EFTA01223493.pdf

LSJE, LLC 6100 Red Hook Quarters, Suite B-3 , St. Thomas, VI 00802-1348 Phone: 340-775-2525 E-mail: [email protected] Subcontractor Employment Form Today's Date: 0.21/1/O2-0/q Start Date: 2/4,4? Position/Title: Hourly Pay Rate: Last Name: LA-)Yes First Name: 1\e4vid Nickname: Date of Birth: /02/0514/ 9 Social Security Number. Driver's License Number: Mailing Address: Physical Address: Cell Phon Phone (other): E-mail: Marital Status: 7/larded In case of emergency, please contact Contact: She)); Veis Relationship: \3,420 Hsi Contact Phone: Supervisor Notes: Proof of eligibility for employm ent is required. Please attach b.) a photo ID AND supporting a.) a Photocopy of your U.S. Passpo documentation establishino US rt or Passport Card OR . Employment Authorizatign Employee Signature: Date: oeL74-0 7 Supervisor Signature: Date: AilvA EFTA01223493  Farm W-9 Request for Taxpayer (Rev. November 2017) Identification Number and Give Form 10 the Departmere of the Treasay tritemal Revenue service Certification requester. Do not Nam7 ► Go to vienciregov on your InCOlha tax robin) Nam /FomiW9 for Instructions * is required on thin Wet do not and the latest information . send to the IRS. michae.I Ave) 2 eusiness narrlefaregarded entity nam leave the ore blank. e. 4 deferent from above 3 Check appropriate box for federal tax cbsefieespri at me person following seven boxes. ose name is entered on fi e 1. Check orly one of the 4 Exemptions (codes apply only to 0 Incividuallsole proprietor or certain enelies, net inr3M 0 c Corporation <Suats; see eagle-member LLC 0 s Corporation 0 4tuucttons on ease 3): Partnership 0 That/estate C3 tented liability company . Enter it. tax classification Exempt payee co** el any) Note:Check the appropriate box (CC corporation. S4 corporati in on, P.Partnership)4 the Fan abov e tor the P, q LLC if the LLC 4 classified another LLC that Is not dsregsded from the owner as a single-member LLC that tax classification of the single-member owner. Do not disregarded from the own is disregarded from the own er unless the owner of the er for U.S. federal tax purposes. Oilie should check the appropriate check Exemption from LLC rarlse. a single-member LLC box for the lex classification that coda any) FOCAreporting e Other sea i of its owner. WolesmaccoReaureflewWWw.U P ReQueSian name and addr ess (0$410014 Taxpayer Identification Number (TIN) Enter your TIN in the app ropriate box. The TIN prov backup withholding, For ided must match the nan Individuals. this is generally o given on fine 1 to avoid resident alien, sole prop your social security num rietor, or disregarded enti ber (SSN). However, for entities. it is your employe ty, see the instructions for Part I, late a r identification number (EIN r. For other TIN, later. ). If you do not have a num ber, see How to get a Note: If the account Is In more than one name, see Number To Give the Req the instructions for line 1. uester for guidelines on Also see What Name and whose number to enter. EMI Certification Under penalties of perjury, I Getty that 1. The number shown on this form is my correct taxpayer 2.1 am not subject to back identification number (or I am up withholding because waiting fora number to be Service (IRS) that 1 am sub : (a) I am exempt from back issued to me); and ject to backup withholding up withholding, Or (b) I hav no longer subject to bac as a result of a failure to e not been notified by the kup wehhoiding; and report all interest or divi Internal Revenue dends. or (c) the IRS has noti 3.1 am a U.S. citizen or fied me that I am other U.S. person (defined 4, The FATCA code(s) below); and entered on this form (d any ) Indicating that I am exe Certification instructions mpt from FATCA reporting . You mist cross out item 2 is correct. you have failed to report all above if you have been notif Interest and dividends on ied by the IRS that you are acquisition or abandonmen your tax return. For real esta currently subiect to back t of secured property, cancellat te transactions, item 2 doe up withholding because other than interest and divi ion of debt, contributions to s not apply. For mortgage dends. y4epr not requied an individual retirement arra interest paid, to sign the certification, but ngement (IRA). and generally Sign Signature you must provide your correct TIN. . payments See the instructions for Part II, later. Here US peraorp offI General instructions Dee* C60 • Form 1099-ON (div 4 / C'1121 Section references are to the idends, including those from Internal Revenue Code funds) stocks or mutual noted. unless otherwise • Form 1099-MISC (various Future developments. For types of income. prizes, the latest information about proceeds) awards, or gross related to Form W-9 and developments its instructions, such as • Form 1099-B (stock after they were pubished, legislation enacted or mutual fund sales and go to tvwwirs.gov/FormW transactions by brokers) certain other 9. Purpose of Form • Form 1099$ (proceed s from real estate tran sactions) An lndMdual or entity (Form • Form 1099-K (mercha W-9 requester) who is requ nt card and third party netw information return with the ired to file an • Form 1098 (home