Fillable District Office Lease Instructions (US House of Representatives)

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District Office Lease Instructions (US House of Representatives)

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District Office Lease – Instructions
A. The preamble has three blank lines to be filled in: (1) Landlord’s name; (2) Landlord’s address;
and (3) Member/Member-Elect’s name.
B. Section 1 has three blank lines to be filled in: (1) square footage of the leased office (optional);
(2) street address of the leased office; and (3) city, state and ZIP code of the leased office.
C. Section 2 confirms that all amenities identified in the District Office Lease Attachment
accompanying the Lease are to be provided by Lessor.
D. Section 3 has two blank lines to be filled in: (1) date lease begins (must be on or after January 3,
2017); and (2) date lease ends (must be on or before January 2, 2019).
E. Section 4 has one blank line for the monthly rent amount (write “zero” if no rent is to be paid).
F. Section 5 has one blank line – the number of days’ notice required for either party to terminate
the lease before the end of the term. A standard period is 30 days, but any figure is acceptable. If
the lease may not be terminated early, enter “N/A” in this blank.
G. Sections 1–9, other than filling in the blanks, may not be altered or deleted.
H. Section 11 has space provided to list any additional lease provisions.
I. Prior to either party signing a lease, the Member/Member-Elect must submit the proposed lease,
accompanied by a copy of the District Office Lease Attachment for the 115
th
Congress, to the
Administrative Counsel for review and approval. If the proposed terms and conditions of the
lease are determined to be in compliance with applicable law and House Rules and Regulations,
the Administrative Counsel will notify the Member/Member-Elect that (s)he may proceed with
the signing of the lease. Please submit the proposed lease and District Office Lease Attachment
either by e-mail in PDF form (leases@mail.house.gov) or fax (202-225-6999).
J. The Member/Member-Elect is required to personally sign the documents. A signed and
dated District Office Lease Attachment must accompany this lease. Once signed by both
parties, the Lease and the District Office Lease Attachment must be submitted to the
Administrative Counsel for final approval. They may be sent by email in PDF form or faxed to
202-225-6999.
K. If approved, Administrative Counsel will send the forms to Finance so that payment can begin. If
there are errors on the form, the Member office will be contacted and required to correct them.
NO LEASE OR ATTACHMENT CAN BE SIGNED BEFORE THEY HAVE BEEN
APPROVED BY THE ADMINISTRATIVE COUNSEL.
The term for a District Office Lease for the 115
th
Congress may not commence prior to January
3, 2017.
Members should endeavor to lease space through the last day of a congressional term rather
than the last day of a calendar year. For the 115
th
Congress, leases should end on January 2,
2019, not December 31, 2018.
U.S. House of Representatives
Washington, D.C. 20515
District Office Lease
(Page 1 of 3 – 115
th
Congress)
Pursuant to 2 U.S.C.A. § 4313, and the Regulations of the Committee on House Administration (as
modified from time to time by Committee Order) relating to office space in home districts, ___________
______________________________, _____________________________________________________
(“Lessor”), and _________________________________, a Member/Member-Elect of the U.S. House of
Representatives (“Lessee”), agree as follows:
1. Location. Lessor shall lease to Lessee _____________ square feet of office space located at
______________________________________________________________________________
in the city, state and ZIP code of __________________________________________.
2. Lease Amenities. Lessee shall be entitled to receive and Lessor shall be required to provide the
amenities selected in Section A of the District Office Lease Attachment (“Attachment”)
accompanying this Lease.
3. Term. Lessee shall have and hold the leased premises for the period beginning _____________,
20____ and ending _____________, 20____. The term of this District Office Lease (“Lease”)
may not exceed two (2) years and may not extend beyond January 2, 2019, which is the end of
the constitutional term of the Congress to which the Member is elected.
4. Rent. The monthly rent shall be $_______________, and is payable in arrears on or before the
last day of each calendar month. Rent payable under this Lease shall be prorated on a daily basis
for any fraction of a month of occupancy.
5. Early Termination. This Lease may be terminated by either party giving ______ days’ prior
written notice to the other party. The commencement date of such termination notice shall be the
date such notice is delivered or, if mailed, the date such notice is postmarked.
