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DocuSign Envelope ID: 237247BF-8CAF-4018-BE4B-97D90F2F31 CF <br />Contract# C0009420 <br />ANOKA COUNTY HUMAN SERVICES <br />CONTRACTOR INFORMATION SHEET <br />Please review the following information for accuracy and <br />completeness, indicate any changes, sign and return to: <br />Angie Rod i ne <br />Anoka County Human Services <br />2100 3rd Ave, Suite 500 <br />Anoka, MN 55303 <br />LEGAL NAME FOR CONTRACTOR: Ramsey, City of <br />(Legal name and name on Certificate of Insurance must be exactly the same in order for County Signatures to be obtained on the <br />Contract.) <br />Doing Business As: <br />Business/Corporate Address: <br />Ramsey, City of <br />7550 S u nwood Drive NW <br />Ramsey, MN 55303 <br />National Provider Identification (NPI) #: <br />Federal Tax Identification #: 41-0910467 <br />NOTICE: Federal Business Tax ID/Social Security Number is needed for tax purposes as mandated by Section 1211 of the Tax Reform Act <br />of 1976 and Minn. Stat 270.66. This information will be shared with the Minnesota Department of Revenue, the Minnesota Department <br />of Human Services, the Internal Revenue Service, and the U.S. Department of Health, Education and Welfare for the purposes of <br />administering the income tax, child support obligation and social security tax programs. <br />Individual who Contractor is designating to receive notice under the contract and to act as the responsible <br />authority for data requests under the Minnesota government data practices act (Minn. Stat. Chap. 13): <br />Name: Phone: Fax: Email: <br />Chris Anderson 763-433-9817 763-427-5543 canderson@cityoframsey.com <br />Signature (Required): Date: <br />Insurance Agency: Name of Agent: <br />Telephone Number of Insurance Agent: <br />Person Completing this Form: <br />Name: Title: <br />Phone: Fax: Email: <br />