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MAYOR <br />Miguel A. Pulido <br />MAYOR PRO TEM <br />Michele Martinez <br />COUNCILMEMBERS <br />P. David Benavides <br />Vicente Sarmiento <br />Jose Solorio <br />Sal Tinajero <br />Juan Vlllegas <br />CITY OF SANTA ANA <br />FINANCE AND MANAGEMENT SERVICES AGENCY <br />Purchasing Division <br />20 Civic Center Plaza Santa <br />Ana, California 92701 <br />Phone: 714-647-6941 Fax: 714-647-6944 <br />Vendor Information Form <br />CITY MANAGER <br />Raul Godlnez <br />CITY ATTORNEY <br />Sonia R. Carvalho <br />CLERK OF THE COUNCIL <br />Maria D. Hulzar <br />The Tax Equity & Fiscal Responsibility Act of 1982 and Backup withholding Regulations of 1983 require <br />us to have a Social Security or Federal Tax Identification Number (TIN) on file for all vendors subject to <br />form 1099 reportable payments. Please print, sign and return this form, along with your completed and <br />signed W-9 (attached). <br />Business Name I Benefit Administrative Services International Corporation <br />DBA (if applicable) I BASIC <br />Purchase -From Address <br />9246 Portage Industrial Dr. <br />Portage, MI 49024 <br />Remit -To Address <br />PO Box 775339 <br />Chicago, IL 60677-5339 <br />Phone Fax Pa ment Terms <br />269-569-4159 269-327-4996 Net 15 <br />Email <br />dgeorge@basiconline.com <br />Web Address <br />https://www.basi-e-o-niine.-c-om <br />Sign Here Title <br />2oJ% Regional Sales Director <br />