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<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)
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<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
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<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
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<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. •
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<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.
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<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
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