Item 11 - FY 22-23 Zip Books Program Grant

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STATE OF CALIFORNIA – DEPARTMENT OF FINANCE 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 Payee listed in Section 1 above. (See instructions on page 2) CORPORATION (see instructions on page 2)☐ SOLE PROPRIETOR / INDIVIDUAL ☐ MEDICAL (e.g., dentistry, chiropractic, etc.)☐ SINGLE MEMBER LLC Disregarded Entity owned by an individual ☐ PARTNERSHIP ☐ ESTATE OR TRUST ☐ LEGAL (e.g., attorney services) ☐ 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. The TIN is a 9-digit number. Note: Payment will not be processed without a TIN. • • • • • • 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 (FTB 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. Social Security Number (SSN) or Individual Tax Identification Number (ITIN) ___ ___ ___ -___ ___ -___ ___ ___ ___ OR Federal Employer Identification Number (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 TITLE E-MAIL ADDRESS SIGNATURE DATE TELEPHONE (include area code) Section 6 – Paying State Agency Please return completed form to: STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION MAILING ADDRESS FAX TELEPHONE (include area code) CITY STATE ZIP CODE E-MAIL ADDRESS Print Form Reset FormDocuSign Envelope ID: 39D3416E-E2CB-4407-9A82-A0F316B701C9 Ca. State Library Sacramento 916-603-7157900 N Street Admin/Accoutning 95814 accounting@library.ca.govCA In Process