay, and in no
                  case later than 30 days after the breach is discovered by the Business Associate, except as otherwise instructed in writing by
                  a law enforcement official pursuant to section 13402(g) of HITECH (42 U.S.C. 17932(g)). A breach is considered
                  discovered as of the first day on which it is, or reasonably should have been, known to the Business Associate. The
                  notification shall include the identification and last known address, phone number and email address of each individual (or
                  the next of kin of the individual if the individual is deceased) whose unsecured protected health information has been, or is
                  reasonably believed by the Business Associate to have been, accessed, acquired, or disclosed during such breach.
             C. The Business Associate agrees to include in the notification to the Covered Entity at least the following information:
                       1. A brief description of what happened, including the date of the breach and the date of the discovery of the breach, if
                            known.
                       2. A description of the types of unsecured protected health information that were involved in the breach (such as full
                            name, Social Security number, date of birth, home address, account number, or disability code).
                       3. The steps the Business Associate recommends that individuals take to protect themselves from potential harm
                            resulting from the breach.
                       4. A detailed description of what the Business Associate is doing to investigate the breach, to mitigate losses, and to
                            protect against any further breaches.
                       5. Whether a law enforcement official has advised either verbally or in writing the Business Associate that he or she
                            has determined that notification or notice to individuals or the posting required under section 13402 of the HITECH
                            Act would impede a criminal investigation or cause damage to national security and; if so, include contact
                            information for said official.
             D. Business Associate agrees to provide appropriate staffing and have established procedures to ensure that individuals informed
                  by the Covered Entity of a breach by the Business Associate have the opportunity to ask questions and contact the Business
                  Associate for additional information regarding the breach. Such procedures shall include a toll-free telephone number, an e-
                  mail address, a posting on its Web site and a postal address. Business Associate agrees to include in the notification of a

                                                                 Page 4 of 9
VENDOR APPLICATION FORM                                                                                                                VEND-03 Form
                                                                                                                    Rev. 7/09, 5/09, 4/09 Created 12/08


                    breach by the Business Associate to the Covered Entity, a written description of the procedures that have been established to
                    meet these requirements. Costs of such contact procedures will be borne by the Contractor.
               E. Business Associate agrees that, in the event of a breach, it has the burden to demonstrate that it has complied with all
                    notification requirements set forth above, including evidence demonstrating the necessity of a delay in notification to the
                    Covered Entity.
(i)   Permitted Uses and Disclosure by Business Associate.
           (1) General Use and Disclosure Provisions. Except as otherwise limited in this Section of the Vendor Application Form, Business
               Associate may use or disclose PHI to perform functions, activities, or services for, or on behalf of, Covered Entity as specified in
               this Vendor Application Form, provided that such use or disclosure would not violate the Privacy Rule if done by Covered Entity
               or the minimum necessary policies and procedures of the Covered Entity.
           (2) Specific Use and Disclosure Provisions.
               A. Except as otherwise limited in this Section of the Vendor Application Form, Business Associate may use PHI for the proper
                    management and administration of Business Associate or to carry out the legal responsibilities of Business Associate.
               B. Except as otherwise limited in this Section of the Vendor Application Form, Business Associate may disclose PHI for the
                    proper management and administration of Business Associate, provided that disclosures are Required by Law, or Business
                    Associate obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential
                    and used or further disclosed only as Required by Law or for the purpose for which it was disclosed to the person, and the
                    person notifies Business Associate of any instances of which it is aware in which the confidentiality of the information has
                    been breached.
               C. Except as otherwise limited in this Section of the Vendor Application Form, Business Associate may use PHI to provide Data
                    Aggregation services to Covered Entity as permitted by 45 C.F.R. §164.504(e)(2)(i)(B).
(j)   Obligations of Covered Entity.
           (1) Covered Entity shall notify Business Associate of any limitations in its notice of privacy practices of Covered Entity, in
                                                                                                                           e ue r i l ue f
                                                                                                                            ’
               accordance with 45 C.F.R. §164.520, or to the extent that such limitation may affect Business Associat s s o d c sr o    so
               PHI.
           (2) Covered Entity shall notify Business Associate of any changes in, or revocation of, permission by Individual to use or disclose
                 H , h x nt sc cags a a et ui s A s ie ue r i l ue f H .
                      o e e a                              f        n
               P It t et thtuh hne m y f cB s es s c t s s o d c sr o P I   o a’               so
           (3) Covered Entity shall notify Business Associate of any restriction to the use or disclosure of PHI that Covered Entity has agreed to
                n codne i 5 ... 14 2,o h x n t sc e r t n a f c B s es s ie ue r i losure of
                                  h                 5          e e a
               i acrac wt 4 CFR §6. 2 t t et thtuhr tco m ya et ui s A sc t s s o d c
                                                                                   sii               f         n       oa’              s
               PHI.
(k)   Permissible Requests by Covered Entity. Covered Entity shall not request Business Associate to use or disclose PHI in any manner that
      would not be permissible under the Privacy Rule if done by the Covered Entity, except that Business Associate may use and disclose PHI
      for data aggregation, and management and administrative activities of Business Associate, as permitted under this Section of the Vendor
      Application Form.
(l)   Term and Termination.
           (1) Term. The Term of this Section of the Vendor Application Form shall be effective as of the date signed below and shall terminate
               when the information collected in accordance with clause (h)(10) of this Section of the Vendor Application Form is provided to
               the Covered Entity and all of the PHI provided by Covered Entity to Business Associate, or created or received by Business
               Associate on behalf of Covered Entity, is destroyed or returned to Covered Entity, or, if it is infeasible to return or destroy PHI,
               protections are extended to such information, in accordance with the termination provisions in this Section.
                 e n i o C ue U o oe d n t nwe e f a r l r h y ui s s ie oe d n t hl
                   m ao                              e      i’           d
           (2) T r i t nfr as. pnC vr E tysko l g o am t i bec b B s esA sc t C vr E tysa
                                                                                       ea a                   n        o a,         e      i      l
               either:
               A. Provide an opportunity for Business Associate to cure the breach or end the violation and terminate the services provided by
                    the Business Associate if Business Associate does not cure the breach or end the violation within the time specified by the
                    Covered Entity; or
               B. Immediately terminate the services provided by the Business Associate if Business Associate has breached a material term of
                    this Section of the Vendor Application Form and cure is not possible; or
               C. If neither termination nor cure is feasible, Covered Entity shall report the violation to the Secretary.
           (3) Effect of Termination.
               A. Except as provided in (l)(2) of this Section of the Vendor Application Form, upon termination of the services provided by the
                    Business Associate, for any reason, Business Associate shall return or destroy all PHI received from Covered Entity, or
                    created or received by Business Associate on behalf of Covered Entity. Business Associate shall also provide the
                    information collected in accordance with clause (h)(10) of this Section of the Vendor Application Form to the Covered Entity
                    within ten business days of the notice of termination. This provision shall apply to PHI that is in the possession of
                    subcontractors or agents of Business Associate. Business Associate shall retain no copies of the PHI.
               B. In the event that Business Associate determines that returning or destroying the PHI is infeasible, Business Associate shall
                    provide to Covered Entity notification of the conditions that make return or destruction infeasible. Upon documentation by
                    Business Associate that return or destruction of PHI is infeasible, Business Associate shall extend the protections of this

