Fillable Vendor 204 And Erg Form (California State University Channel Islands)

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Vendor 204 And Erg Form (California State University Channel Islands)

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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):
-
-
-
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)
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Vendor 204 And Erg Form (California State University Channel Islands)

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Completed 18 July 2020

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