Fillable Ci 204 Vendorpayeedatarecordform 2017 (California State University Channel Islands)

Fill Online, Printable, Fillable, Blank Ci 204 Vendorpayeedatarecordform 2017 (California State University Channel Islands) Form

Use Fill to complete blank online CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Ci 204 Vendorpayeedatarecordform 2017 (California State University Channel Islands)

On average this form takes 24 minutes to complete

The Ci 204 Vendorpayeedatarecordform 2017 (California State University Channel Islands) form is 5 pages long and contains:

  • 0 signatures
  • 52 check-boxes
  • 71 other fields

Country of origin: US
File type: PDF

U.S.A. forms for California State University Channel Islands

BROWSE CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Service Provider/Contractor/Vendor:
Thank you for your interest in doing business with California State University Channel Islands
(CI).We are in the continuous process of maintaining an accurate and current vendor database. To
help with our efforts, please complete the following forms (detailed below) and submit them to the
CI Procurement and Logistical office for processing.
Vendor Data Record (VDR) Form (204 Form)
Before Accounts Payable can process any payment we are required by state law to have a
completed VDR Form on file. If you fail to return the VDR Form, your check could reflect an
approximate 30% reduction. The withdrawn amount will be paid to the IRS or the Franchise Tax
board. If you or your organization is not subject to backup withholding by the IRS or the Franchise
Tax Board, returning the completed VDR Form will guarantee that CI issues the appropriate
payment to your organization. Please be aware that Federal Form W-9 CANNOT substitute the
VDR Form.
VDR Complement Form
Please fill out this form to contribute in developing/maintaining our Vendor/Contractor database
with current information regarding your business, services and/or products. Completing this form
is mandatory for entities doing business with CI. Submission of this form will help confirm all
purchase orders, payments, and correspondences are promptly received by your business.
Voluntary Statistical Data Sheet (OPTIONAL)
This is a strictly voluntary form allowing vendors to provide information regarding ethnicity, race
and gender.
Automated Clearing House Enrollment and Authorization Form (OPTIONAL)
You have the option to enroll in direct deposit. Please complete the form with the accurate bank
information.
Please return completed forms via:
Email: purchasing@csuci.edu
Mail:
Procurement & Logistical Services
California State University Channel Islands
Ironwood Hall
One University Drive
Camarillo, CA 93012
(805) 437-8592
Thank you for your interest in doing business with us.
Division of Business and Financial Affairs
Procurement & Logistical Services
VENDOR DATA RECORD
(204 Form)
Required in lieu of IRS W-9 when doing business with
the State of California
Vendor #: _____________________________
For &68&, Use Only
Section 1
Return To:
PURPOSE: Information contained in this form
will be used by state agencies to prepare
information Returns (Form 1099) 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 2
Name and
Address
Vendor’s Legal Business Name or Sole Proprietor’s Full Name (as shown on your income tax return):
DBA, Trade, or Single Member LLC Name (if applicable):
Phone:
Mailing Address (Street and Number or P.O. Box #):
Fax:
City, State and Zip Code:
Email:
Section 3
Vendor
Entity Type
Taxpayer
Identification
Number
Individual C Corporation S Corporation Partnership Exempt (Non-Profit) Government Entity
Limited Liability Company (LLC) Estate/Trust
Single Member LLC (check IRS tax classification below):
Individual (provide SSN/EIN for individual (not LLC), individual’s name on line 1 section 2, and LLC name on line 2 section 2)
Corporation (provide EIN for LLC, provide LLC name on line 1 section 2. Do not provide individual’s name or SSN)
Multiple Member LLC (check IRS tax classification below):
Partnership Corporation (for either type, provide EIN for section 2.
Individual/Sole Proprietor – Social Security Number/ITIN Number (FEIN):
-
or
-
Note: When taxpayer ID is not provided or does not match IRS records, payment may be subject to backup withholding requirements.
Section 4
Vendor
Activity
Check the Box that Describes Your Primary Business
Services: (Non-Medical)
Equipment & Supplies
Rent
Services: (Medical/Health Care)
Attorney/Legal Fees
Other (Specify)
________________________
Section 5
Vendor
Residency
Status For
Tax Purposes
Check All Boxes That Apply to Federal Income Tax Withholding Status
I am a U.S. Citizen or a
U.S. corporation, partnership, trust, or estate
I am a Permanent Resident Alien and I have a Green Card
I am not a U.S. Citizen and I do not have a Permanent Resident Green Card
(Note: All Foreign Nationals must complete the “Foreign National Data Collection Form” before payments can be made)
Foreign corporation, partnership, trust, estate or other foreign entity
All services to be performed OUTSIDE the United States
Check All Boxes That Apply to California Income Tax Withholding Status
California Resident - Maintains a permanent place of business in CA at the address shown above or is qualified through
the California Secretary of State (SOS) to do business in CA
California Non-resident (see reverse) – Payments to CA non-residents may be subject to state income tax withholding
A Waiver from CA state tax withholding is attached (From the CA Franchise Tax Board, www.ftb.ca.gov)
Section 6
Are you (Vendor) or any of your employees employed by the CSU? Yes No
If yes, provide employee name(s) and relationship as an attachment to this form.
Section 7
Certifying
Signature
I hereby certify under penalty of perjury under the laws of the State of California that the information provided on
this document is true and correct. If my residency status should change, I will promptly inform you.
Authorized Vendor Representative’s Name (Print):
Title:
Signature:
Date:
Phone:
California State University Channel Islands
Procurement & Logistical Services