6. Payments. During the term of this Lease, rent payments under Section 4 of this Lease shall be
remitted to the Lessor by the Chief Administrative Officer of the U.S. House of Representatives
(the “CAO”) on behalf of the Lessee.
7. District Office Lease Attachment for 115
th
Congress. The District Office Lease Attachment
attached hereto is incorporated herein by reference, and this Lease shall have no force or effect
unless and until accompanied by an executed District Office Lease Attachment for the 115
th
Congress.
8. Counterparts. This Lease may be executed in any number of counterparts and by facsimile
copy, each of which shall be deemed to be an original but all of which together shall be deemed
to be one and the same instrument.
9. Section Headings. The section headings of this Lease are for convenience of reference only and
shall not be deemed to limit or affect any of the provisions hereof.
(Office street address)
(Office city, state and ZIP)
(Landlord’s name)
(Landlord’s street address, city, state, ZIP code)
Save Form
U.S. House of Representatives
Washington, D.C. 20515
District Office Lease
(Page 2 of 3 – 115
th
Congress)
10. Modifications. Any amendments, additions or modifications to this Lease inconsistent with
Sections 1 through 9 above shall have no force or effect to the extent of such inconsistency.
11. Other. Additionally, the Lessor and the Lessee agree to the following:
[Signature page follows.]
U.S. House of Representatives
Washington, D.C. 20515
District Office Lease
(Page 3 of 3 – 115
th
Congress)
This District Office Lease must be accompanied with an executed District Office Lease Attachment.
IN WITNESS WHEREOF, the parties have duly executed this District Office Lease as of the later date
written below by the Lessor or the Lessee.
______________________________________ ______________________________________
Print Name of Lessor/Landlord/Company Print Name of Lessee
By: ___________________________________ ______________________________________
Lessor Signature Lessee Signature
Name:
Title:
______________________________________ ______________________________________
Date Date
Save Form
Print Form
District Office Lease Attachment- Instructions
The District Office Lease Attachment must accompany every Lease or District Office Lease Amendment
that is submitted for a Member/Member-Elect’s District Office.
A few things to keep in mind:
A. The Member/Member-Elect is required to personally sign the documents.
B. The Member/Member-Elect must indicate in Section A (“Lease Amenities”) of the
Attachment whether the proposed leased space will serve as a flagship district office.
C. The Lessor must complete the amenities checklist in Section A (“Lease Amenities”), unless
the checkbox at the top of the amenities checklist is marked to indicate that amenities are
listed elsewhere in the Lease.
D. Broadband/cable availability can be confirmed by visiting www.broadbandmap.gov and entering
the address of the proposed leased space.
E. Section B (“Additional Terms and Conditions”) of the Attachment SHALL NOT have any
provisions deleted or changed.
F. Even if rent is zero, an Attachment is still required.
G. Prior to either party signing a Lease or Amendment, the Member/Member-Elect must
submit the proposed Lease or Amendment, accompanied by a copy of the Attachment, to
the Administrative Counsel for review and approval. If the Administrative Counsel
determines that the proposed terms and conditions of the Lease or Amendment are in compliance
with applicable law and House Rules and Regulations, the Administrative Counsel will notify the
Member/Member-Elect that (s)he may proceed with the execution of the Lease or Amendment.
Please submit the proposed Lease or Amendment and Attachment either by e-mail in PDF form
(leases@mail.house.gov) or by fax (202-225-6999).
H. Once signed by both parties, the Lease or Amendment and the Attachment must be submitted to
the Administrative Counsel for final approval. The Attachment should be submitted at the same
time the Lease or Amendment is sent to the Administrative Counsel. They may be sent by email
in PDF form or faxed to (202-225-6999).
I. Without a properly signed and submitted Attachment, the Lease or Amendment cannot be
approved and payments will not be made. The parties agree that any charges for default, early
termination or cancellation of the Lease or Amendment which result from actions taken by or on
behalf of the Lessee shall be the sole responsibility of the Lessee, and are not reimbursable from
the Member’s Representational Allowance.
