AMENDMENT NO. 1 TO PROFESSIONAL SERVICES AGREEMENT
This Amendment (“Amendment No.1”) is hereby entered into effective May 1, 2026, by and between the CITY OF LANCASTER, a municipal corporation and charter city, in the State of California, (“ City”) and VOLTZ COMMERCIAL REALTY ADVISORS, INC. (“Consultant”), (collectively, sometimes referred to hereinafter as the “Parties”), with respect to Section 10. Term; Effective Date of the Agreement for Professional Services between the parties dated May 1, 2023 (“Agreement”).
The Parties agree as follows:
1. Section 5A. Obligations of the City. Section 5A is hereby deleted in its entirety to read as follows:
The City shall pay Consultant an amount not to exceed $220,000 for all work necessary to complete the Services, as described in the Scope of Services and Rates Schedule.
Payments shall be due within thirty (30) days following submittal of an invoice detailing the services performed, at the hourly rates set forth in Exhibit A.
2. Section 10. Term; Effective Date. Section 10 is hereby deleted in its entirety to read as follows:
This Agreement shall be effective as of May 1, 2026, and shall continue in full force and effect for a period of one (1) year, unless sooner terminated in accordance with the provisions of this Agreement. The Parties acknowledge that the original term of the Agreement has expired and hereby agree to reinstate and continue the Agreement for the term set forth herein.
3. No Further Changes. Except as expressly provided to the contrary in this Amendment No. 1, the terms and provisions of the Agreement shall remain in full force and effect as written.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed and attested by their respective officers thereunto duly authorized.
CITY OF LANCASTER VOLTZ COMMERCIAL REALTY ADVISORS, INC.
LANCASTER, CALIFORNIA
__________________________ ______________________________________ Trolis Niebla, City Manager Scott Voltz, President
ATTEST:
Andrea Alexander, City Clerk
APPROVED AS TO FORM:
City Attorney
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AGREEMENT FOR PROFESSIONAL SERVICES
THIS AGREEMENT FOR PROFESSIONAL SERVICES is made and entered into this 1st day of May, 2023, by and between the CITY OF LANCASTER, a municipal corporation and charter city, (“City”), and VOLTZ COMMERCIAL REALTY ADVISORS, INC. of California, Inc, a California corporation (“Consultant”) (collectively, sometimes referred to hereinafter as the “Parties”).
RECITALS
WHEREAS, the City desires to engage Consultant to perform certain technical and professional services, as provided herein, identified as:
On-Call Appraisal Services (THE “SERVICES”)
WHEREAS, the principal members of Consultant are qualified and duly registered/licensed under the laws of the State of California, and Consultant desires to accept such engagement;
NOW, THEREFORE, the parties agree as follows:
1. Parties to the Agreement.
The parties to this Agreement are:
A. CITY: City of Lancaster
B. CONSULTANT: VOLTZ COMMERCIAL REALTY ADVISORS, INC
2. Notices. All written notices required by or re lated to this Agreement shall be sent by Certified Mail, Return Receipt Requested, postag e prepaid and addressed as listed below. Neither party to this Agreement shall refuse to accept such mail; parties to this Agreement shall promptly inform the other party of any changes of address. All notices required by this Agreement are effective on the day of receipt, unless otherwise indicated herein.
CITY City of Lancaster
Attn: Jason Caudle, City Manager
44933 North Fern Avenue
Lancaster, California 93534
CONSULTANT VOLTZ COMMERCIAL REALTY ADVISORS, INC.
Attn: SCOTT VOLTZ
Address: 25350 Magic Mountain Parkway., #300
Valencia, California 91355
3. Successors and Assigns . The terms h ereof shall be binding upon and inur e to the benefit of the successors and assigns of the parties hereto; provided, however, t hat no party hereto shall assign any of the benefits and burdens hereunder, whether voluntarily or by operation of law, without prior written consent of the other party, and any such assignments without said consent shall be void.
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4. Description of Wo rk. The City hereby engages Consultant, and Consultant accepts such engagement, to perform the technical and professional service s set forth in the “Scope of Services and Rates Schedule,” attached hereto as Exhibit “A” and incorporated herein by reference . Consultant shall perform and complete, in a manner satisfactory to the City , all work and services set forth in Exhibit “A.” The City Manager or his designee shal l have the right to review and inspect the work during the course of its performance at su ch times as may be specified by the City Manager, or his designee.