mor ork transactions) IRS must obtain your correct tgage interest), 1098-E (stu identification numb... (TIN) taxpayer 1098-T (tuition) dent loan Interest), which may be your social ISSN), individual taxpayer iden security number • Form 1099-C (canceled deb tification number 011N), t) taxpayer identification number adoption • Form 1099-A (acquisit (ATM), or employer iden ion or abandonment of secu (EIN), to report on an informa tification number red property) tion return the amount paid Use Form W-9 only if you we amount reportable on an info to you, or other a U.S. person (Including a resid rmation return. Examples of alien), to provide your corr ent returns include, but are not information ect TIN. limited to, the following. • Form 1099-INT (Interest It you cio not return Form earned or paid) W-9 to the requester with be subject to backup withhold a TIA1, you might ing. S49 What is backup later, withholding, Cat No.10231X Form W-9 (Rev. 11-2017) EFTA01223494  LSJE, LLC 6100 Red Hook Quarters, Suite B-3 , St. Thomas, VI 00802-1348 Phone: 340-775-2525 E-mail: the [email protected] Emergency Contact Form Today's Date: io,z14 / 9102-og Start Date: Employee Name: Date of Physical Address: Mailing Address: Cell Phone: E-mail: Marital Status: roe/Position: Driver's License N Allergies or Health Concerns: rviA Blood type: O A- O A+ AB- AB+ O 8- 9+ O O- O O+ l_QUnknown Current Medications: Doctor's Name: Mey *vim Doctor's Phone: Doctor's Namet Doctor's Phone: in case of emergency, please contact: Name: Shell; Alves Relationship: ,Y6(45e- Name: Rolation3hIp: Phone: 1 This information is for your safety an d the safety of others. EFTA01223495  ACKNOWLEDGEMENT, ASSUMPTION OF RISK, WAIVER, RELEASE AND INDEMNITY THIS ACKNOWLEDGMEN AND INDEMNITY dated T, ASSUMPTION OF RI Oct SK, WAIVER, RELEASE, 2011. By: (the undersigned, togeth er with all of the past, pres managers, employees, ent and future directors, of subcontractors, represen ficers, undersigned, are hereinaf tatives and agents of ter referred to, collectively, the of the Indemnified Perso as "I" , "me" or "my") in fav ns (as defined below). or WHEREAS, I desire to independent contractor of be engaged as a vend one or more of Nautilus, Inc or, supplier and/or an Jeffrey Epstein, and/or ot ., LSJE, LLC, Great St Jim, LL her corporations, limited C, affiliated with any of the liability companies or en foregoing (hereinafter refe tities provide services and/or rred to as "you" or 'your provide and/or install "), to equipment for, on or with pr od ucts, materials, machinery respect to either or both of , known as Little St. James the properties located at an Island and Great St. Jame d more particularly described s Island (the "Properties"), on Exhibit A hereto (the "W all as ork"); and WHEREAS, my actions in co from the Properties and my nnection with such engagem physical presence on the Pr ent, my travel to and engage in Inherently Dang op erties may cause me to erous Activities (as defin Inherently Dangerous Cond ed below) and expose me itions (as defined below); an to d WHEREAS, as a material in you to consider me for such ducement and an express co engagement, and to so enga ndition precedent for of any such engagement that ge me, and in consideration I may obtain from you, I have of, to waive, and to Release agreed to assume the risk , indemnify and hold harmles (as defined below) from an s the Indemnified Persons d against, any and all past, pres any way arising out of, relat ent and future claims in ed future damage and/or destr to or connected with, any and all past, present and uction to personal property This document is con , any and all past, present fidential and isIntended only for the use LW Unauthorized use. dis of the authorized recipient. It unlawful. O 2017 LSJE, LLCclosure or copying of this document or any part thereo is the property of LS - All rights reserved. f is strictly prohibited and ma JE. y be 1 EFTA01223496  and future personal injuries, and/or my death in connection my past, present and future tra with such engagement, vels to and from the Propertie future physical presence on s, my past, present and the Properties, my past, present any and all Inherently Da and future exposure to ngerous Conditions, my pa participation in any and all st, present and future Inherently Dangerous Activi present and future acts or om ties or any other past, issions on or with respect to the Properties; NOW, THEREFORE, in conside good and valuable considerat ration of the foregoing premis ion, the receipt and sufficiency es, and for other acknowledged by me, 1, inten of which are hereby ding to be legally bound, hereb y agree as follows: 1. ACKNOWLEDGEMENT. 