J. Lessor shall provide a copy of any assignment, estoppel certificate, notice of a bankruptcy
or foreclosure, or notice of a sale or transfer of the leased premises to the Administrative
Counsel by e-mail in PDF form (leases@mail.house.gov).
NO LEASE, AMENDMENT OR ATTACHMENT CAN BE SIGNED BEFORE THEY HAVE
BEEN APPROVED BY THE ADMINISTRATIVE COUNSEL.
The term of a District Office Lease or Amendment for the 115
th
Congress may not commence
prior to January 3, 2017.
Members should endeavor to lease space through the last day of a congressional term rather than
the last day of a calendar year. For the 115
th
Congress, leases should end on January 2, 2019, not
December 31, 2018.
U.S. House of Representatives
Washington, D.C. 20515
District Office Lease Attachment
(Page 1 of 5 – 115
th
Congress)
Send completed forms to: Administrative Counsel, 217 Ford House Office Building, Washington, D.C. 20515.
Copies may also be faxed to 202-225-6999.
SECTION A
(Lease Amenities)
Section A designates whether the leased space will be the Member/Member-Elect’s flagship
(primary) office and sets forth the amenities provided by the Lessor to be included in the Lease. Except as
noted below, the amenities listed are not required for all district offices.
To be completed by the Member/Member-elect:
□ The leased space will serve as my flagship (primary) District Office.
□ The leased space will NOT serve as my flagship (primary) District Office.
To be completed by the Lessor:
□ Amenities are separately listed elsewhere in the Lease.
(The below checklist can be left blank if the above box is checked.)
The Lease includes (please check and complete all that apply):
(Items marked with an asterisk and in bold are required for all flagship offices of Freshman
Members of the 115
th
Congress.)
□ * Broadband and/or Cable Access to the Leased Space (e.g. Comcast, Cox, Verizon, etc.).
(Verify broadband access by entering the address of the leased space at www.broadbandmap.gov)
□ * Interior Wiring CAT 5e or Better within Leased Space.
□ Lockable Space for Networking Equipment.
□ Telephone Service Available.
□ Parking. □____ Assigned Parking Spaces
□____ Unassigned Parking Spaces
□ General Off-Street Parking on an As-Available Basis
□ Utilities. Includes: ____________________________________________________________
□ Janitorial Services. Frequency: __________________________________________________
□ Trash Removal. Frequency: _____________________________________________________
□ Carpet Cleaning. Frequency: ____________________________________________________
□ Window Washing. □ Window Treatments.
□ Tenant Alterations Included In Rental Rate.
□ After Hours Building Access.
□ Office Furnishings. Includes: ___________________________________________________
□ Cable TV Accessible. If checked, Included in Rental Rate: □ Yes □ No
□ Building Manager. □ Onsite □ On Call Contact Name:______________________________
Phone Number:___________________ Email Address:_______________________________
Print Form
Save Form
Clear Page
U.S. House of Representatives
Washington, D.C. 20515
District Office Lease Attachment
(Page 2 of 5 – 115
th
Congress)
Send completed forms to: Administrative Counsel, 217 Ford House Office Building, Washington, D.C. 20515.
Copies may also be faxed to 202-225-6999.
SECTION B
(Additional Terms and Conditions)
1. Incorporated District Office Lease Attachment. Lessor (Landlord) and Lessee
(Member/Member-Elect of the U.S. House of Representatives) agree that this District Office
Lease Attachment (“Attachment”) is incorporated into and made part of the Lease (“Lease”) and,
if applicable, District Office Lease Amendment (“Amendment”) to which it is attached.
2. Performance. Lessor expressly acknowledges that neither the U.S. House of Representatives
(the “House”) nor its Officers are liable for the performance of the Lease. Lessor further
expressly acknowledges that payments made by the Chief Administrative Officer of the House
(the “CAO”) to Lessor to satisfy Lessee’s rent obligations under the Lease – which payments are
made solely on behalf of Lessee in support of his/her official and representational duties as a
Member of the House – shall create no legal obligation or liability on the part of the CAO or the
House whatsoever. Lessee shall be solely responsible for the performance of the Lease and
Lessor expressly agrees to look solely to Lessee for such performance.
