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Print Form Reset Form DocuSign Envelope_ ID: 39D3416E-E2CB-4407-9A_82-AOF316B701C9 PAYEE DATA RECORD (Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021) Section 1 — Payee Information NAME (This is required. Do not leave this line blank. Must match the payee's federal tax return) BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above) MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2) CITY, STATE, ZIP CODE E-MAIL ADDRESS Section 2 — Entity Type Check one 1 box only that matches the entity type of the Pa ee listed in Section 1 above. See instructions on page 2 ❑ SOLE PROPRIETOR / INDIVIDUAL CORPORATION (see instructions on page 2) ❑ SINGLE MEMBER LLC Disregarded Entity owned by an individual ❑ MEDICAL (e.g., dentistry, chiropractic, etc.) ❑ PARTNERSHIP ❑ LEGAL (e.g., attorney services) ❑ ESTATE OR TRUST ❑ EXEMPT (e.g., nonprofit) ❑ ALL OTHERS Section 3 — Tax Identification Number Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN. Social Security Number (SSN) or The TIN is a 9-digit number. Note: Payment will not be processed without a TIN. Individual Tax Identification Number (ITIN) • For Individuals, enter SSN. • If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN. • Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may OR not have a separate FEIN. Those trusts must enter the individual grantor's SSN. p g ( g y), in which the • For Sole Proprietor or Single Member LLC (disregarded entity), Federal Employer Identification Number sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB (FEIN) prefers SSN). • For Single Member LLC (disregarded entity), in which the sole member is a — — — — — — — — — business entity, enter the owner entity's FEIN. Do not use the disregarded entity's FEIN. • For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity's FEIN. Section 4 — Payee Residency Status (See instructions) ❑ CALIFORNIA RESIDENT — Qualified to do business in California or maintains a permanent place of business in California. ❑ CALIFORNIA NONRESIDENT — Payments to nonresidents for services may be subject to state income tax withholding. ❑No services performed in California ❑Copy of Franchise Tax Board waiver of state withholding is attached. Section 5 — Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct. Should my residency status change, I will promptly notify the state agency below. NAME OF AUTHORIZED PAYEE REPRESENTATIVE I TITLE SIGNATURE E-MAIL ADDRESS DATE I TELEPHONE (include area code) Section 6 — Paying State Agency Please return completed form to: STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION Ca. State Library Admin/Accoutning MAILING ADDRESS FAX TELEPHONE (include area code) 900 N Street6-603-71.97 CITY ATE ZIP Sacramento v"Y vvU"v" ICAI958 4 DE c oA ting@Rbrary.ca.gov 'v"v"