Laserfiche WebLink
• <br /> STATE OF CALIFORNIA-DEPARTMENT OF FINANCE ��. i�i, Rd.,,.r ,I6�iCtthh <br /> PAYEE DATA RECORD <br /> (Required when receiving payment from the State of California In lieu of IRS W9 or W-7) <br /> STD 204(Rev.03/2021) <br /> 4 _ °2 d. 4d"tt �s1lSa"ra lk!'," ���,rr yy�;yr pp§§ �� r• ,.pyryY.:, (i"." :'°+:lrF' ,7,..!:.,1x & ,.rr':%I •7ia e�!'I:u'4*Harr , 7 'iI tl("tt(' �a TtYtj(I, i ' .+i 0 n.r.o. ' !9 t"S r.',:.r,?f <br /> NAME(This Is required.Do not leaveythls line blank. Must match the payee's federal tax return) 1 <br /> City of Santa Ana <br /> BUSINESS NAME,DBA 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 /> P.O. Box 1974 M-13 <br /> CITY,STATE,ZIP CODE EMAIL ADDRESS <br /> Santa Ana, CA 92702-1964 <br /> u6e,a , non+w <br /> Milit u§1a#itirt11.V4NV tS <br /> Check one(f)box only that matches the entity type of the Pa ee listed In Section 1 above, (See instructions on page 2) <br /> 0 SOLE PROPRIETOR I INDIVIDUAL CORPORATION(see Instructions on page 2) <br /> O SINGLE MEMBER LLC 0/sm gait/ed EntRy owned by an IndivIdual 0 MEDICAL(e.g.,dentistry,chiropractic,etc.) <br /> O PARTNERSHIP ❑LEGAL(e.g.,attorneysen/ices) <br /> ©ESTATE OR TRUST EXEMPT(e.g„nonprofit) <br /> 0 ALL OTHERS <br /> .' %f4,?.gI,ir' 'i:. - '':".uSect:ld s`tpr.'Tegflei9'ritlfIeat(oh.Hunter <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(1)TIN. Social Security Number(SSN)or <br /> The TIN Is a 9-digit number. Note: Payment will not be processed without a TIN. Individual Tax Identification Number(ITIN) <br /> • For Individuals,enter SSN. <br /> • <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 OR <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 Federal Employer Identification Number <br /> sole member is an individual,enter SSN(ITIN If applicable)or FEIN(FTB (FEIN) <br /> prefers SSN). 9 5 . 6 0 0 0 7 8 5 <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 FEIN. • <br /> :r RrkM'r , ri) v i' . . ill ;, i a 1...:}.,.,:.w`,.a,� ,.,d,`�.id:..a. , . I ^.y'814,f�n;,�.� �ay�t3;r,ftesidPrnCr�.xS.ttltu$.(S2einstl'U.cdOfis} <br /> I CALIFORNIA RESIDENT-Qualified to do business in California or maintains a permanent place of business In California. • <br /> • <br /> 0 CALIFORNIA NONRESIDENT-Payments to nonresidents for services may be subject to state income tax withholding. <br /> ONo services performed in California <br /> CJCopy of Franchise Tax Board waiver of state withholding is attached. <br /> linCia'rl gaigs, " a, --yrk•w�. E.!titetioltiOR +w .}i vx 3to,}'gi�t'ai s„cv.r qr 1 3`� @y <br /> }d��� '34�NdV�i�.ai } ���ik N FY,Sr_kl��.�tIQAIP.L,t rrR.�t..} ...i3.ur� n3ib i�� <br /> I hereby certify under penalty of perjury that the information provided on this document Is true and correct. <br /> Should my residency status change,I will promptly notify the state gooney below. <br /> NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS <br /> Deborah Sanchez Econ. Dev. Spec. IIi dsanchez@santa-ana.org <br /> SIGNATURE Na�awo�o•asA a e DATE TELEPHONE(include area code) <br /> ee�v <br /> Deborah Sanchez Oentenenszatonet.o,ga 08/28/2024 714-565-2621 <br /> 2ar. F ' �' 11710.6�PaVint°w�trz�d 4: hJ sI• <br /> �.a:.�es �,5: ., � r.. 9$ta��lt1'���1C.Yaxs <br /> Please return completed form to: <br /> STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION <br /> Department of Rehabilitation <br /> MAILING ADDRESS FAX TELEPHONE(include area code) <br /> • <br /> CITY STATE ZIP CODE E-MAIL ADDRESS <br />