3. Modifications. Any amendment to the Lease must be in writing and signed by the Lessor and
Lessee. Lessor and Lessee also understand and acknowledge that the Administrative Counsel for
the CAO (“Administrative Counsel”) must review and give approval of any amendment to the
Lease prior to its execution.
4. Compliance with House Rules and Regulations. Lessor and Lessee understand and
acknowledge that the Lease shall not be valid, and the CAO will not authorize the disbursement
of funds to the Lessor, until the Administrative Counsel has reviewed the Lease to determine that
it complies with the Rules of the House and the Regulations of the Committee on House
Administration, and approved the Lease by signing the last page of this Attachment.
5. Payments. The Lease is a fixed term lease with monthly installments for which payment is due
in arrears on or before the end of each calendar month. In the event of a payment dispute, Lessor
agrees to contact the Office of Finance of the House at 202-225-7474 to attempt to resolve the
dispute before contacting Lessee.
6. Void Provisions. Any provision in the Lease purporting to require the payment of a security
deposit shall have no force or effect. Furthermore, any provision in the Lease purporting to vary
the dollar amount of the rent specified in the Lease by any cost of living clause, operating
expense clause, pro rata expense clause, escalation clause, or any other adjustment or measure
during the term of the Lease shall have no force or effect.
7. Certain Charges. The parties agree that any charge for default, early termination or cancellation
of the Lease which results from actions taken by or on behalf of the Lessee shall be the sole
responsibility of the Lessee, and shall not be paid by the CAO on behalf of the Lessee.
8. Death, Resignation or Removal. In the event Lessee dies, resigns or is removed from office
during the term of the Lease, the Clerk of the House may, at his or her sole option, either: (a)
U.S. House of Representatives
Washington, D.C. 20515
District Office Lease Attachment
(Page 3 of 5 – 115
th
Congress)
Send completed forms to: Administrative Counsel, 217 Ford House Office Building, Washington, D.C. 20515.
Copies may also be faxed to 202-225-6999.
terminate the Lease by giving thirty (30) days’ prior written notice to Lessor; or (b) assume the
obligation of the Lease and continue to occupy the premises for a period not to exceed sixty (60)
days following the certification of the election of the Lessee’s successor. In the event the Clerk
elects to terminate the Lease, the commencement date of such thirty (30) day termination notice
shall be the date such notice is delivered to the Lessor or, if mailed, the date on which such notice
is postmarked.
9. Term. The term of the Lease may not exceed the constitutional term of the Congress to which
the Lessee has been elected. The Lease may be signed by the Member-Elect before taking office.
Should the Member-Elect not take office to serve as a Member of the 115
th
Congress, the Lease
will be considered null and void.
10. Early Termination. If either Lessor or Lessee terminates the Lease under the terms of the Lease,
the terminating party agrees to promptly file a copy of any termination notice with the Office of
Finance, U.S. House of Representatives, O’Neill Federal Building, Suite 3220, Attn: Levi
Matthews, Washington, D.C. 20515, and with the Administrative Counsel by e-mail at
leases@mail.house.gov.
11. Assignments. Lessor shall not have the right to assign (by operation of law or otherwise) any of
its rights, interests and obligations under the Lease, in whole or in part, without providing thirty
(30) days prior written notice to Lessee, and any such purported assignment without such notice
shall be void. Lessor shall promptly file a copy of any such assignment notice with the
Administrative Counsel by e-mail at leases@mail.house.gov.
12. Sale or Transfer of Leased Premises. Lessor shall provide thirty (30) days prior written notice
to Lessee in the event (a) of any sale to a third party of any part of the leased premises, or (b)
Lessor transfers or otherwise disposes of any of the leased premises, and provide documentation
evidencing such sale or transfer in such notice. Lessor shall promptly file a copy of any such sale
or transfer notice with the Administrative Counsel by e-mail at leases@mail.house.gov.
