PLEASE
RETURN
TO:
INDIVIDUAL - PAYEE/OWNER'S FULL NAME AS SHOWN ON INCOME TAX RETURN (Last, First, M.I.)
MAILING ADDRESS (Number and Street or P.O. Box Number)
(City, State and Zip Code)
IF YOU USE YOUR SOCIAL SECURITY / ITIN NUMBER TO FILE YOUR INDIVIDUAL/BUSINESS TAXES:
INDIVIDUAL / SOLE PROPRIETOR
- -
IF YOU USE A BUSINESS TAX I.D. NUMBER TO FILE YOUR BUSINESS TAXES:
EXEMPT CORPORATION
PARTNERSHIP
MEDICAL CORPORATION
ESTATE OR TRUST
ALL OTHER CORPORATIONS
LEGAL CORPORATION (Attorney / Law Firm)
-
Yes
CALIFORNIA STATE TAX WITHHOLDING STATUS (APPLIES TO ALL PAYEES):
FEDERAL INCOME TAX WITHHOLDING STATUS (APPLIES TO INDIVIDUALS ONLY):
TELEPHONE NUMBER
California State University, Chico
Accounts Payable Chico, CA 95929-0243
(530) 898-6426 (Voice) - (530) 898-4234 (Fax)
PAYEE DATA RECORD
(REV 1-2010)
Required in lieu of IRS W-9 Form and State of California Form 204 when conducting business with California State University, Chico
PAYEE'S LEGAL BUSINESS NAME PHONE NUMBER
PURPOSE:
Information contained in this form will
be used to prepare information Returns
(Form1099) and for withholding on
payments to nonresident payees.
Prompt return of this fully completed
form will prevent delays when
processing payments.
(See Privacy Statement on reverse)
Section V
W-9
CERTIFICATION
(Please sign
if applicable)
Note: All Foreign Citizens/Entities must complete a tax analysis before payments can be made.
I am a US citizen
I am a Permanent Resident Alien and I have a Green Card
I am Not a US Citizen and I Do Not Have a Permanent Resident Green Card
NOTES:
a. An estate is a resident if decedent
was a California resident at time of
death
b. A trust is a resident if at least one
trust is a California resident.
c. Rules for assessing State taxes differ
significantly from Federal tax rules.
(Please see reverse)
Under the penalties of perjury, I certify that:
1. The number shown on this form is my correct tax payer identification number (or I am writing for a number to be issued to me, AND
2. I 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. I am a U.S. person (including a U.S. resident alien).
California Resident - Qualified to do business in CA or a permanent place of business in CA
Nonresident (See Reverse) Payments to non residents for services may be subject to state witholding.
WAIVER OF STATE WITHHOLDING FROM FRANCHISE TAX BOARD ATTACHED
SERVICES PERFO
RMED OUTSIDE OF CALIFORNIA/GOODS ONLY SOLD TO CALIFORNIA
TITLE
Section III
PAYEE
RESIDENCY
DECLARATION
All Payments Made
By the University
Are
Subject to Federal
And California State
Tax Laws
(REQUIRED)
LIMITED LIABILITY COMPANY (Enter the tax
classification: (
D
=disregarded entity,
C
=corporation,
( )
Section IV
CERTIFYING
SIGNATURE
(REQUIRED)
I hereby certify under penalty of perjury that the information provided on this document
is true and correct. If my residency status should change, I will promptly inform you.
NOTE:
Prior to making payments to foreign
citizens, United States tax laws require
all employers to perform a tax analysis
with respect to country of citizenship to
determine residency for Federal tax
purposes.
(Please see reverse).
IS THE PAYEE OR THE BENEFICIARY OF THE PAYMENT A U.S. CITIZEN OR
PERMANENT RESIDENT ALIEN? (APPLIES TO ALL PAYEES)
AUTHORIZED PAYEE REPRESENTATIVE'S NAME (Type or Print)
SIGNATURE
Section I
PAYEE
(REQUIRED)
DATE
Section II
PAYEE
ENTITY
AND
TAX
I.D.
NUMBER
(TIN)
(REQUIRED)
SOCIAL SECURITY / ITIN NUMBER
See reverse for W-9 Certification Instructions
SIGNATURE OF U.S. PERSON
NOTES:
Governmental entities, federal, state,
and local (including school districts) are
not required to submit this form.
Payment will not be processed without
an accompanying taxpayer I.D. number.
NOTE:
MANDATORY RESPONSE
No (If No, you must contact Accounts Payable for further information)
FEDERAL TAX IDENTIFICATION NUMBER (TIN)
CHECK ONE BOX ONLY IN THIS SECTION
CALIFORNIA STATE UNIVERSITY, CHICO
PAYEE DATA RECORD
(REV 2-2004)
ARE YOU A RESIDENT OR NONRESIDENT?