                                                                   Page 5 of 9
VENDOR APPLICATION FORM                                                                                                               VEND-03 Form
                                                                                                                   Rev. 7/09, 5/09, 4/09 Created 12/08


                  Section of the Vendor Application Form to such PHI and limit further uses and disclosures of PHI to those purposes that
                  make return or destruction infeasible, for as long as Business Associate maintains such PHI. Infeasibility of the return or
                  destruction of PHI includes, but is not limited to, requirements under state or federal law that the Business Associate
                  maintains or preserves the PHI or copies thereof.
(m)    Miscellaneous Provisions.
        (1) Regulatory References. A reference in this Section of the Vendor Application Form to a section in the Privacy Rule means the
             section as in effect or as amended.
        (2) Amendment. The Parties agree to take such action as is necessary to amend this Section of the Vendor Application Form from
             time to time as is necessary for Covered Entity to comply with requirements of the Privacy Rule and the Health Insurance
             Portability and Accountability Act of 1996, Pub. L. No. 104-191.
        (3) Survival. The respective rights and obligations of Business Associate shall survive the termination of the services provided by the
             Business Associate.
        (4) Effect on Vendor Application Form and Other Documents. Except as specifically required to implement the purposes of this
             Section of the Vendor Application Form, all other terms of the Vendor Application Form and any resulting Purchase Order,
             Contract or other document shall remain in force and effect.
        (5) Construction. This Section of the Vendor Application Form shall be construed as broadly as necessary to implement and comply
             with the Privacy Standard. Any ambiguity in this Section of the Vendor Application Form shall be resolved in favor of a meaning
             that complies, and is consistent with, the Privacy Standard.
        (6) Disclaimer. Covered Entity makes no warranty or representation that compliance with this Section of the Vendor Application
                      i e dqa r as c r o B s es s ie o n upss oe d n t hl o b i l Business
                       l             e       ia o
             Form wlb aeut o stf t yfr ui s A sc t s w proe.C vr E tysa nt elb
                                                               n        o a’                           e      i       l          a eto
             Associate for any claim, civil or criminal penalty, loss or damage related to or arising from the unauthorized use or disclosure of
             PHI by Business Associate or any of its officers, directors, employees, contractors or agents, or any third party to whom Business
             Associate has disclosed PHI contrary to the provisions of this Vendor Application Form or applicable law. Business Associate is
             solely responsible for all decisions made, and actions taken, by Business Associate regarding the safeguarding, use and disclosure
             of PHI within its possession, custody or control.
         (7) Indemnification. The Business Associate shall indemnify and hold the Covered Entity harmless from and against any and all
             claims, liabilities, judgments, fines, assessments, penalties, awards and any statutory damages that may be imposed or assessed
               us n t IA ,s m ne, rh IE H c n u n wt u l ti ,t re’f ,xe i ese ,ot
                  u                                   e             , cdg h
             pr atoH P A a a edd o t H T C A ti l i , i oti it n aonyseseprwt s f scs of  m ao t                 e        t n        e      s
             investigation, litigation or dispute resolution, and costs awarded there under, relating to or arising out of any violation by the
             Business Associate and its agents, including subcontractors, of any obligation of Business Associate and its agents, including
             subcontractors, under this Section of the Vendor Application Form, under HIPAA, the HITECH Act, the Privacy Rule and the
             Security Rule.

Vendor, on behalf of itself, its agents and employees, acknowledges that, as a result of a current or future business relationship with UCHC, it
may receive or have access to PHI, including, but not limited to, electronic PHI and patient identifying information.