13. Bankruptcy and Foreclosure. In the event (a) Lessor is placed in bankruptcy proceedings
(whether voluntarily or involuntarily), (b) the leased premises is foreclosed upon, or (c) of any
similar occurrence, Lessor agrees to promptly notify Lessee in writing. Lessor shall promptly file
a copy of any such notice with the Office of Finance, U.S. House of Representatives, O’Neill
Federal Building, Suite 3220, Attn: Levi Matthews, Washington, D.C. 20515, and with the
Administrative Counsel by e-mail at leases@mail.house.gov.
14. Estoppel Certificates. Lessee agrees to sign an estoppel certificate relating to the leased
premises (usually used in instances when the Lessor is selling or refinancing the building) upon
the request of the Lessor. Such an estoppel certificate shall require the review of the
Administrative Counsel, prior to Lessee signing the estoppel certificate. Lessor shall promptly
provide a copy of any such estoppel certificate to the Administrative Counsel by e-mail at
leases@mail.house.gov.
U.S. House of Representatives
Washington, D.C. 20515
District Office Lease Attachment
(Page 4 of 5 – 115
th
Congress)
Send completed forms to: Administrative Counsel, 217 Ford House Office Building, Washington, D.C. 20515.
Copies may also be faxed to 202-225-6999.
15. Maintenance of Common Areas. Lessor agrees to maintain in good order, at its sole expense,
all public and common areas of the building including, but not limited to, all sidewalks, parking
areas, lobbies, elevators, escalators, entryways, exits, alleys and other like areas.
16. Maintenance of Structural Components. Lessor also agrees to maintain in good order, repair
or replace as needed, at its sole expense, all structural and other components of the premises
including, but not limited to, roofs, ceilings, walls (interior and exterior), floors, windows, doors,
foundations, fixtures, and all mechanical, plumbing, electrical and air conditioning/heating
systems or equipment (including window air conditioning units provided by the Lessor) serving
the premises.
17. Lessor Liability for Failure to Maintain. Lessor shall be liable for any damage, either to
persons or property, sustained by Lessee or any of his or her employees or guests, caused by
Lessor’s failure to fulfill its obligations under Sections 15 and 16.
18. Initial Alterations. Lessor shall make any initial alterations to the leased premises, as requested
by Lessee and subject to Lessor’s consent, which shall not be unreasonably withheld. The cost of
such initial alterations shall be included in the annual rental rate.
19. Federal Tort Claims Act. Lessor agrees that the Federal Tort Claims Act, 28 U.S.C. §§ 2671-
80, satisfies any and all obligations on the part of the Lessee to purchase private liability
insurance. Lessee shall not be required to provide any certificates of insurance to Lessor.
20. Limitation of Liability. Lessor agrees that neither Lessee nor the House nor any of the House’s
officers or employees will indemnify or hold harmless Lessor against any liability of Lessor to
any third party that may arise during or as a result of the Lease or Lessee’s tenancy.
21. Compliance with Laws. Lessor shall be solely responsible for complying with all applicable
permitting and zoning ordinances or requirements, and with all local and state building codes,
safety codes and handicap accessibility codes (including the Americans with Disabilities Act),
both in the common areas of the building and the leased space of the Lessee.
22. Electronic Funds Transfer. Lessor agrees to accept monthly rent payments by Electronic Funds
Transfer and agrees to provide the Office of Finance, U.S. House of Representatives, with all
banking information necessary to facilitate such payments.
23. Refunds. Lessor shall promptly refund to the CAO, without formal demand, any payment made
to the Lessor by the CAO for any period for which rent is not owed because the Lease has ended
or been terminated.
24. Conflict. Should any provision of this Attachment be inconsistent with any provision of the
attached Lease or attached Amendment, the provisions of this Attachment shall control, and those
inconsistent provisions of the Lease or the Amendment shall have no force and effect to the
extent of such inconsistency.
U.S. House of Representatives
Washington, D.C. 20515
District Office Lease Attachment
(Page 5 of 5 – 115
th
Congress)
Send completed forms to: Administrative Counsel, 217 Ford House Office Building, Washington, D.C. 20515.
Copies may also be faxed to 202-225-6999.
