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STATE OF CALIFORNIA-DE.PARTMEN'r OF FINANCE <br />PAYEE DATA RECORD <br />(Required when receiving payment from the State of California in lieu of IRS W-g Or W-7) <br />STD 204 (Rev. 4/7.of7) <br />INSTRUCTIONS: Type or print the information. Complete all information on this form. Sign, date; and return to the state <br />agency (departmentloffice) address shown in Sox 6. Prompt return of this fully completed form will prevent delays when <br />processing payments. <br />Information provided in this form will be used by California state agencies to prepare Information Returns (Form1099). See next <br />page for more information and Privacy Statement. <br />NOTE: Governmental entities, i.e. federal, state, and local (including school districts), are not required to submit this form. <br />PAYEE'S LEGAL BUSINESS NAME (As shown on yourincome tax return). <br />City of Santa Ana (New Agreement No. 19-097) <br />SOLE PROPRIETOR tlR INDIVIDUAL— ENTER NAME AS SHOWN ON SSN (Last, First M i.) E MAIL ADDRESS . <br />MAILING ADDRESS BUSINESS ADDRESS - - <br />20 Civic Center Plaza <br />CITY STATE ZIP CODE -CITY STATE ZIP CODE <br />Santa Ana CA 92701 <br />3 <br />aB <br />ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): Cu_L1 — LT-Er_1_�L—� <br />NOTE: <br />PAYEE <br />PARTNERSIdIP CORPORATION; - - <br />Payment will not <br />be. processed <br />ENTITY <br />ESTATE OR TRUST O MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.) <br />without an <br />TYPE <br />Q LEGAL (e.g., attorneye <br />accompanying <br />0 EXEMPT (nonprofit) <br />taxpayer <br />Identification <br />CHECK <br />- 0 ALL OTHERS - <br />number. <br />ONEBOX <br />ONLY <br />SOLE PROPRIETOR OR INDIVIDUAL <br />- <br />Enter social security number (SSN) (SSN required by authontntyy of Cafiromia Revenue-1 <br />or Individual taxpayer identification number (ITIN) <br />and Tex Code sections 18646 and 18661) <br />CALIFORNIA RESIDENT - Qualified to do business in California or maintains a permanent place of business in California. <br />CALIFORNIA NON RESIDENT (see nextpage formars information) - Payments to no for sevices may be subject <br />PAYEE <br />to state income tax withholding. <br />RESIDENCY <br />O No services performed in California <br />STATUS <br />O Copy of Franchise Tax Board waiver of state withholding attached. <br />I hereby certify under penalty of perjury that the information provided on this document is true and correct. <br />5 <br />Should my residency status change, I will promptly notify the state agency below. <br />AUTHORIZED PAYEE REPRESENTATIVE'S NAME (Type or Print) <br />TITLE <br />TELEPHONE (include area code) <br />SIGNATURE <br />DATE <br />E-MAILADDRESS <br />Please return completed form to: <br />DEPARTMENT/OFFICE <br />UNIT(SECTION <br />State Coastal Conservancy <br />Contracts Unit <br />MAILING ADDRESS <br />TELEPHONE (include area code) <br />FAX <br />1515 Clay Street, 10th Floor <br />510-286_0515 <br />CITY <br />E-MAIL ADDRESS <br />Oakland <br />=A94 <br />