Vendor recognizes that any such PHI is and shall remain the property of UCHC and agrees that it acquires no title or rights to such PHI,
including any de-identified information. Vendor further recognizes and agrees that any breach of confidentiality or misuse of such information
may result in the termination of any agreement between UCHC and Vendor, legal action against Vendor, and/or the submission of a report
about the breach or misuse to the Secretary of Health and Human Services.

 h A toi d ersnai ’ i aue e w n i e h t ed r n es d a d cette nv sy f o nc ct ealth
           z                vsg
T e uh r e R peett e s n tr bl idct ta V n o u drtn s n acpsh U i ri o C n et u H
                                             o       as                       a              e t i
Center Business Associate Agreement, as it may be applicable to Vendor now or in the future.



Name and Title of Authorized Representative




Signature                                                                           Date




                                                                  Page 6 of 9
VENDOR APPLICATION FORM                                                                                                                    VEND-03 Form
                                                                                                                        Rev. 7/09, 5/09, 4/09 Created 12/08

                            SECTION 3 of 5: OCCUPATIONAL SAFETY & HEALTH ACT (1970)
      The following information is required pursuant to Section 31-57b of the Connecticut General Statutes:


      In the past three years, have you, your company, or any firm, corporation, partnership or association in which you or
      your company have an interest, been cited for any willful or serious violations of any occupational safety and health
      act, standard, order or regulation?
                                                               YES           NO

      If Yes, attach a list of the following information for each violation/citation: the date of the violation, the date of the citation, the
      nature of the violation (including references to the statutes, regulations, standards or orders violated), the name of the individual
      or company cited, the name of the government agency that issued the citation, and the result/penalty.

      In the past three years, have you, your company, or any firm, corporation, partnership or association in which you or your
      company have an interest, received any criminal convictions related to the injury or death of any employee?
                                                               YES           NO
      If Yes, attach a list of the following information for each criminal conviction: the date of the incident resulting in the
      employee injury/death, the date of the criminal conviction, the court that issued the conviction, the nature of the
      conviction (including references to any statutes, regulations, standards or orders violated), the name of the individual
      or company convicted, and the result/penalty.




                                     SECTION 4 of 5: DEBARMENT AND/OR SUSPENSION
      Has the above named business, any company official, or any subcontractor to the above named business, received any notices
      of debarment and/or suspension from contracting with the State of Connecticut, the Federal Government or any governmental
      entity?
                                                                 YES           NO


      The above authorized signer of the above named business further affirms and declares that neither the business and/or any
      company official nor any subcontractor to the business and/or any company official have received any notices of debarment
      and/or suspension from contracting with other states within the United States.
                                                                 YES           NO


      The above authorized signer of the above named business further affirms and declares that neither the business and/or any
      company official nor any subcontractor to the business and/ or any company official are presently debarred, suspended,
      proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any governmental entity in
      accordance with UCHC Policy No. 2001-3 and applicable federal and state laws. The authorized signer shall disclose to
      UCHC immediately in writing of any debarment, suspension, proposal for debarment, voluntary exclusion or other events that
        ae t    e n i l i e e o”
                         n ib        s
      m kshm a “ eg l pr n.An "Ineligible Person" is an individual or entity who: (i) is currently excluded, debarred,
      suspended, or otherwise ineligible to participate in the Federal health care programs or in Federal procurement or
      nonprocurement programs; or (ii) has been convicted of a criminal offense that falls within the ambit of 42 U.S.C. § 1320a-
      7(a), but has not yet been excluded, debarred, suspended, or otherwise declared ineligible.
                                                                YES            NO


      If the above authorized signer of the above named business , any company official or any subcontractor to the business have
      received notices of debarment and/or suspension from contracting with the State of Connecticut, the Federal Government or
      any governmental entity, said notices must be attached to this document when submitting this application.

                                                    Number of notices attached _________



                                                                     Page 7 of 9
VENDOR APPLICATION FORM                                                                                                               VEND-03 Form
                                                                                                                   Rev. 7/09, 5/09, 4/09 Created 12/08




     CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY
                    EXCLUSION - - LOWER TIER COVERED TRANSACTIONS

                                             INSTRUCTIONS FOR CERTIFICATION
   1) By signing and submitting this application, the prospective recipient of Federal assistance funds is providing the certification as set out
      below.
   2) The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered
      into. If it is later determined that the prospective recipient of Federal assistance funds knowingly rendered an erroneous certification,
      in addition to other remedies available to the Federal Government, UCHC may pursue available remedies, including suspension and/or
      debarment.
   3) The prospective recipient of Federal assistance funds shall provide immediate written notice to the person to whom this application is
      submitted if at any time the prospective recipient of Federal assistance funds learns that its certification was erroneous when submitted
      or has become erroneous by reason of changed circumstances.
   4) The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person,"
      "primary covered transaction," "principal," "application," and "voluntarily excluded," as used in this clause, have the meanings set out
      in the Definitions and Coverage sections of the rules implementing Executive Order 12549.
   5) The prospective recipient of Federal assistance funds agrees by submitting this application that, should the proposed covered
      transactions be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred,
      suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by UCHC.
   6) The prospective recipient of Federal assistance funds further agrees by submitting this application that it will include the clause titled
      "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions," without
      modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
   7) A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that
      it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is
      erroneous. A participant may decide the method and frequency by which it determined the eligibility of its principals. Each participant
      may, but is not required, to check the List of Parties Excluded from procurement or Non-Procurement Programs.
   8) Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith
      the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is
      normally possessed by a prudent person in the ordinary course of business dealings.
   9) Except for transactions authorized under Paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters
      into a lower tier covered transaction with a person who is debarred, suspended, ineligible, or voluntarily excluded from participation in
      this transaction, in addition to other remedies available to the Federal Government, UCHC may pursue available remedies including
      suspension and/or debarment.


