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Ohio Department of Mental Health and Addiction Services

30 East Broad Street, 36th Floor, Columbus OH 43215

Request for Proposal

ENGAGE Wraparound Training & Technical Assistance

Request for Proposal Title: MHA14162 Request for Proposal Issued: January 10, 2014 Request for Proposal Due: January 24, 2014, 2:00 P.M. I. Introduction to the Initiative The Ohio Department of Mental Health and Addiction Services (OhioMHAS) has received a four-year System of Care Expansion grant from the Substance Abuse and Mental Health Services Agency (SAMHSA) called ENGAGE (Engaging the New Generation to Achieve their Goals through Empowerment). The grant was awarded on July 1, 2013 and will end on June 30, 2017. ENGAGE will expand statewide over the next three and half years. The purpose of ENGAGE is to reduce expenditures and improve outcomes related to health, educational, employment and living stability for high risk youth and young adults through statewide System of Care expansion of the evidence-supported, research-based High Fidelity Wraparound (Wraparound) practice. ENGAGE’s target population is youth and young adults in transition, ages 14 through 21 years, with serious emotional disturbance, mental illness, and/or co-occurring conditions (i.e., substance abuse, developmental disabilities) who are/have been involved with child welfare, juvenile justice, criminal justice, and/or been homeless. Current health, education, employment, and living stability outcomes for this very high risk population successfully transitioning into adulthood are quite poor. It is projected that 880 youth and young adults will be served through the ENGAGE SAMHSA System of Care Grant by June 2017. ENGAGE will improve outcomes for high risk youth and young adults in transition with the goal of creating a sustainable statewide System of Care (SOC) infrastructure for Wraparound by June 2017. The approach will focus on workforce development (readiness assessment, training, technical assistance, coaching), capacity building (coach development, facilitator development), evaluation and continuous quality improvement (outcomes study, impact of training and technical assistance), and fidelity (measurement tools). For more information about Wraparound, please refer to the National Wraparound Initiative’s website at http://www.nwi.pdx.edu/ and review the ENGAGE Wraparound Overview summary at http://fcf.ohio.gov/Portals/0/Home/Initiatives/ENGAGE/ENGAGEWraparoundSummary.pdf. To expand High-Fidelity Wraparound statewide for ENGAGE, OhioMHAS is seeking one in-state vendor to provide or sub-contract Wraparound training and technical assistance to selected

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ready communities (up to 28 counties per year), develop the fidelity monitoring and measurements for Wraparound, coordinate communities’ other training needs (i.e., cultural competence, trauma-informed care, youth and family voice), develop the regional coaching virtual sites, assist communities with data collection including fidelity measuring and sustainability planning. II. Scope of Work Vendor will be expected to meet the following deliverables, but may sub-contract specific areas to other contractors. Vendor should have in-depth knowledge regarding the developmental needs, concerns, and issues impacting the ENGAGE population of focus transitioning to adulthood and be aware of evidence-based services and supports (e.g. future planning, life skills) available to assist such needs. Workforce Development: Following the National Wraparound Initiative model, the vendor and/or sub-contractors will need to:

Deliverables By When 1. Develop High-Fidelity Wraparound Training

Curricula (e.g., basic, facilitator, coaching/supervising).

By April 11, 2014

2. Work with certified Transition to Independence Process (TIP) trainers and Wraparound facilitators to determine if certain components of the TIP model could be incorporated and if so, modify Ohio’s High-Fidelity Wraparound model to include such components.

By June 30, 2014

3. Provide initial trainings in person and via webinars to selected communities (up to 28 counties per year).

Starting no later than April 28, 2014

4. Develop learning communities, including with formerly funded SOC communities, to provide support to ready communities beginning to implement Wraparound.

Starting no later May 15, 2014

5. Work with the ENGAGE Management Team to develop, finalize, and implement Ohio’s Wraparound model as well as problem-solve community implementation and evaluation issues.