25. Construction. Unless the clear meaning requires otherwise, words of feminine, masculine or
neuter gender include all other genders and, wherever appropriate, words in the singular include
the plural and vice versa.
26. Fair Market Value. The Lease or Amendment is entered into at fair market value as the result
of a bona fide, arms-length, marketplace transaction. The Lessor and Lessee certify that the
parties are not relatives nor have had, or continue to have, a professional or legal relationship
(except as a landlord and tenant).
27. District Certification. The Lessee certifies that the office space that is the subject of the Lease is
located within the district the Lessee was elected to represent unless otherwise authorized by
Regulations of the Committee on House Administration.
28. Counterparts. This Attachment may be executed in any number of counterparts and by
facsimile copy, each of which shall be deemed to be an original but all of which together shall be
deemed to be one and the same instrument.
29. Section Headings. The section headings of this Attachment are for convenience of reference
only and shall not be deemed to limit or affect any of the provisions hereof.
IN WITNESS WHEREOF, the parties have duly executed this District Office Lease Attachment as of the
later date written below by the Lessor or the Lessee.
________________________________ ______________________________________
Print Name of Lessor/Landlord Print Name of Lessee
By: ____________________________ ______________________________________
Lessor Signature Lessee Signature
Name:
Title:
________________________________ ______________________________________
Date Date
From the Member’s Office, who is the point of contact for questions?
Name_____________________ Phone (_____) __________ E-mail ______________________________@mail.house.gov
This District Office Lease Attachment and the attached Lease or Amendment have been reviewed and are
approved, pursuant to Regulations of the Committee on House Administration.
Signed _________________________________________________ Date ________________________, 20______.
(Administrative Counsel)
U.S. House of Representatives
Substitute W-9 and ACH Vendor/Miscellaneous Payment Enrollment Form
INSTRUCTIONS
FAX NUMBER:
(202) 225-6914
SECTION I UNITED STATES HOUSE OF REPRESENTATIVES INFORMATION
ADDRESS US HOUSE OF REPRESENTATIVES - ACCOUNTING, 3110 O'NEILL FEDERAL BUILDING, WASHINGTON DC 20515
AGENCY IDENTIFIER
53-6002523
AGENCY LOCATION CODE 4832 TELEPHONE NUMBER (202) 226-2277
SECTION II PAYEE/COMPANY INFORMATION
BUSINESS NAME/DISREGARDED ENTITY NAME OR DBA, IF DIFFERENT THAN NAME
ON YOUR INCOME TAX RETURN
ADDRESS/CITY/STATE/ZIP Enter the correct Tax Identification Number type
SOCIAL SECURITY NUMBER (SSN) EMPLOYER TAX ID NUMBER (EIN)
CONTACT PERSON NAME PURCHASE ORDER ADDRESS/CITY/STATE/ZIP
PO EMAIL
TELEPHONE NUMBER FAX NUMBER TELEPHONE NUMBER FAX NUMBER
REMIT TO ADDRESS
CHECK APPROPRIATE BOX FOR FEDERAL TAX CLASSIFICATION (required)
Partnership
Trust/Estate
C Corporation
SECTION III FINANCIAL INSTITUTION INFORMATION
BANK NAME TELEPHONE NUMBER
NINE-DIGIT ROUTING TRANSIT NUMBER
___ ___ ___ ___ ___ ___ ___ ___ ___
DEPOSITOR ACCOUNT TITLE
DEPOSITOR ACCOUNT NUMBER
LOCKBOX NUMBER
TYPE OF ACCOUNT CHECKING SAVINGS LOCKBOX
SECTION IV
SOCIO-ECONOMIC INFORMATION
Type of Business Large Business-No Socio-Economic Designations Minority SmBusiness Sm-Disadv/Minority Sm-Disadv Only SmMin Only
Sm-Disadvantaged Business Prog 8 (a) Firm HUBZone Program HUBZone Eligible
Emerging Small Business
Women-Owned Business
Other Preference Programs Buy Indian Directed to JWOD Non-Profit No Preference/Not Listed Small Business Set-Aside Very Small Business Set-Aside
Veteran Owned Status Non-Vet Owned SmBus Other Vet Owned SmBus Serv-Disabled Vet Other Bus Serv-Disabled Vet Owned SB Vet-Owned Other Bus
Size of Business: (A) 50 or less (B) 51-100 (C) 101-250 (D) 251-500 (E) 501-750 (F) 751-1,000 (G) Over 1,000 (M) 1 million or less
(N) 1.1-2 million (P) 2.1-3.5 million (R) 3.1-5 million (S) 5.1-10 million (T)10.1-17 million (Z)Over 17 million
SECTION V
CERTIFICATION OF DATA BY PAYEE/COMPANY
NAME TITLE/POSITION
SIGNATURE
DATE
TELE
Internal Revenue Code 6109, 31 U.S.C. 3322, 31 CFR 210 and the 1996 Debt Collection Improvement Act require all entities that do business with the United
States Government to provide a Tax Identification Number (TIN) and Electronic Funds Transfer (EFT) information for payment. PL 93-579 protects your privacy
and mandates that the information never be published or used for any other purpose than to pay you. Please complete all sections below, sign and return via the
email or fax number listed.