Each corporation, individual/sole proprietor, partnership,
estate or
trust doing business with the State of California
must indicate their
residency status along with their taxpayer
identification number.
A corporation will be considered a resident of California if it
has a
permanent place of business in California. The
corporation has a
permanent place of business in California
if it is organized and
existing under the laws of this state or,
if a foreign corporation, has
qualified to transact intrastate
business. A corporation that has not
qualified to transact
intrastate business (e.g., a corporation engaged
exclusively
in interstate commerce) will be considered as having a
permanent place of business in this state only if it maintains
a permanent office in this state that is permanently staffed
by its
employees.
For individuals/sole proprietors, the term “resident”
of
California
includes every individual who is in California for
other than a
temporary or transitory purpose and any
individual domiciled in
California who is absent for a
temporary or transitory purpose.
Generally, an individual who
comes to California for a purpose which
will extend over a
long or indefinite period will be considered a
resident.
However, an individual who comes to perform a particular
contract of short duration will be considered a California
nonresident.
For withholding purposes, a partnership is considered a
California
resident partnership if it has a permanent place of
business in
California. An estate is considered a California
estate if the decedent
was a California resident at the time of
death, and a trust is considered
a California trust if at least
one trustee is a California resident.
More information on California residency status can be
obtained by
calling the Franchise Tax Board at the numbers
listed below:
From within the United States, call 1-800-852-5711
From outside the United States, call 1-916-845-6500
For hearing impaired with TDD, call 1-800-822-6268
Website - www.ftb.ca.gov
FOREIGN CITIZENS and FOREIGN BUSINESSES:
Federal tax withholding regulations differ significantly from
California tax withholding requirements. A tax analysis
consultation and additional forms must be completed before a
payment can be released.
ARE YOU SUBJECT TO CALIFORNIA NONRESIDENT
WITHHOLDING?
Payments made to California nonresident payees,
including
corporations, individuals, partnerships, estates
and trusts, are
subject to withholding. California nonresident
payees
performing services in California or receiving rent,
lease or royalty payments from property (real or personal)
located in
California will have 7% of their total payments
withheld for
state income taxes. However, no withholding is
required if total
payments to the payee are $1500 or less for
the calendar year.
A California nonresident payee may request that income
taxes
be withheld at a lower rate or waived by sending a
completed
form FTB-588 to the FTB address below. A waiver
will generally be
granted when a payee has a history of filing
California returns
and making timely estimated payments. If
the payee activity is
carried on outside of California or
partially outside of California, a waiver or reduced
withholding rate may be
granted. For more information,
contact:
Franchise Tax Board
Nonresident Withholding Section
Attention: State Agency Withholding Coordinator
P.O. Box 651 Sacramento, CA 95812-0651
Telephone: (916) 845-4900 FAX: (916) 845-4831
If
a reduced rate of withholding or waiver has been
authorized by the Franchise Tax Board, attach a copy
to
this form.
Section V - W-9 Certification
You must cross out item 2 on the certification 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
1 does not apply. For further instructions
and information, please refer to IRS Form W-9.
PRIVACY STATEMENT
Section 7(b) of the Privacy Act of 1974 (Public Law 93-5791) requires that any federal, state, or local governmental agency which
requests an individual to disclose his social
security account number shall inform that individual whether that disclosure is
mandatory or voluntary, by which statutory or other authority such number is solicited, and what
uses will be made of it.
The State of California requires that all parties entering into business transactions that may lead to payment(s) from the State must
provide their Taxpayer Identification Number (TIN) as required by the State Revenue and Taxation Code, Section 18646 to facilitate
tax compliance enforcement activities and to facilitate the preparation of Form 1099 and
other information returns as required by the
Internal Revenue Code, Section 6109(a). The TIN for individual and sole proprietorships is the Social Security Number (SSN).
It is mandatory to furnish the information requested. Federal law requires that payments for which the requested information is not
provided be subject to a 28% withholding
and state law imposes noncompliance penalties of up to $20,000.
You have the right to access records containing your personal information such as your SSN. To exercise that right, please
contact the business services unit or the accounts
payable unit of the state agency(ies) with which you transact that business.
Please call the Department of Finance, Fiscal Systems and Consulting Unit at (916) 324-0385 if you have any questions regarding
this Privacy Statement. Questions related to
residency or withholding should be referred to the FTB telephone numbers listed above;
all other questions should be referred to the requesting agency.