             Before signing Certification, read all the instructions which are an integral part of the Certification.


   1) The prospective recipient of Federal assistance funds certifies, by submission of this application, that neither it nor its principals are
      presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this
      transaction by any Federal department or agency.
   2) Where the prospective recipient of Federal assistance funds is unable to certify to any of the statements in this certification, such
      prospective participant shall attach an explanation to this application.




 Name and Title of Authorized Representative




 Signature                                                                             Date



                                                                 Page 8 of 9
VENDOR APPLICATION FORM                                                                                                           VEND-03 Form
                                                                                                               Rev. 7/09, 5/09, 4/09 Created 12/08




                                            SECTION 5 of 5: OTHER INFORMATION

Evaluation of Performance: UCHC may conduct evaluations of all Vendor performance including, but not limited to, clinical equipment,
supplies and services. Vendors may be requested to provide quality performance metrics, shall cooperate with UCHC in any such evaluations,
and shall work with UCHC to correct any deficiencies noted.


The links listed below are provided for your convenience. It is your responsibility to ensure that you are compliant with the most
current laws, regulations, rules & policies.


  e r o G ia c fr ed r uh r ai s a te
    e                                     z o
R f t “ ud ne o V n o A toi t n” th following website:
http://www.das.state.ct.us/purchase/info/vendor_authorization_and_guidance_081106.pdf


  e r o G ie o h C d o Ehc o C ret r oe i Sae o t t s a te o o ig ese
    e                                s                na ao l       t
R f t “ ud t te o e f ti F r urn o P t t l tt C nrc r” th fl wn w bi :
http://www.ct.gov/ethics/cwp/view.asp?a=3488&q=414966


 e r o Sae f o nc ct u pi Dv sy rga a te o o
  e               i        e  e t            l
R f t “ tt o C n et u S p lr i ri P orm” th fl wing website:
http://www.das.state.ct.us/Purchase/New_purchHome/busopp_template.asp?F_ID=25


 e r o Sae f o nc ct xct e res a teo o ig esite:
  e               i       v           l
R f t “ tt o C n et u E eui O dr” th fl wn w b
http://www.das.state.ct.us/Purchase/Executive_Orders_new.pdf


 e r o E eui O dr 24 o eamet n upni ” th fl wn w bi :
  e        v                          o        l       t
R f t “ xct e re 159 nD b r n a dS ses n a te o o ig ese
http://www.archives.gov/federal-register/codification/executive-order/12549.html


 e r o C n et u G nrl tte §
  e         i                                    6 a teo o ig ese
                                                        l       t
R f t “ o nc ct eea Saus §4a-60, 4a-60a, and 46a-5” th fl wn w bi :
http://www.cga.ct.gov/2009/pub/chap058.htm#Sec4a-60.htm and http://www.cga.ct.gov/2009/pub/chap814c.htm#Sec46a-56.htm


 e r o U H ’A f mai A t n N n
  e            i  v
R f t “ C C s fr t e c o , o -Discrimination, and Equal O p r nt P ly a te o o ig ese
                      i                                      u y i          l
                                                         p ot i o c” th fl wn w bi :t
http://www.policies.uchc.edu/policies/policy_2002_44.pdf


          C n et u G nrl tte §
               i                7 ” th fl wn w bi :
                                        l
Refer to “ o nc ct eea Saus 31-5b a teo o ig eset
http://www.cga.ct.gov/2007/pub/Chap557.htm#Sec31-57b.htm


 e r o Sae f T reo fnomai o s o a the
  e                          o      sn
R f t “ tt o C F ed m o Ifr t nC mmi i ” t following website:
http://www.state.ct.us/foi/




                                                                Page 9 of 9
Form
(Rev. October 2007)
                                       W-9                                          Request for Taxpayer                                                                 Give form to the
                                                                                                                                                                         requester. Do not
Department of the Treasury
                                                                          Identification Number and Certification                                                        send to the IRS.
Internal Revenue Service
                                       Name (as shown on your income tax return)
See Specific Instructions on page 2.




                                       Business name, if different from above
           Print or type




                                       Check appropriate box:       Individual/Sole proprietor          Corporation         Partnership
                                                                                                                                                                           Exempt
                                          Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership)                     payee
                                           Other (see instructions)
                                       Address (number, street, and apt. or suite no.)                                                        Requester’s name and address (optional)


                                       City, state, and ZIP code


                                       List account number(s) here (optional)


       Part I                                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 your social security number (SSN). However, for a 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 chart on page 4 for guidelines on whose                                                          Employer identification number
 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).
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 4.

