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IWP 11FfrP DocuSign Envelope ID: 39D3416E-E2CB-4407-9A82-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) NAME (This is required. Do not leave this line blank. Must match the payee's federal tax return) City of Santa Ana 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) 20 Civic Center Plaza, M-13 CITY, STATE, ZIP CODE I E-MAIL ADDRESS Santa Ana. CA 92701 one ❑ SINGLE MEMBER LLC Disregarded Entity owned by an individual ❑ PARTNERSHIP ❑ ESTATE OR TRUST GURPORATION (see instructions on page 2) ❑ MEDICAL (e.g., dentistry, chiropractic, etc.) ❑ LEGAL (e.g., attorney services) ❑ EXEMPT (e.g., nonprofit) 0 ALL OTHERS 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 not have a separate FEIN. Those trusts must enter the individual grantor's SSN. • For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FT13 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. a. Federal Employer Identification Number (FEIN) 1111401019411111ft ❑ 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 El Copy of Franchise Tax Board waiver of state withholding is attached. I hereby certify under penalty of perjury that the information provided on this document is true and correct. Should mX residency status change, I will prompa notify the state agencV below. NAME OF AUTHORIZED PAYEE REPRESENTATIVE I TITLE I E-MAIL ADDRESS AT STATE AGENCY/DEPARTMENT OFFICE Ca. State Library MAILING ADDRESS 900 N Street Services Director DATE 11/21/2022 UNIT/SECTION kdmin/Accoutni FAX TELEPHONE (include area code) TELEPHONE (include area code) 916-603-7157 CITY ZIP COI CA STATE 195814 DE lac ounti a(a�IR Sacramento 'Ibrarv.ca.cov