5. Obligations of the City.
A. The City shall pay Consultan t an amount not to exceed $120,000 for all work necessary to complete the Services, as described in the Scope of Services and Rates Schedule. Payments shall be due within thirty (30) days following submittal of an invoice detailing the services performed, at the hourly rates set forth in Exhibit A.
B. No payment made hereunder by the City to Consultant, other than the final payment, shall be construed as an acceptance by the City of any work or materials, nor as evidence of satisfactory performance by Consultant of its obligations under this Agreement.
6. Obligations of the Consultant.
A. Consultant shall perform as require d by this Agreement and in accordance with the Scope of Services and Rates Schedule set forth in Exhibit A.
B. Consultant shall be responsible for payment of all employees’ wages and benefits, and shall comply with all requirements pertaining to employ er’s liability, workers ’ compensation, unemployment insurance, and Social Security.
C. Consultant shall not subcontract any of the work required to perform the Serv ices without the express prior written approval of the City.
7. Hold Harmless and Indemni fication. Consultant agrees to indemnify and hold harmless the City, its elected officials, officers and employees, from and aga inst any and all third party claims, losses, obligations, or liabilities whatsoever, including reasonable attorney’s fees, incurred to the extent arising out of or related to Consultant’s negligent or willful wrongful acts, errors or omissions, or those of its employees or agents. Consultant agrees to defend the City, its officers and employees, using counsel of the City ’s choosi ng, from and against any and all claims covered by the indemnity in the preceding sentence.
8. Amendments. Any amendment, modi fication, or variation from the terms of this Agreement shall be in writing and shall be effective only upon mutual written app roval by the City and Consultant.
9. Non-Discrimination and Equal Employment Opportunity.
A. In the performance of this Agreement, Consultant shall not discrimina te against any employee, subcontractor, or applicant for employment because of race, color, religion, ancestry, sex, national origin, physical or mental disability or age. Consultant will take affirmative action to ens ure DocuSign Envelope ID: 23E135AD-BB25-425D-AEE7-03D3D0CFBE39
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that subcontractors and applicant s are employed, and that employees are treated during employment without regard to their race, color, religion, ancestry, sex, national origin, physical or mental disability or age. Affirmative action relating to emplo yment shall include, but not be limit ed to the following:
employment, upgrading, demotion or transfer; recruitment; layoff or termination; rates of pay or other forms of compensation; and selection for training including apprenticeship.
B. The provision s of subsection A above shall be incl uded in all solicitations or advertisements placed by or on behalf of Consultant for personnel to perform any services under this Agreement. The City shall have access to all documents, data and records of Consultant and its subcontractors for purposes of determining compliance with the equal employment opportunity and non- discrimination provisions of this Section.
10. Term; Effective Date. This Agreement shall become effective and shall be in full force and effect upo n the execution of the Agreement by t he City and the Consultant. This Agreement shall continue in full force and effect for thirty-six (36) months, unless the Agreement is sooner terminated in accordance with this Agreement; provided, however, that the Ci ty and the Consultant may mutually agree in writing to extend the Term of this Agreement.
11. Termination.
A. For Convenience. The City may terminate this Agreement at any time without cause by giving thirty (30) days written notice to the other party o f such termination and specifying the effective date thereof. In the event of termination of this Agreement, Consultant will b e paid for work completed through the date of termination within thirty (30) days following submittal of a final invoice.
B. For Cause. If Consultant fails to perform the services called for by this Agreement or so fails to make progress as to endanger perfo rmance of this Agreement in accordance with its terms, Consultant shall correct such failure within ten (10) days (or such longer period that the City may authorize in writing) after receipt of notice from the City specifying such failure. Should the failu re not be corrected within this time period, the City may immediately terminate the Agreement by written notice to Consultant.
C. In the event of termination, whether f or convenience or cause, reports, plans, studies and other documents (collectively, “documents”) related to the Services shall become the City’s property. Consultant shall provide all documents to the City that have not yet been within ten (10) calendar days after termination of the Agreement.
12. Independent Contractor. Consultant is an ind ependent contractor and shall have no power or authority to incur any debt, obligation or liability on behalf of the City. It is expressly understood between the Parties to this Agreement that no employee/employer relationship is intended.
