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Home My WebLink AboutStonehedge Entertainment New York III, Inc by Keith Adams w � o�*OF SOUjyol ELIZABETH A.NEVILLE '` O Town Hall, 53095 Main Road TOWN CLERK P.O. Box 1179 REGISTRAR OF VITAL STATISTICSG Q Southold, New York 11971 MARRIAGE OFFICER �O Fax(631) 765-6145 m RECORDS MANAGEMENT OFFICER �l� Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER CDU '+� southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD April 26, 2006 Certified Mail Mr Keith Adams Location Manager Untitled Noah Baumbach c/o The Bentley Hotel 161 Hill Station Road, Room 29 Southampton, NY 11968 Dear Mr. Adams: Enclosed are the two (2)money orders you submitted to our office to obtain a filming permit. If there is anything else I can do please do not hesitate to call the office. Sincerely, Lynda M Bohn Deputy Town Clerk 499156143921 499157 REV3 11103 813537093 HOLD DOCUMENT UP TO THE HOLD DOCUMENT UP TO THE LIGHT TO VIEW TRUE WATERMARK LIGHT TO VIEW TRUE WATERMARK (_`-_Js��'�y' RMARK ,. ®Washington Mutual Bank,FA ,D-B6,ZZD 6 63559 MATCH THE AMOUNT IN WORDS WITH THE AMOUNT IN NUMBERS PAY EXACTLY s NOT GOOD FOR MORE THAN$1,000.00 * �WASHINGTON.-pw rn MUTUAL Tvwt i ItCASTS 0 **********Apr 17, 2006 TWO HUNDRED FIFTY DOLLARS AND 00 CENTS ********** TO THE ORDER OF LEVO Y s7. 6{�t fir �/ y�K , JY / L �ooff�' PU HASER'S ADDRESS �— P HAS 'S SIGNATURE Issued By Integrated Payment Systems Inc.,Englewood,Colorado To Citibank,N.A.,Buffalo,NY 6781 105 1150297G30 11:0 2 20008681: 2S006S0063SS9911' 499156143921 499157 REV3 11103 813537093 r o - HOLD DOCUMENT UP TO THE LIGHT TO VIEW TRUE WATEMARK HOLD DOCUMENT UP TO THE LIGHT TO VIEW TRUE WATERMARK -77 ®Washington Mutual Bank,Fn 10-861220 650063560 MATCH THE AMOUNT IN WORDS WITH THE AMOUNT IN NUMBERS k , k k PAY EXACTLY WASHINGTON NOT GOOD FOR MORE THAN$1,000.00 [:x:xx MUTUAL C COTS *************Apr 17, 2006 ONE HUNDRED DOLLARS AND 00 CENTS ************ TO THE ORDER OF ------------------- El PURCHASER'S ADDRES PURCHASER'S SIGNATURE Issued By Integrated Payment Systems Inc.,Englewood,Colorado To Citibank,N.A.,Buffalo,NY - - J 6781 105 1120 29 76 311' CO2200013681: 2 S006 S006 3 S6090 APPLICATION FOR FILMING//STILL PHOTOGRAPHY PERMIT NO: 0 l p Please Print or Type APPLICATION DATE: April 14, 2006 NAME OF APPLICANT: Keith Adams/ Location Manager MAILING ADDRESS:, Untitled Noah Baumbach C/O The Bentley Hotel, 161 Hill Station Rd, Rm 29, Southhampton, NY 11968 PHONE: BUSINESS: 631.204.1600 CELL: 917.841.6820 NAME OF ORGANIZATION / COMPANY: Stonehenge Entertainment New York II, INC.---- Untitled Noah Baumbach Project MAILING ADDRESS: same as above PHONE: same as above FAX: 631.204.16 10 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * DESCRIBE TYPE OF ACTIVITY: Feature Film DATE(S) AND TIME(S) OF PROPOSED FILMING/PHOTOGRAPHY: Tuesday April 25 2006 6A-8P (Subject to change due to weather) PROPOSED LOCATION(S) OF FILMING/PHOTOGRAPHY: (attach additional sheet, if necessary) See Attached Page NAME OF PERSON IN CHARGE AT SITE: Keith Adams— Location Manager NUMBER OF PERSONS AT LOCATION (cast& crew included): Crew of 90 NUMBER AND TYPE OF VECHILES AT LOCATION: 2 Box Trucks, 5 Tractor Trailers, 2 Campers, 4 Pass Vans, 5 Town Cars, 10 personal vehicles TYPE OF SPECIAL EQUIPMENT: 35 mm Camera, Grip, Electric Equipment ANY SPECIAL REQUIREMENTS: See Attached for info about temporary Road Closure Signature Return to: Southold Town Clerk Southold Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 11971 o��pF SO(/ryol ELIZABETH A.NEVILLE '` O Town Hall, 53095 Main Road TOWN CLERK P.O. Box 1179 REGISTRAR OF VITAL STATISTICS y Southold, New York 11971 MARRIAGE OFFICER • �Q Fax (631) 765-6145 RECORDS MANAGEMENT OFFICER �l�' Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER COMM, southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Chief Cochran, Southold Town Police From: Lynda M. Bohn, Deputy Town Clerk Dated: April 18, 2006 Re: Filming Permit Transmitted herewith is the application of Stonehedge Entertainment New York III, Inc by Keith Adams for a Feature Film permit. In accordance with Section 44A.3 of the Town Code please review the application and advise of approval or disapproval of the application and whether a traffic control fee is required and the amount needed. OG SO�r�ol ELIZABETH A. NEVILLE O Town Hall, 53095 Main Road TOWN CLERK l P.O. Box 1179 REGISTRAR.OF VITAL STATISTICS Southold, New York 11971 MARRIAGE OFFICER �� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER Ol� Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER COU I11�,� southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Southold Town Attorney's Office From: Lynda M Bohn Dated: April 18, 2006 Re: Filming Permit In accordance with the Southold Town Code, Chapter 44A, Section 3, Subsection D, the Certificate of Insurance and Indemnification Agreement for a Filming Permit Application for Stonehedge Entertainment New York III. Inc by Keith Adams are att hed hereto. Please review and advise whether these documents meet with y r approval. Thank you. Approved as submitted Disapprove for the following reasons: I 4ur PXI T o T9j �O��pF SO!/ryol ELIZABETH A. NEVILLE O Town Hall, 53095 Main Road TOWN CLERK J l P.O. Box 1179 REGISTRAR OF VITAL STATISTICS G Q Southold, New York 11971 MARRIAGE OFFICER Fax (631) 765-6145 RECORDS MANAGEMENT OFFICER Ol� Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER Mum� southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Southold Town Attorney's Office From: Lynda M Bohn Dated: April 18, 2006 Re: Filming Permit In accordance with the Southold Town Code, Chapter 44A,Section 3, Subsection D, the Certificate of Insurance and Indemnification Agreement for a Filming Permit Application for Stonehedge Entertainment New York III, Inc by Keith Adams are attached hereto. Please review and advise whether these documents meet with your approval. Thank you. Approved as submitted Disapprove for the following reasons: Signature ACORDm CERTIFICATE OF LIABILITY INSURANCE O+► 4/14/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND VANS North America,Inc. CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE 7 Hanover Bare DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. New York,NY 10004 COMPANIES AFFORDING COVERAGE Contact:Terd Herrera COMPANY Phone:(323)9565200 A Travelers Properly Casualty Company of America Fax: 323 8625999 INSURED COMPANY VIACOM,INC. B Travelers Casualty 3 Surety Company Stonehenge Entertainment New York 11 Inc. COMPANY 110 LEROY STREET,6TH FLOOR C NEW YORK,NY 10014 COMPANY D COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE A)MDATE WDDIYY GENERAL LIABILITY EACH OCCURRENCE $6,W0,000 A X COMMERCIAL GENERAL LIABILITY TJGLSA 121D645- 12/312005 12/312006 DAMAGE TO RENTED $5,000,000 PREMISES Ea ooaunanae B CLAIMS MADE [X OCCUR 231 62 8 MED EXP(Any one person) OWNER'S 8 CONTRACTOR'S PROT PERSONAL&ADV INJURY 55.ODD,000 GENERAL AGGREGATE $15.ODD.000 PRODUCTS-COMPIOP AGO $5.000.000 At TOMOBLE LIABLRY COMBINED SINGLE LIMB $3,000,000 A X ANY AUTO TJCAP 121D6466- 12/31/2005 12/31/2006 ALL OWNED AUTOS TIL-05 231D6278 BODILY INJURY : SCHEDULED AUTOS (Par POI HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (PwAwd" PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT f ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT s AGGREGATE S EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND X WC STATU- 7T'M EMPLOYERS'LIABILITYI TORY LIMITS -ER EL EACH ACCIDENT THE PROPRIETOR! PARTNERSIEXECUTIVE INCL EL DISEAS&POLICY LIMIT OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE OTHER $500.COLLISION A Auto PkYncv Doge TJCAP121 D6466TIL 12/312005 12/31/2006 DEDUCTIBLE 05 $500. COMPREHENSIVE DEDUCTIBLE DESCROMON OF OPERATKNISA.00ATIONLNENICLESISPECYAL ITEMS Certificate Holder is included as an Additional Insured as required by the terms of a written agreement between the parties or in the case of a verbal agreement for liability arising out of the msure(fs negligent acts. Further the Certificate Holder is also included as a Loss Payee under the Automobile .Physical Damage policy only if required by written or in the case of a verbal agreement only for negligence acts of the insured This additional insured and/or Loss Payee status arises solely as the fihning of the motion picture and/or television 'on:"Untitled Noah Baumbauch Project." Tom IF A SNOU)d TM outh SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 53095 Main Road EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS PO BOX 1 179 WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO Southold,NY 11971 $O SHALL IMPOSE No OBLIGATION OR LIABILITY OF ANY KIND UPON THE wsuRER ITS Attn: Lynda Bohn-Village Clerk AGENTS OR REPRESENTATIVES. 