Sign                                       Signature of
Here                                       U.S. person                                                                                     Date

General Instructions                                                                                                 Definition of a U.S. person. For federal tax purposes, you are
                                                                                                                     considered a U.S. person if you are:
Section references are to the Internal Revenue Code unless
otherwise noted.                                                                                                     ● An individual who is a U.S. citizen or U.S. resident alien,
                                                                                                                     ● A partnership, corporation, company, or association created or
Purpose of Form                                                                                                      organized in the United States or under the laws of the United
A person who is required to file an information return with the                                                      States,
IRS must obtain your correct taxpayer identification number (TIN)                                                    ● An estate (other than a foreign estate), or
to report, for example, income paid to you, real estate                                                              ● A domestic trust (as defined in Regulations section
transactions, mortgage interest you paid, acquisition or                                                             301.7701-7).
abandonment of secured property, cancellation of debt, or
                                                                                                                     Special rules for partnerships. Partnerships that conduct a
contributions you made to an IRA.
                                                                                                                     trade or business in the United States are generally required to
   Use Form W-9 only if you are a U.S. person (including a                                                           pay a withholding tax on any foreign partners’ share of income
resident alien), to provide your correct TIN to the person                                                           from such business. Further, in certain cases where a Form W-9
requesting it (the requester) and, when applicable, to:                                                              has not been received, a partnership is required to presume that
  1. Certify that the TIN you are giving is correct (or you are                                                      a partner is a foreign person, and pay the withholding tax.
waiting for a number to be issued),                                                                                  Therefore, if you are a U.S. person that is a partner in a
                                                                                                                     partnership conducting a trade or business in the United States,
   2. Certify that you are not subject to backup withholding, or                                                     provide Form W-9 to the partnership to establish your U.S.
   3. Claim exemption from backup withholding if you are a U.S.                                                      status and avoid withholding on your share of partnership
exempt payee. If applicable, you are also certifying that as a                                                       income.
U.S. person, your allocable share of any partnership income from                                                        The person who gives Form W-9 to the partnership for
a U.S. trade or business is not subject to the withholding tax on                                                    purposes of establishing its U.S. status and avoiding withholding
foreign partners’ share of effectively connected income.                                                             on its allocable share of net income from the partnership
Note. If a requester gives you a form other than Form W-9 to                                                         conducting a trade or business in the United States is in the
request your TIN, you must use the requester’s form if it is                                                         following cases:
substantially similar to this Form W-9.
                                                                                                                     ● The U.S. owner of a disregarded entity and not the entity,
                                                                                                         Cat. No. 10231X                                               Form   W-9   (Rev. 10-2007)
Form W-9 (Rev. 10-2007)                                                                                                             Page   2
● The U.S. grantor or other owner of a grantor trust and not the         4. The IRS tells you that you are subject to backup
trust, and                                                             withholding because you did not report all your interest and
● The U.S. trust (other than a grantor trust) and not the              dividends on your tax return (for reportable interest and
beneficiaries of the trust.                                            dividends only), or
Foreign person. If you are a foreign person, do not use Form             5. You do not certify to the requester that you are not subject
W-9. Instead, use the appropriate Form W-8 (see Publication            to backup withholding under 4 above (for reportable interest and
515, Withholding of Tax on Nonresident Aliens and Foreign              dividend accounts opened after 1983 only).
Entities).                                                               Certain payees and payments are exempt from backup
                                                                       withholding. See the instructions below and the separate
Nonresident alien who becomes a resident alien. Generally,             Instructions for the Requester of Form W-9.
only a nonresident alien individual may use the terms of a tax
treaty to reduce or eliminate U.S. tax on certain types of income.       Also see Special rules for partnerships on page 1.
However, most tax treaties contain a provision known as a
“saving clause.” Exceptions specified in the saving clause may
                                                                       Penalties
permit an exemption from tax to continue for certain types of          Failure to furnish TIN. If you fail to furnish your correct TIN to a
income even after the payee has otherwise become a U.S.                requester, you are subject to a penalty of $50 for each such
resident alien for tax purposes.                                       failure unless your failure is due to reasonable cause and not to
   If you are a U.S. resident alien who is relying on an exception     willful neglect.
contained in the saving clause of a tax treaty to claim an             Civil penalty for false information with respect to
exemption from U.S. tax on certain types of income, you must           withholding. If you make a false statement with no reasonable
attach a statement to Form W-9 that specifies the following five       basis that results in no backup withholding, you are subject to a
items:                                                                 $500 penalty.
   1. The treaty country. Generally, this must be the same treaty      Criminal penalty for falsifying information. Willfully falsifying
under which you claimed exemption from tax as a nonresident            certifications or affirmations may subject you to criminal
alien.                                                                 penalties including fines and/or imprisonment.
   2. The treaty article addressing the income.                        Misuse of TINs. If the requester discloses or uses TINs in
   3. The article number (or location) in the tax treaty that          violation of federal law, the requester may be subject to civil and
contains the saving clause and its exceptions.                         criminal penalties.
  4. The type and amount of income that qualifies for the
exemption from tax.                                                    Specific Instructions
   5. Sufficient facts to justify the exemption from tax under the     Name
terms of the treaty article.
                                                                       If you are an individual, you must generally enter the name
   Example. Article 20 of the U.S.-China income tax treaty allows
                                                                       shown on your income tax return. However, if you have changed
an exemption from tax for scholarship income received by a
                                                                       your last name, for instance, due to marriage without informing
Chinese student temporarily present in the United States. Under
                                                                       the Social Security Administration of the name change, enter
U.S. law, this student will become a resident alien for tax
                                                                       your first name, the last name shown on your social security
purposes if his or her stay in the United States exceeds 5
                                                                       card, and your new last name.
calendar years. However, paragraph 2 of the first Protocol to the
U.S.-China treaty (dated April 30, 1984) allows the provisions of         If the account is in joint names, list first, and then circle, the
Article 20 to continue to apply even after the Chinese student         name of the person or entity whose number you entered in Part I
becomes a resident alien of the United States. A Chinese               of the form.
student who qualifies for this exception (under paragraph 2 of         Sole proprietor. Enter your individual name as shown on your
the first protocol) and is relying on this exception to claim an       income tax return on the “Name” line. You may enter your
exemption from tax on his or her scholarship or fellowship             business, trade, or “doing business as (DBA)” name on the
income would attach to Form W-9 a statement that includes the          “Business name” line.
information described above to support that exemption.
