Financial Services
25800 Carlos Bee Blvd.
Hayward, CA 94542
Vendor Data Record
(Rev. 04-2017)
This form is required in lieu of IRS W-9 and State of California Form 204 when doing business with the State of California.
Government entities, federal, state and local (including school districts) are not required to submit this form.
Part I Vendor Business and Contact Information
1 Vendor Name (Sole Proprietor - Please Enter Owner's Full Name)
3 Address (number, street, and apt. or suite no.)
4 City, state, ZIP code and Country
5 Phone Number
6 Fax Number
7 Sales Personnel
8 Sales Personnel Email
9 Accounts Receivable Personnel 10 Accounts Receivable Personnel Email
11 Accepted Payment Methods (Check all that apply)
ACH Check Credit Card
12 Discount Offered for Prompt Payment?
Yes No
Payment Terms:
Part II Entity and Certification
1 Check appropriate box for federal tax classification; check only one of the following six boxes:
Individual/sole proprietor or single-member LLC
CorporationPartnership Trust/estate
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
Other (please specify)
2 Check appropriate box which best describes your primary business with CSU East Bay:
Other (please specify)
Legal Services
Legal Settlements
Medical Services
Services other than Medical
Prizes / Awards
Equipment / Supplies Royalties
3 Certification (Check if applicable)
OSDS Certification No.
CA Certified DVBE
CA Certified Small Business
CA Certified Micro Business
Part III Taxpayer Identification Number (TIN) Note: Payment will not be processed without an accompanying taxpayer I.D. number.
Federal Employer Identification Number
If vendor entity type is a corporation, partnership,
estate or trust, enter FEIN.
Social Security Number
If vendor entity type is individual or sole proprietor, enter SSN. Authority
of Revenue and Taxation Code Section 18646 (See Page 2)
Vendor Residency Declaration Note: All payments made by the University are subject to Federal and California state tax laws.Part IV
1 California State Tax Withholding Status (See Page 2 for instructions) (Applies to all vendors):
California Resident - Qualified to do business in CA or have a permanent place of business in CA
California Nonresident (Payments for services by nonresidents may be subject to state withholding)
A waiver of CA state tax withholding from the
California Franchise Tax Board (attached)
All services related to the payment were
performed outside of the state of California
2 Federal Income Tax Withholding Status (Applies to individuals only):
I am a US citizen
Tax exempt by tax treaty (check if applicable)
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 alien green card
Country of Residency
Note: All foreign citizens/entities must complete a tax analysis before payments can be made
Part V Certification
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.
Name Date
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2 Doing Business As (DBA)
Each corporation, individual/sole proprietor, partnership, estate or
trust doing business with the State of California must indicate
their residency status along with their vendor identification
A corporation will be considered a “resident” 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
For individuals/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.
For withholding purposes, a partnership is considered a 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 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 ……..1-916-854-6500
From hearing impaired with TDD, call …...1-800-822-6568
Payments made to nonresident vendors, including corporations,
individuals, partnerships, estates and trusts, are subject to income
tax withholding. 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
California tax withholding is required if total payments to the
vendor are $1500 or less for the calendar year.
A nonresident vendor may request that income taxes be withheld
at a lower rate or waived by sending a completed form FTB 587
to the address listed below. A waiver will generally be granted
when a vendor has a history of filling California returns and
making timely estimated payments. If the vendor 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
Withhold at Source Unit
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.
Federal tax withholding regulations differ significantly from
California tax withholding requirements. A tax analysis
consultation and additional forms may be required before a
payment can be released.
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. 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 business.
Please call the Department of Finance, Fiscal Systems and Consulting Unit at (916) 324-0385 if you have any questions regarding this Privacy
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 Part I.
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