1 Properties, including, but no understand and acknowledge t limited to, the pathways, that the buildings, structures, impro roadways, docks, riprap, vements, landscape, topograp shores, surrounding waters, hy, hardscape, ponds, falls, and other features thereof, bo may contain defects, both th natural and man made, hidden and obvious, and vegetation, animals and other "attractive nuisances," conditions ("Property Conditio used on the Properties tools, ns"), and that there are equipment, machinery, chemic as a material part of the condu als , and other materials ct of normal operations on the Equipment and Materials"), Properties ("Property and that such Property Co Equipment and Materials ma nditions and Property y be dangerous to my person an Dangerous Conditions"). I fur d property ("Inherently ther understand and acknowle with my present and future dge that in connection engagement, my past, present from the Properties, and my and future travel to and past, present and future ph Properties, I may have been ysical presence on the and may be required to eng exposed or will expose me to suc age in activities that h Property Conditions, and req my use of such Property Equip uired or may require ment and Materials, and that suc dangerous to my person or pro h activities may be perty ("Inherently Dangerous acknowledge, agree and rep Activities"). I further resent that I fully understan Inherently Dangerous Conditio d the nature of the ns previously, presently or Properties and the nature of hereafter on the any Inherently Dangerous Ac undertaken or may undertake tivities that I have , and that 1 am in good heath condition to bear the risk of exp an d in proper physical osure to such Inherently Dang to engage in any such Inherentl erous Conditions and y Dangerous Activities. I furthe shall be my sole responsibility to, r agree that it is and and I shall, obtain and maintain insurance policies for the wo my own liability rk, naming you as an addition amounts as we shall mutually al insured, in such agree, and I have obtained an maintain workman's compensa d shall obtain and tion insurance for my employee and with such coverages as are s, in such amounts required by law, to insure again future damage and destruction st past, present and to personal property, and past, personal injury or death to my present and future subcontractors and direct and who have provided or may herea indirect employees fter provide the Work 2. ASSUMPTION OF TH present and future engagement E RISK. I fully understand that (a) my by you to provide the Work, my This document is confidentia past, present l and is intended only for the use LLC Unauthorized use. disclosu d the authorized recipient It is the ursawtul. 2017 LSJE, LW Allre or copying of this document or any pan thereof is strictly proh property of LSJE. - rights reserved. ibited and may be 2 EFTA01223497  and future travel to and from the Proper physical presence on ties, my past, presen the Properties, my pa t and future any Inherently Da st, present and future ngerous Conditions exposure to engagement in any and my past, pres Inherently Dangerous ent and future DANGERS of serious Activities INVOLVES bodily injury, includi RISKS AND and death ("Danger ng permanent disa s"); (b) these Danger bility, paralysis my own actions or s may have been or inactions, the actions may be caused by existing at the time or inactions of others that the Dangers occu , the conditions Indemnified Person r, or the negligence s; and (c) there are of one or more losses either not kn or may be other risks own to me or not re , damages and FULLY ACCEPT AND adily foreseeable at th ASSUME ALL SUCH is time; and I RESPONSIBILITY FOR DANGERS AND RISKS ALL LOSSES, COSTS, AND ALL and may hereafter be AND DAMAGES that incurred by me as a re may have been Properties, my presen sult of or in connectio t or future engagem n with the past, present and fu en t by you to provide th ture travel to and fro e Work, my and future physical m the Properties, m presence on the Prop y past, present exposure to any Inhe erties, my past, pres rently Dangerous Co ent and future future engagement in nditions and my past, any Inherently Dange present and and agree that I HAVE rous Activities. I fully BEEN, AM AND SHALL understand OWN SAFETY WHILE BE FULLY RESPONSIBL ON THE PROPERTIES. E FOR MY risk and liability th I expressly agree to at I have suffered or assume the injury, including, bu may suffer, directly t not limited to, tota or indirectly, or personal injury, in l loss or destruction, cluding, but not limite to my property whether due to some d to serious bodily ha Inherently Dangerous rm or death, Activity or otherwise Condition, Inherently , whether known or Dangerous shareholder, membe unknown to you, or r, director, officer, an y owner, representative, attorn manager, supervisor, ey, contractor or agen employee, such owners, shar t of you (you, together eholders, members, with all supervisors, employee di rectors, officers, s, representatives, at managers, you, collectively, th torneys, contractors an e "Indemnified Perso d agents of disclosed to me, and ns"), whether disclo whether or not caus sed or not Indemnified Person, as ed by any act of negl long as such acts do ig ence of any misconduct. not constitute willful an d wanton 3. CAREFUL INSPECTION carefully consider and in . I agree, represent an spect each Inherently Da d warrant that I will exposed and each Inhe ngerous Condition to wh rently Dangerous Activ ich I am observe any condition ity in which I take part, which I consider to be un and that, if I I will notify you in wr acceptably hazardous or iting regarding the sam dangerous, unacceptably