                                                                       Limited liability company (LLC). Check the “Limited liability
   If you are a nonresident alien or a foreign entity not subject to   company” box only and enter the appropriate code for the tax
backup withholding, give the requester the appropriate                 classification (“D” for disregarded entity, “C” for corporation, “P”
completed Form W-8.                                                    for partnership) in the space provided.
What is backup withholding? Persons making certain payments               For a single-member LLC (including a foreign LLC with a
to you must under certain conditions withhold and pay to the           domestic owner) that is disregarded as an entity separate from
IRS 28% of such payments. This is called “backup withholding.”         its owner under Regulations section 301.7701-3, enter the
Payments that may be subject to backup withholding include             owner’s name on the “Name” line. Enter the LLC’s name on the
interest, tax-exempt interest, dividends, broker and barter            “Business name” line.
exchange transactions, rents, royalties, nonemployee pay, and
certain payments from fishing boat operators. Real estate                For an LLC classified as a partnership or a corporation, enter
transactions are not subject to backup withholding.                    the LLC’s name on the “Name” line and any business, trade, or
                                                                       DBA name on the “Business name” line.
   You will not be subject to backup withholding on payments
you receive if you give the requester your correct TIN, make the       Other entities. Enter your business name as shown on required
proper certifications, and report all your taxable interest and        federal tax documents on the “Name” line. This name should
dividends on your tax return.                                          match the name shown on the charter or other legal document
                                                                       creating the entity. You may enter any business, trade, or DBA
Payments you receive will be subject to backup                         name on the “Business name” line.
withholding if:                                                        Note. You are requested to check the appropriate box for your
   1. You do not furnish your TIN to the requester,                    status (individual/sole proprietor, corporation, etc.).
   2. You do not certify your TIN when required (see the Part II       Exempt Payee
instructions on page 3 for details),
   3. The IRS tells the requester that you furnished an incorrect      If you are exempt from backup withholding, enter your name as
TIN,                                                                   described above and check the appropriate box for your status,
                                                                       then check the “Exempt payee” box in the line following the
                                                                       business name, sign and date the form.
Form W-9 (Rev. 10-2007)                                                                                                                         Page   3
Generally, individuals (including sole proprietors) are not exempt                  Part I. Taxpayer Identification
from backup withholding. Corporations are exempt from backup
withholding for certain payments, such as interest and dividends.                   Number (TIN)
Note. If you are exempt from backup withholding, you should                         Enter your TIN in the appropriate box. If you are a resident
still complete this form to avoid possible erroneous backup                         alien and you do not have and are not eligible to get an SSN,
withholding.                                                                        your TIN is your IRS individual taxpayer identification number
   The following payees are exempt from backup withholding:                         (ITIN). Enter it in the social security number box. If you do not
                                                                                    have an ITIN, see How to get a TIN below.
   1. An organization exempt from tax under section 501(a), any
IRA, or a custodial account under section 403(b)(7) if the account                     If you are a sole proprietor and you have an EIN, you may
satisfies the requirements of section 401(f)(2),                                    enter either your SSN or EIN. However, the IRS prefers that you
                                                                                    use your SSN.
   2. The United States or any of its agencies or                                      If you are a single-member LLC that is disregarded as an
instrumentalities,                                                                  entity separate from its owner (see Limited liability company
  3. A state, the District of Columbia, a possession of the United                  (LLC) on page 2), enter the owner’s SSN (or EIN, if the owner
States, or any of their political subdivisions or instrumentalities,                has one). Do not enter the disregarded entity’s EIN. If the LLC is
  4. A foreign government or any of its political subdivisions,                     classified as a corporation or partnership, enter the entity’s EIN.
agencies, or instrumentalities, or                                                  Note. See the chart on page 4 for further clarification of name
   5. An international organization or any of its agencies or                       and TIN combinations.
instrumentalities.                                                                  How to get a TIN. If you do not have a TIN, apply for one
                                                                                    immediately. To apply for an SSN, get Form SS-5, Application
   Other payees that may be exempt from backup withholding                          for a Social Security Card, from your local Social Security
include:                                                                            Administration office or get this form online at www.ssa.gov. You
   6. A corporation,                                                                may also get this form by calling 1-800-772-1213. Use Form
  7. A foreign central bank of issue,                                               W-7, Application for IRS Individual Taxpayer Identification
  8. A dealer in securities or commodities required to register in                  Number, to apply for an ITIN, or Form SS-4, Application for
the United States, the District of Columbia, or a possession of                     Employer Identification Number, to apply for an EIN. You can
the United States,                                                                  apply for an EIN online by accessing the IRS website at
                                                                                    www.irs.gov/businesses and clicking on Employer Identification
   9. A futures commission merchant registered with the                             Number (EIN) under Starting a Business. You can get Forms W-7
Commodity Futures Trading Commission,                                               and SS-4 from the IRS by visiting www.irs.gov or by calling
  10. A real estate investment trust,                                               1-800-TAX-FORM (1-800-829-3676).
  11. An entity registered at all times during the tax year under                      If you are asked to complete Form W-9 but do not have a TIN,
the Investment Company Act of 1940,                                                 write “Applied For” in the space for the TIN, sign and date the
                                                                                    form, and give it to the requester. For interest and dividend
  12. A common trust fund operated by a bank under section                          payments, and certain payments made with respect to readily
584(a),                                                                             tradable instruments, generally you will have 60 days to get a
  13. A financial institution,                                                      TIN and give it to the requester before you are subject to backup
  14. A middleman known in the investment community as a                            withholding on payments. The 60-day rule does not apply to
nominee or custodian, or                                                            other types of payments. You will be subject to backup
                                                                                    withholding on all such payments until you provide your TIN to
  15. A trust exempt from tax under section 664 or described in                     the requester.
section 4947.
                                                                                    Note. Entering “Applied For” means that you have already
  The chart below shows types of payments that may be                               applied for a TIN or that you intend to apply for one soon.
exempt from backup withholding. The chart applies to the                            Caution: A disregarded domestic entity that has a foreign owner
exempt payees listed above, 1 through 15.                                           must use the appropriate Form W-8.
IF the payment is for . . .                 THEN the payment is exempt              Part II. Certification
                                            for . . .
                                                                                    To establish to the withholding agent that you are a U.S. person,
Interest and dividend payments              All exempt payees except                or resident alien, sign Form W-9. You may be requested to sign
                                            for 9                                   by the withholding agent even if items 1, 4, and 5 below indicate
Broker transactions                         Exempt payees 1 through 13.             otherwise.
                                            Also, a person registered under            For a joint account, only the person whose TIN is shown in
                                            the Investment Advisers Act of          Part I should sign (when required). Exempt payees, see Exempt
                                            1940 who regularly acts as a            Payee on page 2.
