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<br />Docus€gn Envelope ID: 8530CBCD-5AA1-4E36-B236-387775C6289D
<br />PAYEE DATA RECORD
<br />(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7)
<br />STD 204 (Rev. 0312021)
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<br />NAME (This Is required. Do not leave this line blank. Must Snatch the payee's federal tax return)
<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 />CITY, STATE, ZIP CODE
<br />E-MAIL ADDRESS
<br />Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2)
<br />❑ SOLE PROPRIETOR/ INDIVIDUAL
<br />CORPORATION (see instructions on page 2)
<br />❑ SINGLE MEMBER LLC Disregarded Entity owned by an individual
<br />❑ MEDICAL (e.g., dentistry, chiropractic, etc.)
<br />❑ PARTNERSHIP
<br />❑ LEGAL (e.g., attorney services)
<br />❑ ESTATE OR TRUST
<br />❑ EXEMPT (e.g., nonprofit)
<br />❑ 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.
<br />Social Security Number (SSN) or
<br />The TIN is a 9-digit number. Note: Payment will not be processed without a TIN,
<br />Individual Tax Identification Number (ITIN)
<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 />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
<br />Federal Employer Identification Number
<br />sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB
<br />(FEIN)
<br />prefers SSN).
<br />• For Single Member LLC (disregarded entity), in which the sole member is a
<br />-- -------
<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 />® 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 />I hereby certify under penalty of perjury that the information provided on this document is true and correct.
<br />Should mK residency status change, I will gromptly notIEL the state agency below.
<br />NAME OF AUTHORIZED PAYEE REPRESENTATIVE I TITLE I E-MAIL ADDRESS
<br />SIGNATURE
<br />Please return completed form to:
<br />DATE I TELEPHONE (include area code)
<br />STATE AGENCYIDEPARTMENT OFFICE UNITISECTION
<br />United States Admin/Accoutning
<br />MAILING ADDRESS FAX TELEPHONE (include area code)
<br />26 Civic Center Plaza 1 916-603-7157
<br />CITY STATE ZIP Sant Ana lCalifornia 192701oDE 1ac ou ti g@IRbrary.ca.gov
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