631/765.1800 Fax AUTHORIZED REPRESENTATIVE , ACORD 25-3(7197) . CORPORATION1M INDEMNIFICATION AGREEMENT TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY PERMIT The Applicant shall indemnify and hold harmless the Town from and against all suits, claims, demands or actions for any damage and/or injury sustained or alleged to be sustained by any party or parties in connection with the performance of filming or still photography by the Applicant, his employees or agents or any subcontractor and in case of any such action brought against the Town,the applicant shall immediately take charge of and defend the same at his own cost and expense. In addition,the Applicant will name the Town as an additional insured on any applicable policies. Signature Date 0 rr'FI ADgAAs Printed name L o(-ATro4 MA,,JPK KS Title Untitled Noah Baumbach Project: Filming Date: Tuesday April 25, 2006 6A-8P (OR later its week for weather) Scope of Work: Feature Film, Driving Shots with moving vehicles, Scene driving onto N. Ferry Co. Boat Request Police Assistance for entire day, one unit with radio car Request permission to film driving shots with Southhold Police assistance on ONE OF TWO ROADS (suggested by Capt. Flatley SPD) to be decided week of 4/17 Request permission for TEMPORARY CLOSURE OF ROAD FOR SAFETY of crew per SPD discretion 1. Chapel Lane b/w RT 48 & RT 25 OR 2. Soundview Ave b/w Mill Lane & Soundview Inn NOTE: Company will park all vehicles near N. Ferry company ferry landing & will take only necessary vehicles and equipment to location for driving work. Request Permission to film at North Ferry Company Landing (deal in place with Bridg Hunt of N. Ferry Co.) Request Permission to park production vehicles on Wiggins Street (permission requested to Inc. Village of Greenport) C: Keith Adams / Location Manager 917.841.6820 keithadamsl@mac.com TOWN CLERK'S CHECKLIST FOR FILMING PERMIT NOTE: All payments must be cash or certified check Applicant: K 2 k 4j N AG__vAA s Date Received: LI - J1 -b(, Completed application $100 nonrefundable application fee Certificate of insurance that evidences a public liability insurance policy covering the town as an additional insured in the amount of$1,000,000 (one million dollars)per occurrence for the duration of the filming or still photography. Indemnification agreement stating the applicant agrees to assume all liability for and will indemnify and hold the town harmless of and free from any and all damages that occur to persons or property by reason of said filming or still photography. 46Forward completed application to Chief of Police for approval or disapproval and determination if Traffic Control Fee is required Approved Disapproved No Fee Required 1 000 Fee in the amount of$(g required T Forward certificate of insurance and indemnification agreement to Town Attorney fory�pproval Approved Disapproved COLLECT FEES AS FOLLOWS: Permit Fees (Prior to issuance of permit): Film Fee - $100 per day of each day covered by the permit Cleanup deposit: Separate certified check for$250 for each day covered by the permit. Traffic control fee - $1000 for each day covered by the permit if required by the Chief of Police. NOTE: Additional funds may be required by Police if it is determined that $1000 per day fee will be expended prior to the termination of the permit period. VBeach Parking fee - $10 per vehicle, per day between May 1 and September 30. ISSUED PERMIT Countersign application Issue permit with name of applicant, locations(s), date(s), and time(s) NOTIFICATION of ISSUED PERMIT Chief of Police Chief Building Inspector Fire Marshal Code Enforcement Officer Superintendent of Highways Superintendent of Parks and Recreation REQUEST FOR EXTENSION OF PERMIT Forward extension permit request to Chief of Police If granted, collect additional $100 per day filming fee Amend permit to indicate granted extension period COMPLETION OF PERMIT PERIOD Chief of Police to provide applicant with statement of cost for providing Traffic Control and police coverage. (Refund overpayment or collect for additional costs within 30 days of termination of permit) Superintendent of Highways inspections locations listed on permit and determine if cleanup efforts by town personnel is required. *If cleanup is required, Superintendent will provide Town Clerk with a statement of actual costs. (Refund overpayment or collect for additional costs within 30 days of termination of permit) *If not cleanup is required, Superintendent of Highways will notify Town Clerk and Town Clerk will remit the $250 certified check to applicant. � pF SO�r�ol ELIZABETH A.NEVILLE O Town Hall, 53095 Main Road TOWN CLERK l l P.O. Box 1179 REGISTRAR OF VITAL STATISTICS G Q Southold, New