13. Insurance.
A. The Consultant, at its expense, shall maintain in effect at all times during the term of this Agreement the following cover age and limits of insurance, which sh all be maintained with insurers listed “A-, VIII” or better in the Best’s Key Rating Guide:
Commercial General Liability
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Each Occurrence $1,000,000
Per Project General Aggregate $2,000,000
Including Products/Completed Operations; Contractual Liability/Independent Contractors; Property Damage
(Coverage shall be at least as broad as ISO form CG2010 11/85 or CG2010 07/04 and CG2037 07/04 combined, or an equivalent providing ongoing and completed operations)
Commercial Automobile Liability
Combined Single Limit per Accident for
Bodily Injury and Property Damage $1,000,000
(Coverage shall be at least as broad as ISO form CA00 01)
Workers Compensation
As Required by the State of California Statutory Limits
Employers’ Liability
Each Accident $1,000,000
Bodily Injury by Disease $1,000,000
Each Employee $1,000,000
(A Waiver of Subrogation must be provided on behalf of the Certificate Holder for the Workers Compensation & Employers’ Liability policies)
Professional Liability
Each Occurrence $1,000,000
General Aggregate $1,000,000
Provide one of the following for cyber-related services Technology Professional Liability
(Errors and Omissions)
Each Occurrence $2,000,000
General Aggregate $2,000,000
(Coverage shall be sufficiently broad to respond to the duties and obligations as are undertaken by Consultant pursuant to this Agreement and shall include, without limitation, claims involving invasion of privacy violations, informa tion theft, damage to or destruction of electronic information, release of private information, alteration of electronic inform ation, extortion and network security. The policy shall provide coverage for breach response costs as well as any applicable regu latory fines and penalties as well as credit monitoring expenses with limits sufficient to respond to these obligations.)
Or
Cyber Liability Insurance
Each Occurrence $2,000,000
General Aggregate $2,000,000
B. The Consultant’s insurance shall apply separately to each insured against w hom claim is made or suit is brought, except with respect to the limits of the insured’s liability.
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C. Professional liability and/or cyber insurance written on a “claims made” basis must be renewed for a period of three ( 3) years after this contract expires or is terminated. Such insurance must have the same coverage and limits as the policy tha t was in effect during the term of this contract and will cover Consultant for all claims made by the City insured entities arisi ng out of any acts or omissions of Co nsultant or its officers, employees, or agents during the time this Agreement was in effect.
D. Any deductibles or self-insurance retentions must be declared and approved by the City. At the City’s option, either the ins urer shall reduce or eliminate such d eductibles or self -insured retentions as respects the City insured entities or the insurer shall procure a bond guaranteeing payment of losses and related investigations, claim administration and defense expenses.
E. All insurance shall be primary and non -contributory as respects the City insured entities. Any insurance or self-insurance maintained by the City insured entities shall be in excess of the Consultant’s insurance and shall not contribute with it.
F. Consultant shall furnish the City with Certificat es of Insurance and with original endorsements effecting coverage required by this Agreeme nt. Certificates of Insurance shall meet the following requirements:
(1) Show that the insurance policy has been endorsed to st ate that coverage shall not be suspended, voided, cancelled, reduced in coverage or in limits except after 30 days’ prior written notice (10 days’ written notice for non-payment) to the City of Lancaster.
(2) List in the “Descriptions of Operations/Locations/Vehicles” section:
“On-Call Appraisal Services
The City of Lancaster, its elected officials, officers, employees and vol unteers are included as additional covered parties, but only insofar as the operations under this contract are concerned.”
(3) List in the “Certificate Holder” section:
The City of Lancaster, 44933 Fern Avenue, Lancaster, California 93534.
14. Commencement and Completion of Work . The Services to be provided by Consultant pursuant to t his Agreement shall commence within 15 days after execution of this Agreement, and shall be completed no later than 30 days following commencement; provided however, that the Parties may agree to extend the time for completion upon mutual written agreement.
15. Ownership of Documents . All plans, specifications, reports, studies, map s and other documents prepared or obtained by Consultant in the course of performing the w ork and are required by this Agreement to be delivered to the City shall be the property of the City. Basic sketches, charts, computations and similar data prepared or obtained by Consultant under this Agreement shall, upon request, be made available to City without restriction or limitation on their use.
16. Data Provided to Consultant. City shall provide to Consultant, without charge, all data, including reports, records, maps and other information, now in the City’s possession which may facilitate the timely performance of the work described in Exhibit A.
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17. Consultant’s Warranties and Representations.
