Equipment/Supplies Prizes/Awards Interest Attorney Fees
Non-Med Services Rent Travel Reimb Legal Settlement
Medical Services Royalties Other
Authorized Payee Representative’s Name Title
Signature Date Telephone Number
All payments made by the university are subject to federal and California state tax laws.
Is the payee or the beneciary of the payment a U.S. citizen or permanent resident
alien? (Applies to all payees)
Yes No
(If No, you must contact Accounts Payable for further information)
California state tax withholding status (applies to all payees)
California Resident
(Qualied to do business in CA or a permanent place of business in CA)
Nonresident (See Reverse)
Payments to nonresidents for services may be subject to state withholding.
Waiver of state withholding from Franchise Tax Board attached
Services performed outside of California/goods only sold to California
Federal income tax withholding status (applies to individuals only)
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
If you use your Social Security / ITIN number to le your individual/business taxes:
Social Security / ITIN Number:
Individual/Sole Proprietor
If you use a business tax I.D. number to le your business taxes:
Federal Tax Identication Number (TIN):
Exempt Corporation Medical Corporation
Legal Corporation
(Attorney / Law Firm)
Estate Or Trust All Other Corporations
For Business: Payee’s Legal Business Name
For 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
Partnership/Limited Liability Company
State ZIP Phone Number
Payee Data Record
page 1
Required in lieu of IRS W-9 Form and State of California Form 204 when conducting business with Chico State Enterprises and University
Foundation.
PURPOSE: Information contained in this form will be used 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 page 2 for more
information and privacy statement)
Updated July 2015
PAYEE INFORMATION
PAYMENT TYPE
Select applicable classication.
PAYEE ENTITY AND
TAX I.D. NUMBER (TIN)
Payment will not be processed
without an accompanying
taxpayer I.D. number.
PAYEE RESIDENCY
DECLARATION
CERTIFYING
SIGNAT
URE
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.
CHICO STATE ENTERPRISES
25 Main Street
Chico, CA 95928-5388
www.csuchico.edu/cse
530-898-6811 (phone)
530-898-6021 (fax)
University Foundation
C/O Chico State Enterprises
25 Main Street
Chico, CA 95928-5388
ARE YOU A RESIDENT OR NONRESIDENT?
Each corporation, individual/sole proprietor, partnership,
estate or trust doing business with the CSU, Chico Research
Foundation or University Foundation must indicate their
residency status along with their taxpayer identication
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 qualied to transact intrastate
business. A corporation that has not qualied 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 ofce 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 indenite 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
FOREIGN CITIZENS and FOREIGN BUSINESSES
Federal tax withholding regulations differ signicantly 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 address below. A waiver
will generally be granted when a payee has a history of ling
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.
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 Identication 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 31% 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 telephone numbers listed above; all other questions should be referred
to the requesting agency listed in Section 1.
Payee Data Record
page 2
Updated July 2015
CHICO STATE ENTERPRISES
25 Main Street
Chico, CA 95928-5388
www.csuchico.edu/cse
530-898-6811 (phone)
530-898-6021 (fax)
University Foundation
C/O Chico State Enterprises
25 Main Street
Chico, CA 95928-5388