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EXHIBIT 1 <br />1?55:'t'!`tlllt <br />STATE OF CALIFORNIA--DEPARTMENT OF FINANCE <br />PAYEE DATA RECORD <br />(Required when receiving payment from the State of Californla In lieu of IRS W'-® orW' 7) <br />STD 204 (Rev. 0312021) <br />.r:,:j <br />-;r"'A<.:.:' <br />NAME (This Is required. Do not leave lhls line blank. Must match the payee's federal tax return) <br />I3USINESS NAME, DSA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above) <br />MAILING ADDRESS (number, street, apt. or suite no,) (See Instructions on Page 2) <br />CITY, STATE, ZIP CODE <br />E-MAIL ADDRESS <br />Check one f box only that matches the Gntltr type of the AaYee listed In Section 1 above. See Instructions on page 2 <br />❑ SOLE PROPRIETOR l INDIVIDUAL CORPORATION (see instructions on page 2) <br />❑ 81NGLE MEMBER LLC Disregaided Entltyowned byanindivldual ❑ MEDICAL (e.g., dentistry, chiropractic, etc.) <br />❑ PARTNERSHIP ❑ LEGAL (e.g., atfornoysorvk9s) <br />❑ ESTATE OR TRUST ❑ EXEMPT (e.g,, mnproflp <br />❑ ALL OTHERS <br />Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must <br />match the name given in Section 1 of this form. Do not provide more than one (t) TIN. <br />The TIN is a 0-digit number. Note: Payment will not be processed without a TIN. <br />• For Individuals, enter SSN. <br />• If you are a Resident Alien, and you do not have and are not eligible to get an <br />SSN, enter your ITIN. <br />• Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may <br />not have a separate FEIN. Those trusts must enter the individual grantor's SSN. <br />• For Sole Proprietor or Single Member LLC (disregarded entity), in which the <br />sole-m em b efl"n-Individual—enter-GSN-(I-TIN-if-appi icabl e)-orFEI N-(F-TB <br />prefers SSN). <br />• For Single Member LLC {disregarded entity), In which the sole member is a <br />business entity, enter the owner entity's FEIN. Do not use the disregarded <br />entity's FEIN. <br />• For all other entities including LLC that is taxed as a corporation or partnership, <br />estates/trusts (with FEINs), enter the entity's FIE IN. <br />Social Security Number (SSN) or <br />Individual Tax Idonttfication Number (ITIN) <br />OR <br />Federal Employer Identification Number <br />0 CALIFORNIA RESIDENT -- Qualified to do business In California or maintains a permanent place of business In California. <br />❑ CALIFORNIA NONRESIDENT — Payments to nonresidents for services may be subject to state income tax withholding. <br />[-]No services performed In California <br />❑ Copy of Franchise Tax Board waiver of state withholding is attached. <br />1 hereby certify under penalty of perjury that the lnforrnation provided on this document is true and correct. <br />Should my residency status change, 1 will Prompt& notify the state acrencv below. <br />NAME OF AUTHORIZED PAYEE REPRESENTATIVE <br />SIGNATURE <br />STATE AGENCYIDEPARTMENT OFFICE <br />MAILING ADDRESS <br />TITLE I E-MAIL ADDRESS <br />DATE I TELEPHONE (Include area code) <br />UNIT1SEgCTION <br />FAX I TELEPHONE (Include area code) <br />CITY I STATE I ZIP CODE I i -MAIL ADDRESS <br />