Consultant warrants and represents to City as follows:
A. Consultant has not employed or retained any person or entity, other than a bona fide employee working exclusively for Consultant, to solicit or obtain this Agreement.
B. Consultant has not paid or agreed to pay a ny person or entity, other than a bon a fide employee working exclusively for Consultant, any fee, commission, percentage, gift, or any other consideration contingent upon or resulting from the execution of this Agreement. Upon any breach or violation of t his warranty, City shall have the rig ht, in its sole discretion, to terminate this Agreement without further liability, or, in the alternative, to deduct from any sums payable hereunder the full amount or value of any such fee, commission, percentage or gift.
C. Consultant has no knowledge that any officer or employee of the City has any interest, whether contractual, noncontractual, financial, proprietary, or otherwise, in this transaction or in the business of the Consultant, and that if any such interest comes to the knowledge of Consultant at any time, a complete written disclosure of such interest will be made to City, even if such interest would not be deemed a prohibited “conflict of interest” under applicable laws.
D. Upon the execution of this Agreement, Consultant has no interest, direct or indirect, in any transaction or business entity which would conflict with or in any manner hinder the performance of services and work required by this Agreement, nor shall any such interest be acquired during the term of this Agreement.
18. Resolution of Disputes.
A. Disputes regarding the interpretation or application of any pr ovisions of this Agreement shall, to the extent reasonably feasible, be resolved through good faith negotiations between the parties.
B. If the parties cannot resol ve the dispute through good faith negotiations, either party may give Notice of Dispute to the other party. The Notice of Dispute shall state the nature of the dispute and the corrective action necessary to remedy the dispute.
After Notice of Dispute, th e parties shall first attempt to resolve any disputes by mediation. The parties shall agre e on a single mediator . Mediation shall be conducted in Lancaster, California. Each party shall pay its own attorneys ’ fees and the costs of mediation shall be split equally between the parties.
If the dispute has not been resolved by mediation within 4 5 days after Notice of Dispute, or the parties are unable to agree to a mediator, within 15 days after Notice of Dispute, then, the dispute may, upon agreement of the parties be resolved by binding arbitration.
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C. If any action at law or in equity is brought to enforce or interpret any provisions of this Agreement, the prevailing party in such action shall be entitled to reasonabl e attorney’s fees, cost and necessary disbursements, in addition to such other relief as may be sought and awarded.
19. Exhibits.
The following exhibits to which reference is made in this Agreement are deemed incorporated herein in their entirety:
Exhibit “A” Scope of Services and Rates Schedule
20. Governing Law.
This Agreement shall be governed by the laws of the State of California.
21. Effective Date.
This Agreement shall become effective as of the date set forth below on which the last of the parties, whether City or Consultant, executes said Agreement.
[Signatures begin on next page.]
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IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed and attested by their respective officers thereunto duly authorized.
CITY OF LANCASTER
LANCASTER, CALIFORNIA
By:
Jason Caudle, City Manager
Dated:
_________________________________
By:
(Name, Title)
Dated:
ATTEST:
City Clerk
APPROVED AS TO FORM:
City Attorney
DocuSign Envelope ID: 23E135AD-BB25-425D-AEE7-03D3D0CFBE39 May 10, 2023 | 9:37:44 AM PDT
May 18, 2023 | 8:51:04 AM PDT
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EXHIBIT A
SCOPE OF SERVICES
AND RATES SCHEDULE
APPRAISAL RATE SHEET
DATE
April 10, 2023
CLIENT
City of Lancaster 44933 Fern
Avenue
Lancaster, California 93534
The following are base prices for real estate appraisal assignments and can vary depending on the difficulty of the assignment:
Land: $3,000
Improved Non-Residential Real Estate: $3,500 Easement
Valuations: $3,500
Appraisal Reviews: $750
11700 W. Charleston Blvd., #170517 25350 Magic Mountain Parkway, Suite 300
[email protected]
Las Vegas, Nevada 89135 Valencia, California 91355 www.voltzrealestate.com 661-259-8009 702-749-5968 800-520-1654
DocuSign Envelope ID: 23E135AD-BB25-425D-AEE7-03D3D0CFBE39