York 11971 MARRIAGE OFFICER Fax (631) 765-6145 RECORDS MANAGEMENT OFFICERl Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER �COMM,Nc� southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD F A X To: Accounting Department 631.204.1610 From: Lynda M Bohn Deputy Town Clerk Re: w-9 Date: April 14,2006 Pages: 2 including cover Let me know if you need anything else. Form w-9 Request for Taxpayer Give form to the (Rev.January 2003) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service N Name N0) TovJv� u-�'1n o Business name,if different from above c 0 d C T.Co0Individual/ u , xempt from backup ` Check appropriate box: El proprietor Corporation Partnership Other ► 1._wr 1�llj V.ithholding o Address( c N number,street,and apt.ory'e no.) Requester's name and address(optional) O 117 != Cit state,and ZIP code C v d Nil 11911 m List account number(s)here(optional) a� N Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box. For individuals,this is your social security number(SSN). Social security number 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. or Note:If the account is in more than one name,see the chart on page 4 for guidelines on whose number Employer identification number to enter. , 6 d O 111131 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. 1 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. 1 am a U.S. person(including a U.S.resident alien). 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 o er than interest and dividends,you are not required to sign the Certification, but you must provide your correct TIN. (See the instructio on page 4.) Sign Signature of Here U.S.person ► Date ► Purpose of Form Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the A person who is required to file an information return with terms of a tax treaty to reduce or eliminate U.S.tax on the IRS, must obtain your correct taxpayer identification certain types of income. However, most tax treaties contain a number(TIN)to report, for example, income paid to you, real provision known as a "saving clause." Exceptions specified estate transactions, mortgage interest you paid, acquisition in the saving clause may permit an exemption from tax to or abandonment of secured property, cancellation of debt, or continue for certain types of income even after the recipient contributions you made to an IRA. has otherwise become a U.S. resident alien for tax purposes. U.S. person. Use Form W-9 only if you are a U.S. person If you are a U.S. resident alien who is relying on an (including a resident alien), to provide your correct TIN to the exception contained in the saving clause of a tax treaty to person requesting it(the requester) and, when applicable, to: claim an exemption from U.S. tax on certain types of income, 1. Certify that the TIN you are giving is correct(or you are you must attach a statement that specifies the following five waiting for a number to be issued), items: 2. Certify that you are not subject to backup withholding, 1. The treaty country. Generally, this must be the same or treaty under which you claimed exemption from tax as a 3. Claim exemption from backup withholding if you are a nonresident alien. U.S. exempt payee. 2. The treaty article addressing the income. Note: If a requester gives you a form other than Form W-9 3. The article number (or location) in the tax treaty that to request your TIN,you must use the requester's form if it is contains the saving clause and its exceptions. substantially similar to this Form W-9. 4. The type and amount of income that qualifies for the Foreign person. If you are a foreign person, use the exemption from tax. appropriate Form W-8 (see Pub. 515, Withholding of Tax on 5. Sufficient facts to justify the exemption from tax under Nonresident Aliens and Foreign Entities). the terms of the treaty article. Cat.No. 10231X Form W-9 (Rev. 1-2003) Form W-9(Rev.1-2003) Page 2 Example.Article 20 of the U.S.-China income tax treaty Specific Instructions allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the Name United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United If you are an individual, you must generally enter the name States exceeds 5 calendar years. However, paragraph 2 of shown on your social security card. However, if you have the first Protocol to the U.S.