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STATE OF CALIPORNIA OWARTMENT OF FINANCE <br />PAYEE DATA RECORD <br />(Required when receiving payment from the State of California In Ilou of II18 W 9 Or W-7) <br />STD 204 (Nov, 41207) <br />INSTRUOTIONS Type or print the Information. Complete all Information on this form. Sign, date, and return to the state <br />agency (department)office) address shown In Box 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 (FormI009). See next <br />page for more information and Privacy Statement. <br />NOTE: Governmental entitles, be, federal, state, and local (including school districts), are not required to subunit this form. <br />1''AYEE'"a LEOAL DUSiNESS NAME (As shown on yourhicomo, tax rehrm) <br />City of Santo Ana (Now Agreement No, 19-095) <br />SCALE pROPRIE'fOR Out INDIVIDUAL —ENTER NANIB AS StIOWN ON S5N (f.:asf, first, d91.) LK•MAIL ADDRESS <br />DustNESSADI"' <br />20 Civic Center Plaza <br />CITY..:.�,.�.., STATE-` ZIP CODE CITY STATE ZIPCODE <br />Santa Ana CA 92701r'„YXWW"y^ <br />_. <br />�y <br />`y <br />ENTER FEDERAL EMPLOYER WN11FICAT'ION NUMBER (PEIN): ��—�T�—_.L_J�._�.,,_� NOTE: <br />Payment will not <br />? PARTNERSHIP CORPORATION: be processed <br />PAYEE <br />ENTITY <br />MEDICAL (o.g, denpsrry, psychotherapy; ehkopracPo, ele.) without on <br />E5'rATiE on TRUST 0accompanying <br />TYPE <br />© LEGAL (o,g., alloweysen1aes) taxpayer <br />0 EXEMPT(nonpmfig Identification <br />CHECK <br />Q ALL OTHERS number. <br />ONEROx <br />ONLY <br />SOLB PROPRIETOR OR INDIVIDUAL �❑ I� - �� <br />Enter social security number(SSN) (SSN mqulmd hyaufhodlgofCe/Homfe Aevenae <br />or Individual taxpayer identification number (ITIN) and Tax Code sections 10640 and focal) <br />CALIFORNIA RESIDENT- Quallred to do business In California or maintains a pernamn it place of business in California, <br />0 CALIFORNIA NON RESIDENT (see noxt pope for mcro Inferina6an) - Payments to nonresidents for services may be subject <br />PAYEE <br />to state Income tax withholding. . <br />RESIDENCY <br />Q No services performed in California, <br />STATUS <br />Q Copy of Franchise Tax Board waiver of state withholding attochod, <br />I hereby certify under penalty of perjury that the Information provided on this document Is true and correct, T <br />Should my rosldoncy Status.eharige, I will prompilly notify the state agency below, <br />AUTnORIZED PAYEE REPRESENTATIV05 NAME (Typo orPrhrt) <br />TITLE <br />TELEPHONE (Include area code) <br />SIGNATURE <br />DATE <br />E-MAILIL AD�� — <br />Please return completed form tm <br />DEPARTMEW1OFFICE <br />UNITISECTION <br />Stale Coastal Conservanoy <br />Contraou'Unit <br />MAILING ADDRESS <br />TELEPHONE (Include area code) <br />FAX <br />1515 Clay Street, 10th rider <br />510-286-0515 <br />CITY <br />STATE <br />ZIP CODE <br />E-MAIL ADDRESS ._.��..........—, <br />Oaidond <br />CA <br />94612 <br />