Email: purchasing@csuci.edu or Fax: (805) 437-8436
Clear Form
VENDOR DATA RECORD
(204 Form)
Required in lieu of IRS W-9 when doing business with
the State of California
Are you a California resident or nonresident?
Each corporation, individual/sole proprietor, partnership, estate,
or trust doing business with the State of California must indicate
residency status along with their taxpayer identification number.
A corporation is defined as a “resident” if it has a permanent
place of business in California or is qualified through the
Secretary of State to do business in California.
For individuals and sole proprietors, the term “resident”
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 nonresident.
A partnership is considered a resident partnership if it has a
permanent place of business in California. An estate is a resident
if the decedent was a California resident at time of death. A trust
is a resident if at least one trustee is a California resident.
For information on residency status, contact 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
Are you subject to California nonresident withholding?
Payments made to California nonresident vendors, including
corporations, individuals, partnerships, estates and trusts, are
subject to California income tax withholding. California
nonresident vendors 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 $1,500 or less for the calendar
year.
A California nonresident vendor may request that income tax
withholding be waived by sending a completed form FTB 588 to
the 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 vendor activity is carried on outside of
California or partially outside of California, a waiver may be
granted.
A California nonresident vendor may request a reduction in the
standard 7% income tax withholding amount by sending a
completed form FTB 589 to the address below, or by completing
the form online at www.ftb.ca.gov. If a reduced rate of
withholding or waiver has been authorized by the Franchise Tax
Board, attach a copy to this form.
For more information, contact the Franchise Tax Board:
Withholding Services and Compliance Section
P.O. Box 942867
Sacramento, CA 94267-0651
Telephone from within the U.S.: 1-888-792-4900
Telephone from outside the U.S.: 1-916-845-4900
Fax: (916) 845-9512 Email: wscs.gen@ftb.ca.gov
Foreign Individuals and Foreign Businesses
Federal tax withholding regulations differ significantly from California’s tax withholding requirements. A tax analysis is required and
all foreign individuals must complete the “Foreign National Data Collection Form” to determine U.S. residency status. Failure to
complete the form may require up to 30% federal tax withholdings from payment. For more information, refer to the IRS website for
nonresident withholding at http://www.irs.gov/Individuals/International-Taxpayers/NRA-Withholding.
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 Revenue and Taxation Code Section 18646, to facilitate tax
compliance enforcement activities and preparation of Form 1099 and other information returns as required by Internal Revenue Code
Section 6109(a). The TIN for individuals and sole proprietorships is their 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 is subject to withholding and state law imposes noncompliance penalties 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
SSU Accounts Payable at 707-664-3833.
Please call the Department of Finance, Fiscal Systems and Consulting Unit at (916) 324-0385 if you have any questions regarding this
Privacy Statement. All other questions should be referred to the requesting department listed in section 1.
VOLUNTARY STATISTICAL DATA SHEET
Information to be used for reporting purposes only
Public Contract Code 10111 requires state agencies to capture information on ethnicity, race and gender (ERG) of business owners on all
awarded contracts and procurements to the extent that the information has been voluntarily reported to the department. The awarding
department is prohibited from using this data to discriminate or provide a preference in the solicitation or acceptance of bids, quotes, or
estimates for goods, services, construction and/or information technology. This information shall not be collected until after the contract award
is made. The completion of this form is strictly voluntary.
The data you provide on this form should best describe the ownership of your business. Ownership of a business should be determined as
follows:
For a business that is an sole proprietorship, partnership, corporation, or joint venture at least 51 percent is owned by one or more
individuals in a classification designated below or, in the case of any business whose stock is publicly held, at least 51 percent of the
stock is owned by one or more individuals in a designated classification, or
For other business entities, the owner is the person controlling management and daily operations and who “owns” the business.
For purposes of this report, respond only if the business has its home office in the United States and which is not a branch or subsidiary of a
foreign corporation, firm, or other business.
Ethnicity/Minority Classification As defined in Public Contract Code Section 2051 (c)
Asian-Indian – a person whose origins are from India, Pakistan, or Bangladesh.
Black – a person having origins in any of the Black racial groups of Africa.
Hispanic – a person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish or Portuguese culture
or origin regardless of race.
Native American – an American Indian, Eskimo, Aleut, or Native Hawaiian.
Pacific Asian – a person whose origins are from Japan, China, Taiwan, Korea, Vietnam, Laos, Cambodia, the Philippines,
Samoa, Guam, or the United States Trust Territories of the Pacific including the Northern Marianas
Other – Any other group of natural persons identified as minorities in the respective project specifications of an awarding
department or participating local agency.
Race Classification As defined by the Office of Management and Budget, Federal Register Notice,
October 30, 1997, at http://www.whitehouse.gov/omb/fedref/1997standards.html