Starting no later than March 15, 2014

6. Work with ENGAGE Cultural Competence Team to develop a cultural competence training curriculum that could be used with ready communities, creative training methods (e.g. webinar), and identify appropriate trainer(s).

By June 30, 2014

7. Work with OhioMHAS to develop a trauma-informed care training curriculum that could be used for ready communities, creative training methods (e.g. webinar), and identify appropriate trainer(s).

By June 30, 2014

8. Work with the ENGAGE Youth and Young Adults Advisory Council and Family Advisory Council to

Starting no later than April 28, 2014

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determine best methods for engaging and empowering youth, young adults, and family members and develop such training curricula that could be used for ready communities and creative training methods (e.g. webinar).

9. Provide on-sight and virtual technical assistance to ready communities regarding Wraparound implementation.

Starting no later than May 30, 2013

10. Provide cultural competence training. Beginning in October 2014

11. Provide trauma informed training. Beginning in October 2014

Capacity Building: Following the National Wraparound Initiative model, the vendor and/or sub-contractors will need to:

Deliverables By When 1. Work with ready communities to build the capacity for

cross-system buy-in and support for Wraparound. Starting no later than

September 2014 2. With the goal of increasing the number of available trained

Wraparound facilitators throughout Ohio, work with ready communities to imbed the Wraparound practice by providing trainings to the various systems designated staff (behavioral health, juvenile justice, criminal justice, child welfare, FCFC, education, developmental disabilities).

Starting no later than July 2014

3. Identify experienced, trained Wraparound facilitators to serve as contracted coaches to ready communities and ensure enough coaches per region for newly trained facilitators.

Starting no later than May 30, 2014

4. Provide Wraparound Coaching trainings to identified qualified individuals.

Starting no later than July 2014

5. Provide training and assistance to Coaches on fidelity monitoring, data collection, and problem-solving service gaps within communities and across regions.

Starting no later than September 2014

6. Train Coaches to become trainers for Wraparound Basic and Facilitators (Training of Trainers model) and deploy them to communities building to readiness for trainings.

Starting no later than January 2015

Evaluation and Continuous Quality Improvement: Working with ENGAGE Evaluation Team, the vendor and/or sub-contractors will need to:

Deliverables By When 1. Work with the ENGAGE Evaluation Team to develop a

plan to evaluate the impact of Wraparound on intended youth outcomes and cost-savings, and assist communities with sustainability planning.

Starting no later than December 2014

2. Evaluate the impact of Wraparound trainings and modify curricula, approach and techniques in response to the

Every year for annual report due on the 15th

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results of the evaluation. of July following the State Fiscal Year

3. Evaluate the impact of Wraparound technical assistance and modify delivery, approach and techniques in response to the results of the evaluation.

Every year for annual report due on the 15th of July following the

State Fiscal Year Fidelity: Working with ENGAGE Evaluation Team, the vendor and/or sub-contractors will need to:

Deliverables By When 1. Partner with the Wraparound Evaluation and Research

Team at the University of Washington (http://depts.washington.edu/wrapeval/index.html) to determine specific fidelity measurement tool(s) Ohio will use to monitor Wraparound.

By June 30, 2014

2. Secure license (if not already in place) to use the University of Washington’s Wraparound fidelity tool(s).

By June 30, 2014

3. Work with communities to determine the best methods for conducting fidelity reviews and collecting necessary data (e.g., technology needs, person(s) responsible, how often).

Starting no later than June 2014

4. Train Wraparound Coaches, Facilitators, and other community representatives as needed on fidelity measurements, monitoring requirements, and data collections.

Starting no later than September 2014

5. Monitor communities’ fidelity data collection and work with those not entering data on a timely basis to bring them into compliance.

Starting no later than December 2014

6. Provide targeted technical assistance to communities with low fidelity to the model.

Starting no later than January 2015

III. Wraparound Training & Technical Assistance Timeline: The below timeline is being shared to illustrate the three and half year plan for Wraparound training and technical assistance. This timeline is being included as a reference only and is subject to change.