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
INSURER(S) AFFORDING COVERAGE
INSURER F :
INSURER E :
INSURER D :
INSURER C :
INSURER B :
INSURER A :
NAIC #
NAME:
CONTACT
(A/C, No):
FAX
E-MAIL
ADDRESS:
PRODUCER
(A/C, No, Ext):
PHONE
INSURED
REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
OTHER:
(Per accident)
(Ea accident)
$
$
N / A
SUBR
WVD
ADDL
INSD
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $
$
$
$PROPERTY DAMAGE
BODILY INJURY (Per accident)
BODILY INJURY (Per person)
COMBINED SINGLE LIMIT
AUTOS ONLY
AUTOSAUTOS ONLY
NON-OWNED
SCHEDULEDOWNED
ANY AUTO
AUTOMOBILE LIABILITY
Y / N
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
DESCRIPTION OF OPERATIONS below
If yes, describe under
ANY PROPRIETOR/PARTNER/EXECUTIVE
$
$
$
E.L. DISEASE - POLICY LIMIT
E.L. DISEASE - EA EMPLOYEE
E.L. EACH ACCIDENT
ER
OTH-
STATUTE
PER
LIMITS(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
POLICY EFF
POLICY NUMBERTYPE OF INSURANCELTR
INSR
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
EXCESS LIAB
UMBRELLA LIAB $EACH OCCURRENCE
$AGGREGATE
$
OCCUR
CLAIMS-MADE
DED RETENTION $
$PRODUCTS - COMP/OP AGG
$GENERAL AGGREGATE
$PERSONAL & ADV INJURY
$MED EXP (Any one person)
$EACH OCCURRENCE
DAMAGE TO RENTED
$PREMISES (Ea occurrence)
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO-
JECT LOC
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
CANCELLATION
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
Lancaster, CA 93534
44933 Fern Avenue
City of Lancaster, California
City of Lancaster, California is additional insured with respects to General Liability, if required by written contract, as per the General Liability Additional Insured Endorsement Form SS0008.
2,000,000
2,000,000
1,000,000
10,000
1,000,000
1,000,000
02/03/2023
02/03/2022
53SBMBA7945
Y
✘
✘
✘
A
11000
SENTINEL INS CO LTD
91355
CA
Valencia
300
25350 Magic Mountain Pkwy Ste
Voltz Commercial Realty
[email protected]
(702) 395-6277
Kristin Butler
89129
NV
Las Vegas
#240
9960 W Cheyenne Ave
Acrisure, LLC dba AMS Insurance
9/7/2022
DocuSign Envelope ID: 23E135AD-BB25-425D-AEE7-03D3D0CFBE39
September 8, 2022
Risk Management
City of Lancaster
44933 Fern Avenue
Lancaster, CA. 93534
Re: Worker’s Compensation
To Whom it May Concern,
This letter is provided to certify that Voltz Commercial Realty Advisors, Inc., does not have employees and therefore, is exempt from carrying Workers Compensation Insurance.
If you require additional information, please feel free to contact me.
Thank you,
P. Scott Voltz, MAI, AI-GRS
Voltz Commercial Realty Advisors, Inc.
DocuSign Envelope ID: 23E135AD-BB25-425D-AEE7-03D3D0CFBE39 W-9 Requestfor Taxpayer ldentificationNumber and CertificationForm Give Fomm to the Rev. October 2018) Departmentof the Treasury IntemalRevenueService requester. Do notsendto the IRS. Go to www.irsgoviFomWs forinstructions andthe latestinformation. 1 Name(as shownonyour incometax retum). Name isrequired on thiskne;do not leave this line blank.
VoLTZ COme RoMY tD VISoRS, LAV2 Business name'dksregarded ertity name. # dfferent from above VLTZ LOmmERCB REMYY AAVISoRS, AL 3 Check aporopriate box for federal tax classification ofthe personwhosename is entered n ine 1. Checkonly oneof the4 Exemptions (codes apply only to following seven boxes. certain entities, not individuals: see instructions on page 3): ndividual sole proprietor or single-member LLC c Corporation s Corporation Partnership Trust/estate Erempt payee code (i any) ULimited fiability company Enter the tax classihficatkon (C-C corporation. S-S corporation, P-Partnership) Note Checthe aoropriate box in the ine abovefor the tax ctasshication ofthe singtememberownerDo not check Exenption trom FATCA reporting LLc he uC is cassfied as a single-membe UC that is disregartded from the owner unless the owner of the lLC is anotherLLC that is not disregarded trom the owner for U.S. federaltax purposes. Otherwise, a singlememberLLC that is disragarded trom the owner should check the appropriate box for the tax classification of its owner Other(see instructions) polestd ns irtaint aticn th US.) 5 Address(number,street,and apt. or sute no,) See instructions Requester's name and address(optional 3 100_WCharesonB_ #170 6 City.spate,and ZP code 7 List account number(s) here (optiohal)
Part Taxpayerldentification Nunmber(TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoidbackupwithholding. For individuals, this is generally your socialsecuitynumber(SSN).However,for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part , later. For otherentities. it is your employeridentification number(EIN).If you do not have a number, see How to get a TIN, later.