American Indian or Alaska Native Asian
Black or African American Native Hawaiian or Other Pacific Islander
Other White
Gender Classification
 Female Male
Sexual Orientation Classification As defined by Public Contract Code 10111(f)
Lesbian Bisexual
Gay Transgender
ITEMS BELOW TO BE COMPLETED BY STATE AGENCY/DEPARTMENT ONLY
 Goods Services Construction
Total Contract Purchase: ________________ Contract Award Date: ________________
DGS VSDS (Rev 12/12)
CSU Channel Islands Vendor Data Record (VDR) Complement Form Supplier#__________________
(Assigned by CSUCI)
This information is required from each
service provider/contractor/vendor doing business with the State of California.
The completed form must be on file
with
California State University Channel Islands prior to payment. Questions? Call (805) 437-8449.
PLEASE USE BLACK INK, PRINT OR TYPE
Send ORDERS to:
Company Name ___________________________________________
STREET/P.O. BOX ______________________________________________________________________________________
CITY, STATE, ZIP CODE _________________________________________________________________________________
AREA CODE AND PHONE _______________________________________________________________________________
SITE FAX (for FAX orders) ________________________________________________________________________________
SITE E-MAIL ___________________________________________________________________________________________
CONTACT NAME _______________________________________________________________________________________
CONTACT TITLE _______________________________________________________________________________________
CONTACT AREA CODE AND PHONE # (if different from site phone) ______________________________________________
Send PAYMENTS to:
STREET/P.O. BOX ______________________________________________________________________________________
CITY, STATE, ZIP CODE __________________________________________________________________________________
AREA CODE AND PHONE ________________________________________________________________________________
FAX # _________________________________________________________________________________________________
EMAIL _________________________________________________________________________________________________
CONTACT NAME ________________________________________________________________________________________
CONTACT TITLE ________________________________________________________________________________________
CONTACT AREA CODE AND PHONE _ (if different from site phone) _______________________________________________
CSUCI standard t
erms are Net 30 unless payment discount offered.
Payment Terms:____________________________________________
Ship Via: _________________________________________________
FOB:
Destination
Ship Point
Prepaid and Allowed
Freight Terms:
Prepaid and Add
Contractor's license classification: ____________________________
(Example: MasGnry, C-29)
(if class is Limited Specialty, C-61, specify specialty)
Briefly describe primary commodity, equipment or service offered:
(List
one only. Enclose product line card and catalogue CD if available.)
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________
________________
WEB Site Address: ___________________________________________________________
Send BIDS to:
STREET/P.O. BOX __________________________________________________________________________________________
CITY, STATE, ZIP CODE ____________________________________________________________________________________
SITE AREA CODE AND PHONE # ______________________________________________________________________________
FAX # (for bid) ______________________________________________________________________________________________
EMAIL ____________________________________________________________________________________________________
CONTACT NAME ____________________________________________________________________________________________
CONTACT TITLE _____________________________________________________________________________________________
CONTACT AREA CODE AND PHONE ____________________________________________________________________________
Check all that apply:
Supplier/Contractor is
certified in the following categories:
__
_Disabled Veteran Owned Business*
Must be certified through OSBCR; 51 % ownership and
10% service-related disability.
___
Small Business*
Must be certified by the State of California through OSBCR
* Attach Office of Small Business Certification and Resources
(OSBCR) certification letter (formerly OSMB).
Supplier provides
recycled products:
Compost and Co-Compost
Fine Printing and Writing Paper
Glass Products
Lubricating Oils
Paint
Emergency Resource Information: By providing the following information, supplier/contractor may be called upon to provide resources in the event of
a campus emergency or when the campus is designated a relief shelter for area residents by the County Emergency Services Depa
rtment. This data
is confidential and will only be used in time of extreme emergencies.
Contact (after business hours):___________________________________________________________
Relation to business: _____________________
(Example: owner partner, manager)
Residence Phon
e: _________________________________
Cellular Phone:____________________________________
Deliver to Emergency sites?
Yes
No
Emergency Resource Information will be updated annually.
Yes
No
Rev.3/17
Supplier/Contractor's endorsement on VDR Form 204 certifies that all information provided herein is correct. Supplier/Contractor is aware of Sect. 12650 et
seq, of the Government Code which imposes treble damages for false claims against the State, and Sect.
10115,10 of the Public Contract Code
making it
a crime for intentional untrue statements in this certification.
Paper Products
Plastics
Steel
Solvents
Tire-Derived Products
Tires
Accept return of unused supplies?
March 2017
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Ci 204 Vendorpayeedatarecordform 2017 (California State University Channel Islands)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document