HomeMy WebLinkAboutExhibit 5To be completed upon document execution
Exhibit A
Incumbent Information
The following questions are required for processing Electronic Funds Transfers and if
Incumbent wants Nextel to complete the FCC filings on its behalf. All information contained
herein shall be kept strictly confidential and will be used only in completion of the Frequency
Reconfiguration transaction.
I. INCUMBENT INFORMATION
Please provide the following information:
Company/Name: City of Miami, Florida
Contact: Title:
Address: 444 S.W. 2°I Avenue, Floor
City/State/Zip: Miami, Florida 33130
Phone:
Fax:
If not identified in the contract, please provide the following:
If Incumbent is a Partnership, please provide name, address and phone numbers of all other
partners:
Name: Name:
Address: Address:
City/State/Zip: City/State/Zip:
Phone: Phone:
II. BANK ACCOUNT INFORMATION (Required for payment via electronic funds
transfer.)
Name of Bank:
Addrese. of Bank:
City/State/Zip:
Bank Phone #:
ABA (Routing #):
Account #:
Name on Account:
Federal, State or Individual SS #:
Name of Brokerage Firm (if applicable):
Brokerage Account # (if applicable):
In the event Incumbent will not provide information for electronic funds transfer, Incumbent
acknowledges that all payments made by check will be mailed within thirty (30) days of the dale
of performance required by Incumbent (for each payment) as stipulated in the Agreement.
Acknowledged by Incumbent:
(signature required only if Incumbent does not want an electronic funds transfer)
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III. TAX INFORMATION
The Internal Revenue Service and state tax authorities require Nextel to report all transactions,
even if the transaction is exempt from taxation (if so, it will be reported to the IRS as a like -kind
exchange). Therefore, it is necessary for Nextel to collect the information below. If you have
specific questions about your tax implications in this transaction, you should consult your own
accountant or financial advisor.
Incumbent's Federal, State or Individual Tax
ID #, FFIN (Federal) or SSN (individuals): 59-6000375
State(s) — sales tax license, resale permit,
employment, etc.):
Local (if applicable):
Current State and County location for your Miami -Dade County. Florida
principal executive office:
If there has been more than one location for
the principal executive office within the past
five (5) years, list each such
City/County/State location:
IV. REGULATORY INFORMATION
Would you like Nextel's Regulatory department to prepare and file all necessary FCC
paperwork on your behalf? Yes / No
If yes, please provide the following
Universal Licensing System ("ULS")
information for your licenses:
FRN (FCC Registration Number):
ULS PASSWORD:
Contact Representative for any FCC
related issues:
Name: Luis Selema, Supervisor of
Communications
If no, please provide the following information
regarding who will take care of the preparation and
filing of all necessary FCC paperwork on your '
behalf:
Contact Name:
Organization:
Address:
City:
State/Zip:
Phone Number:
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City of Miami
General Services Administration
1390 N. W. 20th St. Miami , FL 33142-
7722
Phone Number: (305)329-4847
Email Address:
I hereby acknowledge that all of the information provided herein is true and correct as
of the date signed below.
Incumbent Signature:
Print Name:
Title:
Date:
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