hazardou e and will not take s or dangerous activ pa rt in such corrected. ity until the condition has been 4. WAIVER AND RELEASE OF acquit and forever discha CLAIMS. I rge each and all of the In hereby waive, and release, liability for, any and al demnified Persons from l past, present and fu all ture claims, demands, This document Is Con fide ntial and lo ss es , or Unauthorized use, disclosur iS intended only for the use of the authorized rec unlawful. C2017 LSJE. e or copying of this docum ipient. It is the property of U.0 • All rights reserved. ent or any part thereat is stri LSJE. ctly prohibited and may be 3 EFTA01223498  damages previously, now or hereafter arising out of, with, the Properties, my pre relating to, or connected sent and future engageme Work, my past, present or nt by you to provide the future travel to and from present or future physical the Properties, my past, presence on the Properties future exposure to any Inh , my past, present or erently Dangerous Cond or future engagement itions and my past, presen in any Inherently Da t not limited to, any and ngerous Activities, including, bu all claims, demands, losses t present and future loss or , or damages for past, destruction, to my property and future serious bodily or for any past, present harm or death, and includ and all claims, demands, los ing , but not limited to, any ses or damages arising ou future negligence of any of t of the past, present and the Indemnified Persons as "Released Claims"). (hereinafter referred to 5. COVENANT NOT TO SUE. or initiate, prosecute, I hereby expressly covena participate in or otherwise nt not to sue action against any of the pursue any claim or cause of Indemnified Persons arisin Released Claim, whether pa g out of or relating to any st, present or future. 6. INDEMNIFICATION. To the I defend, indemnify and ho fullest extent permitted by ld harmless each and all of law, I shall from any and all claims, the Indemnified Persons actions and/or damages in relating to, or connected any way arising out of, with any and all matters, future, within the scope of whether past, present or any Released Claims, wheth and/or damages are assert er such claims, actions ed by me or any third pa limitation, for past, presen rties, including, without t and future bodily injury an well as for attorneys fees an d property damage, as d costs of you. This Indem waiver of any immunity co nity shall constitute a nferred by any applicable wo laws. rkers compensation 7. ADDENDA. I shall cause each the undersigned and each an and every one of the subco d every one of the direct or ind ntractors of undersigned who may provid ire ct employees of the e the Work to agree in writin bound by, the provisions g to be subject to, and of this instrument for the ben Persons, as if such subcontract efit of the Indemnified or or employee was an origin signing an Addendum in the for al signatory hereto, by m of Exhibit B attached hereto. 8. THIRD-PARTY BENEFICIAR expressly agree that the provis IES. I hereby acknowledge and ions of this ACKNOWLEDG RISK WAIVER, RELEASE, AND EMENT, ASSUMPTION OF INDEMNITY shall be fully enf any of the Indemnified Perso orceable against me by ns, each of whom is hereby exp intended third-party beneficia ressly deemed to be an ry hereof. 9. GOVERNING LAW. This ACKN RISK WAIVER, RELEASE, AND IND OWLEDGEMENT, ASSUMPTIO EMNITY shall be governed by, N OF accordance with, the laws of the and construed in United States Virgin Islands, applic able to contracts TMs document is confidential and is intended only for LLC Unauthorized use, disclosu the use of the authorized recipien re t. It Is the prop unlawful O2017 LSJE, LW - All or copying of this document or any part thereof is strictly prohibite erty of LSJE, rights reserved.* d and may be 4 EFTA01223499  executed and to be perform ed entirely therein without ap of conflicts of laws. plication of any principles [SIGNATURE ON THE NE XT PAGE) IN WITNESS WHEREOF, th executed as of the day and ye e undersigned has caused th ar first above written. is Agreement to be Name: It AJtieS Name and Title, if any, of Au thorized Signatory: This document Is confide ntial and is intended only for the LLC Unauthorized use, disclo use of the authorized recipient. tt is uniaeAul. O 2017 LSJE, LLC sure or copying of this document or any part thereof is strictly the property of LSJE. - Ail rights reserved. prohibited and may be S EFTA01223500  CONFIDENTIALITY A GREEMENT In order to induce LSJE. LLC, a Virgin "Company"), to conside Islands limited liability r me for employment company (the an independent contr with the Company or actor of the Company, to consider engaging engagement that I ma and in consideration me as y obtain with the Company of any future employm be hereafter paid to me in an*any_comit ensation or en t or connection therew other remuneration to referred to as the Ap ith , I, pitVILI VteS plicant"), acknowledge (hereinafter sometimes hereunder and that such that I have been inform ed of my obligations employment or engageme obligations are a condition to the Company's nt by the Company, an consideration of my may obtain, and I he d any subsequent emplo