Laserfiche WebLink
DocuSign Envelope ID: 2BA5E40A•FF10-4F0E-ACB6-71IF2F7F2DFF <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 some in order for County Signatures to be obtained on the <br />Contract.) <br />Doing Business As: <br />Business/Corporate Address: <br />Centerville, City of <br />1880 Main Street <br />Centerville, MN 55038 <br />National Provider Identification (NPI) #: <br />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 Welfore 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: Fax: <br />651-792-7933 651-429-8629 <br />—DoDocusigned by: <br />Signature (Required): '�i <br />Insurance Agency: <br />Telephone Number of Insurance Agent: <br />Person Completing this Form: <br />Name: Mark Statz <br />Email: <br />tbender@centervillemn.com <br />Date: 4/25/2023 <br />Name of Agent: <br />Title: City Administrator/Engineer <br />Phone: 651-792-7931 Fax: NIA Email: info@centervillemn.com <br />