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DocuSign Envelope ID:2BA5E40A-FF10-4F0E-ACB6-711 F2F7F2DFF <br /> Contract# C0009950 <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 same 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: Phone: Fax: Email: <br /> Teresa Bender 651-792-7933 651-429-8629 tbender@centervillemn.com <br /> r—DocuSigned by: <br /> �. <br /> Signature (Required): Date: 4/25/2023 <br /> �CB5A2C8C4E584A0 <br /> Insurance Agency: Name of Agent: <br /> Telephone Number of Insurance Agent: <br /> Person Completing this Form: <br /> Name: Mark Statz Title: City Administrator/Engineer <br /> Phone: 651-792-7931 Fax: N/A Email: info@centervillemn.com <br />