1st Year 3rd Quarter (Jan – Mar): • 1st Cohort of SOC communities is

selected • Training & technical assistance

package is developed in partnership with the ENGAGE Management Team, including how Transition to Independence Process elements can be incorporated into the model

4th Quarter (Apr – Jun): • Training and technical

assistance begins for 1st cohort of SOC communities

• Begin to form learning communities and include formerly funded SOC communities

• Work with YYAT Advisory Councils & Family Advisory Councils to determine best methods for engaging youth in Wraparound

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• Begin to work with ready communities on capacity building for collaboration across systems to support Wraparound

Year 2: July 1, 2014 – June 30, 2015

1st Quarter (July-Sept): • Continue providing training & TA

to 1st Cohort with emphasis on fidelity measurements & monitoring

• Begin training experienced Wraparound facilitators as regional Coaches for new communities

2nd Quarter (Oct-Dec): • Provide cultural competence

training to 1st cohort • Provide trauma informed

training to 1st cohort

3rd Quarter (Jan-Mar): • Select 2nd Cohort SOC communities

and begin training & TA • Begin sustainability planning with

1st cohort

4th Quarter (Apr – Jun): • Continuing providing training

& TA to 2nd cohort with emphasis on fidelity measurements & monitoring

Year 3: July 1, 2015 – June 30, 2016

1st Quarter (July-Sept): • Provide cultural competence

training to 2nd cohort • Provide trauma informed training to

2nd cohort • Provide training to new experienced

Wraparound facilitators to serve as regional Coaches

2nd Quarter (Oct-Dec): • Select 3rd Cohort of SOC

communities and begin training & TA

• Begin sustainability planning with 2nd cohort

3rd Quarter (Jan-Mar): • Continuing providing training & TA

to 3rd cohort with emphasis on fidelity measurements & monitoring

• Provide cultural competence training to 3rd cohort

• Provide trauma informed training to 3rd cohort

4th Quarter (Apr-June): • Provide training to new

experienced Wraparound facilitators to serve as regional Coaches

Year 4: July 1, 2016 – June 30, 2017

1st Quarter (July – Sept): • Select 4th Cohort of SOC

communities (remainder of state) and begin training & TA

• Begin sustainability planning with 3rd cohort

• Work with Centers of Excellence, Ohio Child Welfare Training Program, and other existing statewide system-specific training programs to incorporate the Wraparound trainings into such programs for long-term sustainability and capacity building.

2nd Quarter (Oct-Dec): • Continuing providing training

& TA to 4th cohort with emphasis on fidelity measurements & monitoring

• Provide cultural competence training to 4th cohort

• Provide trauma informed training to 4th cohort

3rd Quarter (Jan-Mar): • Provide training to new experienced

Wraparound facilitators to serve as regional Coaches

4th Quarter (Apr-Jun): • Finalize training, technical

assistance, data collection, sustainability planning, reports

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• Begin sustainability planning with 4th cohort

IV. Availability of Funds Total Maximum Award for March 2014-June 30, 2015: $365,836.00. The funds will be available March 2014 through June 30, 2015. The contract may be renewed for up to two years, for the period beginning on July 1, 2015 and ending June 30, 2017. No match requirements apply. V. Proposal Contents

1. Proposal Narrative must describe: a. Demonstrated knowledge and experience relating to the Scope of Work, including

statewide workforce development, statewide and regional capacity building, evaluation, and fidelity.

b. Demonstrated knowledge of and experience with High-Fidelity Wraparound. c. The role of the vendor and what deliverables will be met via the vendor and the

role of sub-contractor(s) and what deliverables will be met by sub-contractor(s), if applicable.

d. Vendor’s plan for expanding High-Fidelity Wraparound statewide in three years and achieving sustainability post grant, including aligning this initiative with other efforts the Vendor and/or sub-contractors may be leading.

e. Vendor’s knowledge of and experience with building community capacity to collaborate across systems and creating learning communities.

f. Experience and capacity with disseminating culturally competent training and technical assistance to a variety of professionals.

g. Vendor’s plan to oversee and evaluate the training and technical assistance program.

h. Knowledge of the system of care framework, the needs and issues of youth and young adults, evidence-based practices appropriate for the ENGAGE population, trauma-informed care, and the Transition to Independence process.