Social security number
Employer identification number Note:f the accountis in more than one name,see the instructions for line 1. Also see What Name and Number To Gve the Requester for guidelines on whose number to enter. 4o72dsadPart Il Certification Underpenalties of periury,I certify that: 1. The number shown on this form is my correcttaxpayeridentification number(or I am waiting for a number to be issued to me); and 2.I am not subjectto backup withholding because: (a)I am exempt from backup withholding, or (b) I have not been notifiedby the Internal Revenue Service(IRS)that I am subject to backupwithholding as a resutof a failureto reportall interestor dividends, or (c) the IRS has notifiedme that I am no longersubjectto beackupwithholding; and 3.I am a U.S. citizenor other U.S. person (defined below); and 4. The FATCA codes) entered on this fom (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must crossout item 2 above if you have been notifiedby the IRS that you are currently subjectto backupwithholding becauseyou have failedto report all interestand dividends on your tax retum. For real estatetransactions, item 2 does not apply. For mortgageinterestpaid,acqursiton or abandonment of secured property, cangeil2on of debt,contnbutions to an individual retirement arrangement (IRA),and generally. paymentsother than mterest and dividends, you apenot reqyired o sign the centification, but you must provideyour correctTIN. See the instructions for Part Il, later.
P /24 2 Signatreof US personHere Date GeneralInstructions Sectonreterences are to the InternalRevenueCabe yhlessotherwise Fom 1099-DIV(dividends, including thosefrom stocksor mutualfunds)Fom 1099-MISC (varioustypesof income,prizes,awards,or gross proceeds) oted. Future developmenrts. For the latestinfomation aboutdevelopments ralaied lo Fom W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.govFormW9. Fom 1099-8 (stock or mutual fund sales and certain other transactions by brokers) Fom 1099-S (proceeds trom real estate transactions) Purpose of Form Form 1099-K (merchant card and third party network transactions) Fom 1098 (home mortgageinterest), 1098-E(studentloan interest), 1098-T (tuition) An indivdual or entty (Form W-9 requester) who is required to file an iamatonretumwh the RS must ctain your correcttaxpayeridenticabun umber () wich may be your social security number (SSN), ind1vidual tapayeridetification umber(TN),adoptiontaxpayarideritficaton numberATIN),o employeridenutication number(E), to report an an indomation retun the amount paid to you, or other afiount r&ponable on an indormation return. Exanples of information relum inciude, but are not kimitedto, the folowng.Fon 1099-INT (rterest earned or paid) Fom 1099-C (canceled deb) Form 1099-A (acquisition or abandonment of secured property) Use For1 W-9 only if you are a U.S. person (inctuding a resident allen), to provide your correct TIN. It you do not retun Form W-9 to the requester with a TIN, you might be subyect to backup withhokding. See What is backup withholding. ka ter Form W-9 (Rev. 10-2018)Cal. o 10231X DocuSign Envelope ID: 23E135AD-BB25-425D-AEE7-03D3D0CFBE39
Personal Auto Policy Declarations
Notice of Amended Policy
Effective October 31, 2022
This Declarations Page Replaces Any Previous Declarations Page Please Read and Attach to Your Policy
POLICY NUMBER:
PROGRAM:
NVSS104147116
AAA Select
Sales Rep Name & Address 6518530
AAA NCNU/Wendy L Everson
10860 W Charleston Blvd
Las Vegas, NV 89135
(702) 545-9620
POLICY PERIOD
FROM:
07/09/22
TO:
07/09/23
TIME:
12:01 A.M.