-China treaty(dated April 30, changed your last name, for instance, due to marriage 1984) allows the provisions of Article 20 to continue to apply without informing the Social Security Administration of the even after the Chinese student becomes a resident alien of name change, enter your first name, the last name shown on the United States. A Chinese student who qualifies for this your social security card, and your new last name. exception (under paragraph 2 of the first protocol) and is If the account is in joint names, list first, and then circle, relying on this exception to claim an exemption from tax on the name of the person or entity whose number you entered his or her scholarship or fellowship income would attach to in Part I of the form. Form W-9 a statement that includes the information Sole proprietor. Enter your individual name as shown on described above to support that exemption. your social security card on the "Name" line. You may enter If you are a nonresident alien or a foreign entity not your business, trade, or "doing business as (DBA)" name on subject to backup withholding, give the requester the the"Business name" line. appropriate completed Form W-8. Limited liability company(LLC). If you are a single-member What is backup withholding? Persons making certain LLC (including a foreign LLC with a domestic owner)that is payments to you must under certain conditions withhold and disregarded as an entity separate from its owner under pay to the IRS 30% of such payments (29% after December Treasury regulations section 301.7701-3, enter the owner's 31, 2003; 28% after December 31, 2005). This is called name on the "Name" line. Enter the LLC's name on the "backup withholding." Payments that may be subject to "Business name" line. backup withholding include interest, dividends, broker and Other entities. Enter your business name as shown on barter exchange transactions, rents, royalties, nonemployee required Federal tax documents on the "Name" line. This pay, and certain payments from fishing boat operators. Real name should match the name shown on the charter or other estate transactions are not subject to backup withholding. legal document creating the entity. You may enter any You will not be subject to backup withholding on payments business,trade, or DBA name on the "Business name" line. you receive if you give the requester your correct TIN, make Note: You are requested to check the appropriate box for the proper certifications, and report all your taxable interest your status(individual/sole proprietor, corporation, etc.). and dividends on your tax return. Payments you receive will be subject to backup Exempt From Backup Withholding withholding if: If you are exempt, enter your name as described above and 1. You do not furnish your TIN to the requester, or check the appropriate box for your status, then check the 2. You do not certify your TIN when required (see the Part "Exempt from backup withholding" box in the line following II instructions on page 4 for details), or the business name, sign and date the form. 3.The IRS tells the requester that you furnished an Generally, individuals (including sole proprietors)are not incorrect TIN, or exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as 4.The IRS tells you that you are subject to backup interest and dividends. withholding because you did not report all your interest and Note: If you are exempt from backup withholding,you should dividends on your tax return (for reportable interest and still complete this form to avoid possible erroneous backup dividends only), or withholding. 5. You do not certify to the requester that you are not Exempt payees. Backup withholding is not required on any subject to backup withholding under 4 above(for reportable payments made to the following payees: interest and dividend accounts opened after 1983 only). 1.An organization exempt from tax under section 501(a), Certain payees and payments are exempt from backup any IRA, or a custodial account under section 403(b)(7) if the withholding. See the instructions below and the separate account satisfies the requirements of section 401(0(2); Instructions for the Requester of Form W-9. 