NAME AS SHOWN ON YOUR INCOME TAX RETURN
EMAIL
RETURN FORM TO:
Exemptions (codes apply only to certain
entities, not individuals):
Exempt payee code
(if any)
Exemption from FATCA reporting code
(if any)
(Applies to accounts maintained outside
the U.S.)
U.S.)
S Corporation
Individual/Sole Proprietor or
Single Member LLC
Limited Liability Company. Check the tax classification: C corporation S corporation Partnership
Note. For a
single-member LLC
that is disregarded, check the appropriate box for the tax classi fication of the single-member owner.
Government Entity. Check the tax classification:
Federal State Local
Other
This form must be completed using Adobe Reader.
vendorEFT@mail.house.gov
or
USHR v. 2015.3b ms
Instructions for Completing
U.S. House of Representatives
Substitute W-9 and ACH Vendor/Miscellaneous Payment Enrollment Form
Section I - Agency Information – Includes the name and address, agency identifier, agency location code and
telephone number for the House of Representatives.
Section II - Payee/Company Information – Print or type the name of the payee/company and address that will
receive payment, social security or taxpayer ID number, contact person name, telephone number and email of the
payee/company. Print or type the purchase order and remit to addresses if different from the payee/company
address. Check the appropriate boxes for federal tax classification.
Section III - Financial Institution Information – Print or type the name and address of the payee/company’s
financial institution who will receive the ACH payment, ACH coordinator name and telephone number, nine-digit
routing transit number, depositor (payee/company) account title and account number. Check the appropriate box
for type of account. Payee/Company may include a voided check with this form.
ACH Account Information Located on a Check or Deposit Ticket
FINANCIAL INSTITUTION NAME name of the financial institution to which the payments are to be directed
ROUTING TRANSIT NUMBER (RTN) financial institution's 9 digit routing transit number;
found on the bottom of a check or deposit ticket or from your Financial Institution
ACCOUNT TITLE employee's or vendor's name on the account
ACCOUNT NUMBER account number at the financial institution
Section IV - Socio-Economic Information – Check the boxes for each category, if applicable: type of business,
small disadvantaged business program, HUBZone program, emerging small business, women-owned business,
other preference programs, Veteran owned status and size of business. Detailed information related to Small
Business programs can be found at http://www.sba.gov/.
Section V - Certification of Data By Payee/Company – Print or type the name, title/position and phone number of
the Authorized official. The Authorized official must sign and date the form.
1. Routing Transit Number (RTN)
– nine digits located between
two symbols. This number
identifies the bank holding your
account and check processing
center.
2. Account number – this is your
complete account number.
Your account number can be
up to 17 digits. Please include
leading zeros.
3. ACH Routing Transit Number –
Automated Clearing House
routing number, use this
number for your Routing
Transit Number (RTN) if you
bank with SunTrust Bank.
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District Office Lease Instructions (US House of Representatives)

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Completed 10 November 2021

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