2. Budget: Itemized direct and indirect costs for SFY 14 (February – June 30, 2014) and for SFY 15 (July 1, 2014 – June 30, 2015). Budget should specify costs for each area under the Scope of Work: Workforce Development; Capacity Building; Evaluation; and, Fidelity. Please note these restrictions for the budget:

• Indirect cost are not to exceed 10% of the proposed project budget • At least $15,000 of budget must be set aside for cultural competency and trauma

informed care trainings. • At least $28,000 (for July 1, 2014 – June 30, 2015 budget) must be set aside for

fidelity measurement needs (e.g., license, tools, community technology needs (i.e., tablets), collection, analysis)

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3. Applicant Eligibility: Describe the vendor’s history in meeting grant requirements,

history and knowledge with High-Fidelity Wraparound, and providing training and technical assistance to Ohio’s communities. If sections of the program will be contracted to sub-contractors, the proposal must identify sub-contractor(s) if known, detail history of sub-contractor(s), how the vendor will oversee deliverables and what areas the sub-contractor(s) will be addressing.

VI. Submission of Proposals 1. Application Due Date: Friday, January 24th by 2:00 P.M. Proposals must be

received by this time to be considered. Proposals may be submitted electronically or by paper copy.

2. Where to Send Proposal: Electronic proposals must be sent to:

OhioMHASBidOpportunity@mha.ohio.gov

Original bid may be sent via U.S. mail to: Lucille Fuller Office of Financial Management 30 East Broad St., Suite 1100 Columbus, OH 43215

3. The bid number MHA14162 must be clearly marked on the sealed envelope.

4. Conditions of Submission: The proposal may be no more than 5 pages, typed in 12

font size, with 1” margins, not including the cover letter and letters of support. Only one copy must be submitted.

OhioMHAS reserves the right to make no award, make an award for a lesser amount, make an alternative award for the specified project or make an award for a shorter duration. OhioMHAS reserves the right to ask clarifying questions, issue conditional awards, negotiate an alternative project plan or scope and negotiate a best and final application with one or more applicant(s). OhioMHAS reserves the right to waive errors and omissions that do not materially affect the outcome of said application. Errors and omissions may result in lower evaluation scores or rejection of the application. OhioMHAS reserves the right to reject, in whole or in part, any and all proposals where the department, taking into consideration factors including but not limited to, cost and the results of the evaluation process, has determined that the award would not be in the best interest of the department. OhioMHAS will not be liable for any costs incurred by an applicant in responding to this RFP, regardless of whether the department awards through this process, decides not to go forward with this process, cancels this RFP or awards the project through some other process.

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Applicant will be solely responsible for reporting, withholding, and paying all employment related taxes, payments, and withholdings for his/her self and any personnel, including but not limited to: Federal, State, and local income taxes, social security, unemployment or disability deductions, withholdings, and payments.

5. Proposals must include: a cover letter including the organization name, address, Federal Tax Identification number, contact person, phone number, authorized signature; proposal narrative; budget; statement of applicant eligibility; evaluation plan; and three letters of support from entities that are aware of organization’s capacity to meet the grant requirements.

6. Questions/Inquires must be sent via the State of Ohio Procurement Website www.procure.ohio.gov. Click on the link for ‘Procurement Opportunities’, select ‘View All’ at the bottom of the page, click on the Request for Proposal and then click the “Submit Inquiry” button.

7. Anticipated Award Date: February 21, 2014

VII. Factors and Criteria for Evaluation Proposals Proposals will be scored and point values given to the following criteria.