                                            broker                                  Signature requirements. Complete the certification as indicated
Barter exchange transactions                Exempt payees 1 through 5               in 1 through 5 below.
and patronage dividends                                                                1. Interest, dividend, and barter exchange accounts
                                                                                    opened before 1984 and broker accounts considered active
Payments over $600 required                 Generally, exempt payees
                                                        2                           during 1983. You must give your correct TIN, but you do not
to be reported and direct                   1 through 7                             have to sign the certification.
                  1
sales over $5,000
                                                                                       2. Interest, dividend, broker, and barter exchange
1                                                                                   accounts opened after 1983 and broker accounts considered
    See Form 1099-MISC, Miscellaneous Income, and its instructions.
2                                                                                   inactive during 1983. You must sign the certification or backup
    However, the following payments made to a corporation (including gross
    proceeds paid to an attorney under section 6045(f), even if the attorney is a
                                                                                    withholding will apply. If you are subject to backup withholding
    corporation) and reportable on Form 1099-MISC are not exempt from               and you are merely providing your correct TIN to the requester,
    backup withholding: medical and health care payments, attorneys’ fees, and      you must cross out item 2 in the certification before signing the
    payments for services paid by a federal executive agency.                       form.
Form W-9 (Rev. 10-2007)                                                                                                                                           Page   4
   3. Real estate transactions. You must sign the certification.                                     Secure Your Tax Records from Identity Theft
You may cross out item 2 of the certification.
                                                                                                     Identity theft occurs when someone uses your personal
   4. Other payments. You must give your correct TIN, but you                                        information such as your name, social security number (SSN), or
do not have to sign the certification unless you have been                                           other identifying information, without your permission, to commit
notified that you have previously given an incorrect TIN. “Other                                     fraud or other crimes. An identity thief may use your SSN to get
payments” include payments made in the course of the                                                 a job or may file a tax return using your SSN to receive a refund.
requester’s trade or business for rents, royalties, goods (other
than bills for merchandise), medical and health care services                                           To reduce your risk:
(including payments to corporations), payments to a                                                  ● Protect your SSN,
nonemployee for services, payments to certain fishing boat crew                                      ● Ensure your employer is protecting your SSN, and
members and fishermen, and gross proceeds paid to attorneys                                          ● Be careful when choosing a tax preparer.
(including payments to corporations).
                                                                                                        Call the IRS at 1-800-829-1040 if you think your identity has
  5. Mortgage interest paid by you, acquisition or                                                   been used inappropriately for tax purposes.
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529), IRA,                                            Victims of identity theft who are experiencing economic harm
Coverdell ESA, Archer MSA or HSA contributions or                                                    or a system problem, or are seeking help in resolving tax
distributions, and pension distributions. You must give your                                         problems that have not been resolved through normal channels,
correct TIN, but you do not have to sign the certification.                                          may be eligible for Taxpayer Advocate Service (TAS) assistance.
                                                                                                     You can reach TAS by calling the TAS toll-free case intake line
                                                                                                     at 1-877-777-4778 or TTY/TDD 1-800-829-4059.
What Name and Number To Give the Requester
                                                                                                     Protect yourself from suspicious emails or phishing
          For this type of account:                         Give name and SSN of:                    schemes. Phishing is the creation and use of email and
                                                                                                     websites designed to mimic legitimate business emails and
    1. Individual                                    The individual
                                                                                                     websites. The most common act is sending an email to a user
    2. Two or more individuals (joint                The actual owner of the account or,
       account)                                      if combined funds, the first
                                                                                                     falsely claiming to be an established legitimate enterprise in an
                                                     individual on the account
                                                                               1
                                                                                                     attempt to scam the user into surrendering private information
    3. Custodian account of a minor                  The minor
                                                                 2                                   that will be used for identity theft.
       (Uniform Gift to Minors Act)
                                                                               1
                                                                                                        The IRS does not initiate contacts with taxpayers via emails.
    4. a. The usual revocable savings                The grantor-trustee                             Also, the IRS does not request personal detailed information
       trust (grantor is also trustee)                                                               through email or ask taxpayers for the PIN numbers, passwords,
                                                                           1
       b. So-called trust account that is            The actual owner                                or similar secret access information for their credit card, bank, or
       not a legal or valid trust under                                                              other financial accounts.
       state law
    5. Sole proprietorship or disregarded            The owner
                                                                   3
                                                                                                        If you receive an unsolicited email claiming to be from the IRS,
       entity owned by an individual                                                                 forward this message to phishing@irs.gov. You may also report
                                                            Give name and EIN of:
                                                                                                     misuse of the IRS name, logo, or other IRS personal property to
          For this type of account:
                                                                                                     the Treasury Inspector General for Tax Administration at
 6. Disregarded entity not owned by an               The owner                                       1-800-366-4484. You can forward suspicious emails to the
    individual                                                                                       Federal Trade Commission at: spam@uce.gov or contact them at
                                                                       4
 7. A valid trust, estate, or pension trust          Legal entity                                    www.consumer.gov/idtheft or 1-877-IDTHEFT(438-4338).
 8. Corporate or LLC electing                        The corporation
    corporate status on Form 8832                                                                      Visit the IRS website at www.irs.gov to learn more about
 9. Association, club, religious,                    The organization                                identity theft and how to reduce your risk.
    charitable, educational, or other
    tax-exempt organization
10. Partnership or multi-member LLC                  The partnership
11. A broker or registered nominee                   The broker or nominee
12. Account with the Department of                   The public entity
    Agriculture in the name of a public
    entity (such as a state or local
    government, school district, or
    prison) that receives agricultural
    program payments
1
    List first and circle the name of the person whose number you furnish. If only one person
    on a joint account has an SSN, that person’s number must be furnished.
2
    Circle the minor’s name and furnish the minor’s SSN.
3
    You must show your individual name and you may also enter your business or “DBA”
    name on the second name line. You may use either your SSN or EIN (if you have one),
    but the IRS encourages you to use your SSN.
4
    List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN
    of the personal representative or trustee unless the legal entity itself is not designated in
    the account title.) Also see Special rules for partnerships on page 1.

