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2022-10-12 CC Packet
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2022-10-12 CC Packet
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DocuSign Envelope ID: 656F3A3D-164D-46BE-AF4D-F6B87DF98D38 <br />Contract# C0009406 <br />ANOKA COUNTY HUMAN SERVICES <br />CONTRACTOR INFORMATION SHEET <br />Please review the following information for accuracy and Angie Rodine <br />completeness, indicate any changes, sign and return to: Anoka County Human Services <br />2100 3rd Ave, Suite 500 <br />Anoka, MN 55303 <br />LEGAL NAME FOR CONTRACTOR: Centerville, City of <br />(Legal name and name on Certificate of Insurance must be exactly the some in order for County Signatures to be obtained on the <br />Contract.) <br />Doing Business As: Centerville, City of <br />Business/Corporate Address: 1880 Main Street <br />Centerville, MN 55038 <br />National Provider Identification (NPI) #: N/A <br />Federal Tax Identification #: 41-1267014 <br />NOTICE: Federal Business Tax ID/Social Security Number is needed for tax purposes as mandated by Section 1211 of the Tax Reform Act <br />of 1976 and Minn. Stat 270.66. This information will be shared with the Minnesota Department of Revenue, the Minnesota Department <br />of Human Services, the Internal Revenue Service, and the U.S. Department of Health, Education and Welfare for the purposes of <br />administering the income tax, child support obligation and social security tax programs. <br />Individual who Contractor is designating to receive notice under the contract and to act as the responsible <br />authority for data requests under the Minnesota government data practices act (Minn. Stat. Chap. 13): <br />Name <br />Teresa Bender <br />Phone: <br />651-792-7933 <br />Fax: <br />651-429-8629 <br />Email: <br />tbender@centervillemn.com <br />DocuSigned by: <br />Signature (Required):EDEOF-9GE9EE38473-tyusa' bu/'� Date: ... <br />Insurance Agency: <br />Telephone Number of Insurance Agent: <br />Person Completing this Form: <br />Name: Teresa Bender <br />Name of Agent: <br />Title: City Clerk <br />9/28/2022 <br />Phone: 651-792-7933 Fax: 651-429-86289 Email: tbender@centervillemn.com <br />
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