Technical Criterion Weight Rating (0-5) Technical Score (WxR)

Scope of Work Organization’s demonstrated knowledge of and experience with the Scope of Work, including statewide workforce development, statewide and regional capacity building, evaluation, and fidelity, (Years, examples provided, and effectiveness of such statewide workforce programs)

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Organization’s demonstrated knowledge of and experience with High-Fidelity Wraparound (Years, examples provided, and effectiveness of established Wraparound teams)

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Organization’s demonstrated knowledge of and experience with expanding High-Fidelity Wraparound and being able to sustain post grant, including aligning this initiative with other efforts the Vendor and/or sub-contractors may be leading (Years, examples provides, and vision for expanding Wraparound statewide).

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Organization’s demonstrated knowledge of and experience with building community capacity to collaborate across systems and creating learning

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communities. Organization’s experience with and capacity for disseminating culturally competent training and technical assistance to a variety of professionals.

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Organization’s knowledge of the system of care framework, the needs and issues of youth and young adults, evidence-based practices appropriate for the ENGAGE population, trauma-informed care, and the Transition to Independence process.

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Organization’s proposed plan in meeting the Scope of Work’s timeline.

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Scope of Work Technical Score 32 Max 35 Max 1120 Max

Organizational Capacity Weight Rating (0-5) Technical Score (WxR)

Clear description of the role of the vendor and what deliverables will be met via the vendor and the role of sub-contractor(s) and what deliverables will be met by sub-contractor(s), if applicable.

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Ability to oversee and monitor sub-contracts 3 Oversight and evaluation plan for the training and technical assistance program. 4

Detailed budget to meet the deliverables for each fiscal year. 5

Total Weight 17 Max 20 Max 340 Max

Total Technical Score 1460 Max

Rating Explanation

0 Does Not Meet. Proposal does not comply with the requirement and/or does not meet expectations for the criterion.

1 Weak. Proposal does not substantially meet the requirement and/or does not substantially meet expectations for the criterion.

2 Moderate. Proposal generally meets requirement, but is weak in meeting minimal expectations for the criterion.

3 Meets. Proposal meets the requirement, and meets expectations for the criterion.

4 Strong. Proposal meets the requirement and exceeds expectations for the criterion.

5 Greatly Exceeds. Proposal meets the requirement and significantly exceeds expectations for the criterion.

OBM-5657 05/02/2011

VENDOR INFORMATION FORM

All parts of the form must be completed by the vendor and returned to Ohio Shared Services. The information must be legible.

SECTION 1 – PLEASE SPECIFY TYPE OF ACTION

NEW (W-9 OR W-8ECI FORM ATTACHED) CHANGE OF CONTACT PERSON/INFORMATON

ADDITIONAL ADDRESS (PLEASE PROVIDE COPY OF INVOICE OR LETTER OF EXPLANATION)

CHANGE OF ADDRESS – ENTER OLD ADDRESS

CHANGE OF TIN (NEW W-9 AND LETTER OF EXPLANATION OF CHANGE, WHICH INCLUDES OLD TIN, IS REQUIRED)

CHANGE OF NAME (NEW W-9 AND LETTER OF EXPLANATION OF CHANGE IS REQUIRED)

CHANGE OF PAY TERMS CHANGE OF PO DISPATCH METHOD OTHER_____________________________________

SECTION 2 – PLEASE PROVIDE VENDOR INFORMATION

LEGAL BUSINESS OR INDIVIDUAL NAME: (MUST MATCH W-9 OR W-8ECI FORM)

BUSINESS NAME, TRADE NAME, DOING BUSINESS AS: (IF DIFFERENT THAN ABOVE)

FEDERAL TAX ID (TIN), EMPLOYER ID (EIN) OR SOCIAL SECURITY NUMBER (REQUIRED):

BUSINESS ENTITY: (IF A SOLE PROPRIETOR, THE INDIVIDUAL’S NAME MUST APPEAR IN LEGAL BUSINESS NAME) CHECK ONE:

INDIVIDUAL/SOLE PROPRIETOR CORPORATION S CORPORATION PARTNERSHIP TRUST/ESTATE

LIMITED LIABILITY COMPANY CIRCLE THE TAX CLASSIFICATION (C=CORPORATION, S= S CORPORATION, P=PARTNERSHIP) ______________

OTHER (PLEASE EXPLAIN)

SECTION 3 – PLEASE PROVIDE COMPLETE ADDRESS 1 (IF MORE THAN 2 ADDRESSES, INCLUDE A SEPARATE SHEET)

ADDRESS: COUNTY:

CITY: STATE: ZIP CODE:

SECTION 4 – PLEASE PROVIDE COMPLETE ADDRESS 2

ADDRESS: COUNTY:

CITY: STATE: ZIP CODE:

OBM-5657 REV. 02/15/2011

SECTION 5 – CONTACT INFORMATION AND PERSON TO RECEIVE PURCHASE ORDER

NAME:

WEBSITE:

PHONE: FAX:

E-MAIL:

SECTION 6 - STRATEGIC SOURCING CONTACT INFO (PERSON TO RECEIVE E-MAIL NOTICE OF BID EVENTS)

THE USER ID & PASSWORD TO COMPLETE STRATEGIC SOURCING REGISTRATION WILL BE SENT TO E-MAIL ADDRESS BELOW.

NAME::

E-MAIL: PHONE NUMBER:

SECTION 7 – IS YOUR BUSINESS CURRENTY CERTIFIED AS? (PLEASE CHECK)

MBE (MINORITY BUSINESS ENTERPRISE) EDGE (ENCOURAGING DIVERSITY, GROWTH, & EQUITY) N/A

SECTION 8 – PAYMENT TERMS (PLEASE CHECK ONE, OTHERWISE NET 30 WILL BE APPLIED BY DEFAULT)

2/10 NET 30 NET 30 NET 45 NET 60 NET 90

SECTION 9 – PURCHASE ORDER DISTRIBUTION-OTHER THAN USPS MAIL (NOTE: APPLICABLE FOR VENDORS THATRECEIVE PO ONLY (INPUT E-MAIL ADDRESS OR FAX NUMBER BELOW)

E-MAIL OR FAX:

SECTION 10 – PLEASE SIGN AND DATE

PRINT NAME:

SIGNATURE:

DATE:

SECTION 11 – STATE OF OHIO AGENCY CONTACT INFORMATION (AGENCY WHERE GOODS OR SERVICES ARE DELIVERED)

AGENCY NAME: OHIO DEPARTMENT OF MENTAL HEALTH

E-MAIL: Lucille.Fuller@mh.ohio.gov PHONE NUMBER: 614-466-7697

COMMENTS:

Note: This document does contain sensitive information. Sending via non-secure channels, including e-mail and fax can be a potential security risk.

SUBMIT FORM TO:

Mail: Ohio Shared Services P.O. Box 182880 Cols., OH 43218-2880

Fax: (614) 485-1052 E-mail: vendor@ohio.gov

QUESTIONS? PLEASE CONTACT:

Phone: 1 (877) OHIO-SS1 (1-877-644-6771) 1 (614) 338-4781 E-mail: vendor@ohio.gov

Form W-9(Rev. January 2011)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the

requester. Do not

send to the IRS.

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Name (as shown on your income tax return)

Business name/disregarded entity name, if different from above

Check appropriate box for federal tax

classification (required): Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

Other (see instructions)

Exempt payee

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

Requester’s name and address (optional)

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 the “Name” line to avoid 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.

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Social security number

– –

–

Employer identification number

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 Here

Signature of

U.S. person Date

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Purpose of FormA person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners’ share of effectively connected income.

Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are

considered a U.S. person if you are:

• An individual who is a U.S. citizen or U.S. resident alien,

• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,

• An estate (other than a foreign estate), or

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners’ share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income.

Cat. No. 10231X Form W-9 (Rev. 1-2011)