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<br />STATE OF CALIFORNIA <br />PP,YEE [jATA RECORD <br />(Required in lieu of IRS W-9 when doing business with the State of California, <br />STD. 204 (REV 2-2000) <br /> <br />NOTE: Governmental entities, federal, state, and local (including school districts) are not required to submit this form. <br /> <br /> DE"A 'CE I PURPOSE: Information contained in this form will I <br />1 DEPARTMENT OF JUSTICE/OFFICE OF THE ATTORNEY GENERAL be used by state agencies to prepare Information <br /> STREET ADDRESS Returns (Forms 1099) and for withholding on payments <br /> PLEASE 1300 I STREET, 8TH FLOOR to nonresident payees. Prompt return of this fully <br /> RETURN CITY STATE ZIf' CODE completed form will prevent delays when processing <br /> TO: <br /> SACRAMENTO, CA 95814 ATTN: JOAN E. KIRTLAN payments, <br /> TElEPHONl::NUMBER (See Privacy Statement on reverse) <br /> (916) 322-5596 <br /> , , "ME <br />2 <br /> MAiliNG ADDRCSS (Numbor ~nd Simer or P 0 tk.. Numoerj <br /> rCily, Stille, and Zip Code; <br /> CHECK ONF BOX ONLY <br />3 NOTE: State and <br /> o LEGAL CORPORATION local governmental <br /> entities, including school <br /> VENDOR districts are <br /> ENTITY not required to <br />INFORMATION o MEDICAL CORPORATION o PARTNERSHIP submit this form <br /> o EXEMPT CORPORATION (Non-profit) o ESTATE OR TRUST <br /> o ALL OTHER CORPORATIONS NOTE: Payment <br /> FEDl::KAl EMPlOYFR'S IDENTIFICATION NUMIJI::R (FEIN) will not be <br /> processed without <br /> U ~ '=LLL.LL.LJ ~ an accompanying <br /> taxpayer 1.0. number <br /> o INDIVIDUAUSOLE PROPRIETOR <br /> SOr.IAl SECURITY NUMBE-k OF OWNER OWNER'S f-Ull NAME (Plint) <br /> U~J~~-.J-.J~-.J-.J-.J <br /> CHECK APPROI-'''IATf FlOX=S <br />4 NOTE: <br /> 0 California Resident - Qualified to do business in CA or a permanent place of business in a. An estate is a <br /> PAYEE CA resident if decedent <br /> was a California <br /> RESIDENCY resident at time of <br /> STATUS 0 Nonresident (See Reversa) Payments to nonresidents may be subject to state death <br /> withholding b. A trust is a resident <br /> o WAIVER or STATE WITHHOLDING FROM FRANCHISE TAX BOARD ATTACHED if at ieast one <br /> trustee is a <br /> o SERVICES PERFORMED OUTSIDE OF CALIFORNIA/GOODS ONLY SOLO TO CALIFORNIA California resident. <br /> (See reverse) <br />5 I hereby certify under penalty of perjury that the informatIon provided on this document is true and <br /> correct. If my residency status should change, I will promptly inform you. <br /> CERTIFYING AUTHORIZED PAYEEREPRES"N1AIIV~'SNAM:. [Type orPrinl) TITLE <br /> SIGNATURE <br /> SIGl"ATURF M" TElEPIIONENUM8Ei{ <br /> 1<<U , <br /> <br />SECTION 1 must be completed b~ the requestinq state agency before forwardinq to the payee <br /> <br />SlA I E OF CAliFORNIA <br />