AAA Insured Since 2012
Named Insured(s) & Mailing Address
PETER E VOLTZ, SHAWN VOLTZ
1009 DOUGLAS FLAT PL
LAS VEGAS, NV 89138-6098
AAA Insurance
underwritten by CSAA General Insurance Company
PO Box 24511 Oakland, CA 94623-9865
For claims or customer service call
800.207.3618
AA02NVA 10 20 SEE BACK OF THIS FORM FOR ADDITIONAL INFORMATION Issued: 10/31/2022 10:48 AM MST
DESCRIPTION OF VEHICLE (S) YOU WILL BE BILLED SEPARATELY FOR ANY BALANCE DUE.
VEHICLE YEAR MAKE MODEL VEHICLE IDENTIFICATION ZIP CODE 1 2019 LINC MKC SUV 5LMCJ1C95KUL03824 89138
2 2017 NISS SENTRA SEDAN 3N1AB7AP3HY317181 89138
Insurance is provided only with respect to the following coverages for which a specific limit of liability is shown. Subject to all conditions of this policy.
COVERAGES LIMIT OF LIABILITY VEHICLE INFORMATION
1 DED 2 DED
Bodily Injury $100,000 / person
$300,000 / accident
1,595.00 1,366.00
Property Damage $50,000 / accident 540.00 496.00
Uninsured and Underinsured Motorist
Bodily Injury
$50,000 / person
$100,000 / accident
517.00 633.00
Uninsured Motorist Property Damage
Or Collision Deductible Waived
See Vehicle Information 8.00 3500
/accident----
8.00 3500
/accident----
Medical Payments No Cov. No Cov.
Comprehensive (Less deductible) 115.00 500 80.00 500
Collision (Less deductible) 921.00 500 865.00 500
Special Equipment INCL
1,000
INCL
1,000
Rental Car Reimbursement
(Up to 30 Days)
$30 / day 25.00 25.00
Automobile Death Benefits (See driver info) $15,000/person 9.00 FULL TERM PREMIUM $3,730 $3,473
FULL TERM PREMIUM TOTAL: $7,203.00
TOTAL CHARGES: $7,017.00
CHANGES MADE TO: VEHICLES
FORMS AND ENDORSEMENTS
FORMS AND ENDORSEMENTS MADE PART OF THIS POLICY:
AAADXX 01 12 AA49XX 01 12 AAAENV 01 20 AA09XX 01 12 AA01NV 05 09 AA15NV 01 18 AA11NV AA16NV 07 14
NOT AVAILABLE FOR RATING
The Named Insured has identified the following individuals as Not Available for Rating and does not wish coverage to apply to these individuals.
NONE
DocuSign Envelope ID: 23E135AD-BB25-425D-AEE7-03D3D0CFBE39
The following endorsement applies when a lienholder is shown on the declarations page:
/uni00A0
Loss Payable Endorsement
AALPXX 01 12
Loss or damage under this policy shall be paid, as interest may appear, to you and the loss payee shown in the Declarations or in this endorsement. This insurance with respect to the interest of the loss payee, shall not become invalid because of your fraudulent acts or omissions unless the loss results from your conversion, secretion or embezzlement of "your covered auto". However, we reserve the right to cancel the policy as permitted by policy terms and the cancellation shall terminate this agreement as to the loss payee's interest. We will give the same advance notice of cancellation to the loss payee as we give to the named insured shown in the Declarations.
When we pay the loss payee we shall, to the extent of payment, be subrogated to the loss payee's rights of recovery.
Copyright, Insurance Services Office, Inc., 1986
AA02NVA 10 20
Lienholder information: L=Lienholder A=Additional Insured/Interest C=Certificate Holder C 1 THE CITY OF LANCASTER, CALIFORNIA 44933 FERN AVE Lancaster CA 93534 L 2 CAPITAL ONE AUTO FINANCE PO BOX 390907 Minneapolis MN 55439 Driver # Name Birthdate Marital Status Gender Auto Death Benefits 1 PETER VOLTZ **/**/1962 Married Male Yes
2 SHAWN VOLTZ **/**/1962 Married Female Yes
3 VANESSA VOLTZ **/**/2003 Single Female No
DISCOUNT INFORMATION
Policy: Multi-Policy Discount; Membership Discount; Loyalty Discount; Multi-Vehicle Discount; NonStacking Discounts Driver: #3: SMART Driver Discount; Good Student Discount Vehicle: #1: Passive Restraint Discount; #2: Passive Restraint Discount Driver # Date Violation Driver # Date Violation
DocuSign Envelope ID: 23E135AD-BB25-425D-AEE7-03D3D0CFBE39