2.The United States or any of its agencies or instrumentalities; Penalties 3. A state, the District of Columbia, a possession of the Failure to furnish TIN. If you fail to furnish your correct TIN United States, or any of their political subdivisions or to a requester, you are subject to a penalty of$50 for each instrumentalities; such failure unless your failure is due to reasonable cause 4.A foreign government or any of its political subdivisions, and not to willful neglect. agencies, or instrumentalities; or Civil penalty for false information with respect to 5.An international organization or any of its agencies or withholding. If you make a false statement with no instrumentalities. reasonable basis that results in no backup withholding, you Other payees that may be exempt from backup are subject to a $500 penalty. withholding include: Criminal penalty for falsifying information.Willfully 6. A corporation; falsifying certifications or affirmations may subject you to 7. A foreign central bank of issue; criminal penalties including fines and/or imprisonment. Misuse of TINS. If the requester discloses or uses TINS in $• A dealer in securities commodities required to register violation of Federal law, the requester may be subject to civil in the United States, the District of Columbia, or a possession of the United States; and criminal penalties. Form W-9(Rev.1-2003) Page 3 9.A futures commission merchant registered with the Part I. Taxpayer Identification Commodity Futures Trading Commission; Number (TIN) 10. A real estate investment trust; 11.An entity registered at all times during the tax year Enter your TIN in the appropriate box. If you are a resident Y 9 9 Y alien and you do not have and are not eligible to get an under the Investment Company Act of 1940; SSN,your TIN is your IRS individual taxpayer Identification 12.A common trust fund operated by a bank under number(ITIN). Enter it in the social security number box. If section 584(a); you do not have an ITIN, see How to get a TIN below. 13.A financial institution; If you are a sole proprietor and you have an EIN,you may enter either your SSN or EIN. However, the IRS prefers that 14.A middleman known in the investment community as a you use your SSN. nominee or custodian; or If you are a single-owner LLC that is disregarded as an 15. A trust exempt from tax under section 664 or entity separate from its owner(see Limited liability described in section 4947. company(LLC)on page 2), enter your SSN (or EIN, if you The chart below shows types of payments that may be have one). If the LLC is a corporation, partnership, etc., enter exempt from backup withholding. The chart applies to the the entity's EIN. exempt recipients listed above, 1 through 15. Note: See the chart on page 4 for further clarification of If the payment is for... THEN the payment is exempt name and TIN combinations. for... How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Interest and dividend payments All exempt recipients except Application for a Social Security Card, from your local Social for 9 Security Administration office or get this form on-line at www.ssa.gov/online/ss5.htmi. You may also get this form Broker transactions Exempt recipients 1 through 13. by calling 1-800-772-1213. Use Form W-7, Application for Also,a person registered under IRS Individual Taxpayer Identification Number, to apply for an the Investment Advisers Act of ITIN, or Form SS-4, Application for Employer Identification 1940 who regularly acts as a Number, to apply for an EIN. You can get Forms W-7 and broker SS-4 from the IRS by calling 1-800-TAX-FORM Barter exchange transactions Exempt recipients 1 through 5 (1-800-829-3676) or from the IRS Web Site at www.irs.gov. and patronage dividends If you are asked to complete Form W-9 but do not have a TIN,write "Applied For" in the space for the TIN, sign and Payments over$600 required Generally,exempt recipients date the form, and give it to the requester. For interest and to be reported and direct 1 through 7 z dividend payments, and certain payments made with respect sales over$5,000' to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are See Form 1099-MISC,Miscellaneous Income,and its instructions. subject to backup withholding on payments. The 60-day rule 'However,the following payments made to a corporation(including gross does not apply to other types of payments. You will be proceeds paid to an attorney under section 6045(f),even if the attorney is a subject to backup withholding on all such payments until you corporation)and reportable on Form 1099-MISC are not exempt from backup withholding:medical and health care payments,attorneys'fees;and payments provide your TIN to the requester. for services paid by a Federal executive agency. Note: Writing "Applied For"means that you have already applied for a TIN or that you intend to apply for one soon. Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8. Form W-9(Rev.1-2003) Page 4 Part II. Certification What Name and Number To Give the To establish to the withholding agent that you are a U.S. Requester person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 3, For this t of account: Give name and SSN of: and 5 below indicate otherwise. 1.Individual The individual For a joint account, only the person whose TIN is shown in 2.Two or more individuals(joint The actual owner of the account Part I should sign (when required). Exempt recipients, see account) or, if combined funds,the first Exempt from backup withholding on page 2. individual on the account' Signature requirements. Complete the certification as 3.Custodian account of a minor The minor 2 indicated in 1 through 5 below. (Uniform Gift to Minors Act) 4.a.The usual revocable The grantor-trustee' 1. Interest,dividend, and barter exchange accounts savings trust(grantor is opened before 1984 and broker accounts considered also trustee) active during 1983.You must give your correct TIN, but you b.So-called trust account The actual owner' do not have to sign the certification. that is not a legal or valid 2. Interest, dividend, broker,and barter exchange trust under state law accounts opened after 1983 and broker accounts 5.Sole proprietorship or The owner 3 considered inactive during 1983. You must sign the single-owner LLC certification or backup withholding will apply. If you are For this type of account: Give name and EIN of: subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 s.Sole proprietorship or The owner 3 in the certification before signing the form. single-owner LLC 3. Real estate transactions.You must sign the 7.A valid trust,estate,or Legal entity certification. You may cross out item 2 of the certification. pension trust 4.Other payments.You must give your correct TIN, but 8.Corporate or LLC electing The corporation you do not have to sign the certification unless you have corporate status on Form been notified that you have previously given an incorrect TIN. 8832 "Other payments" include payments made in the course of the requester's trade or business for rents, royalties, goods 9.Association,club, religious, The organization (other than bills for merchandise), medical and health care charitable,educational, or services (including payments to corporations), payments to a other tax-exempt organization nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to 10.Partnership or multi-member The partnership attorneys (including payments to corporations). LLC 5. Mortgage interest paid by you, acquisition or 11.A broker or registered The broker or nominee abandonment of secured property,cancellation of debt, nominee qualified tuition program payments(under section 529), 12.Account with the Department The public entity IRA or Archer MSA contributions or distributions,and of Agriculture in the name of pension distributions. You must give your correct TIN, but a public entity(such as a you do not have to sign the certification. state or local government, school district,or prison)that receives agricultural program payments List first and circle the name of the person whose number you furnish.If only one person on ajoint account has an SSN,that person's number must be furnished. 'Circle the minor's name and furnish the minor's SSN. 3 You must show your individual name,but you may also enter your business or"DBA"name.You may use either your SSN or EIN(if you have one). "List first and circle the name of the legal trust,estate,or pension trust.(Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA or Archer MSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, or to Federal and state agencies to enforce Federal nontax criminal laws and to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply. POLICE DEPAQTMENT TOWN Of 6OUTHOLD CARLISLE E. COCHRAN,JR. Telephone Emergency Dial 911 Chief of Police MEMORANDUM TO: Linda J. Cooper, Deputy Town Clerk FROM: Chief Carlisle E. Cochran, Jr. � DATE: April 24, 2006 RE: Filming Permit- Stonehedge Entertainment New York III, Inc., by Keith Adams As per Section 44A.3 of the Southold Town Code,it is the recommendation of the Chief of Police that application dated April 14, 2006, Stonehedge Entertainment New York III,Inc.,by Keith Adams, be APPROVED. As per Section 44A.4, Traffic Control Fee, the projected cost for traffic control will be approximately$600.00. 41405 Route 25 • P.O. Box 911 • Peconic, N.Y. 11958 Administrative (631) 765-2600/2601 • Fax (631) 765-2715