Note. If no name is circled when more than one name is listed,
the number will be considered to be that of the first name listed.

Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest,
dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or
contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return.
The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal
nontax 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. Payers must generally withhold 28% of taxable interest, dividend, and certain other
payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.
                                                                                                      Form A
                                                                                                  07-08-2009
                  STATE OF CONNECTICUT
                  NONDISCRIMINATION CERTIFICATION — Representation
                  By Individual
                  For All Contract Types Regardless of Value

Written representation that complies with the nondiscrimination agreements and warranties under
Connecticut General Statutes §§ 4a-60(a)(1) and 4a-60a(a)(1), as amended


INSTRUCTIONS:

For use by an individual who is not an entity (corporation, limited liability company, or partnership) when
entering into any contract type with the State of Connecticut, regardless of contract value. Submit to the
awarding State agency prior to contract execution.


REPRESENTATION OF AN INDIVIDUAL:

I, _____________________________ , of _________________________________________________ ,
           Signatory                                Business Address

represent that I will comply with the nondiscrimination agreements and warranties of Connecticut General

Statutes §§ 4a-60(a)(1)and 4a-60a(a)(1), as amended.




___________________________________________                ___________________________________
Signatory                                                  Date


___________________________________________
Printed Name
                                                                                                      Form B
                                                                                                  07-08-2009
                  STATE OF CONNECTICUT
                  NONDISCRIMINATION CERTIFICATION — Representation
                  By Entity
                  For Contracts Valued at Less Than $50,000

Written representation that complies with the nondiscrimination agreements and warranties under
Connecticut General Statutes §§ 4a-60(a)(1) and 4a-60a(a)(1), as amended


INSTRUCTIONS:

For use by an entity (corporation, limited liability company, or partnership) when entering into any contract
type with the State of Connecticut valued at less than $50,000 for each year of the contract. Complete all
sections of the form. Submit to the awarding State agency prior to contract execution.


REPRESENTATION OF AN ENTITY:

I, _________________________ , ___________________ , of _______________________________ ,
       Authorized Signatory           Title                    Name of Entity

an entity duly formed and existing under the laws of __________________________________ ,
                                                         Name of State or Commonwealth

represent that I am authorized to execute and deliver this representation on behalf of

________________________________ and that ________________________________
          Name of Entity                           Name of Entity

has a policy in place that complies with the nondiscrimination agreements and warranties of Connecticut

General Statutes §§ 4a-60(a)(1) and 4a-60a(a)(1), as amended.



___________________________________________                ___________________________________
Authorized Signatory                                       Date


___________________________________________
Printed Name

				
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