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DocuSign Envelope ID: E1227292-CABD-4035-9075-56C5CB154254 <br />Contract# C0010120 <br />ANOKA COUNTY HUMAN SERVICES <br />CONTRACTOR INFORMATION SHEET <br />Please review the following information for accuracy and Angie Rodine <br />completeness, indicate any changes, sign and return to: 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 some in order for County Signatures to be obtained on the <br />Contract.) <br />Doing Business As: Ramsey, City of <br />Business/Corporate Address: 7550 Sunwood Drive NW <br />Ramsey, MN 55303 <br />National Provider Identification (NPI) #: NA <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 />DocuSigned by: <br />Signature (Required): 01e��S gt&JA'Y�6vu <br />Insurance Agency: <br />Telephone Number of Insurance Agent: <br />Person Completing this Form: <br />Name: Chris Anderson <br />Date: 9/19/2023 <br />Name of Agent: <br />Title: Senior Planner <br />Phone: 763-433-9817 Fax: 763-433-9848 Email: canderson@cityoframsey.com <br />