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STATE OF CALIFORNIA DEPARTMENT OF FINANCE <br />PAYEE DATA RECORD <br />(Required when receiving payment from the State of California in lieu of IRS W-9) <br />STD. 264 (Rev. 6-2003) <br /> <br />INSTRUCTIONS: Complete all information on this form. Sign, date, and return to me mate agency taeF??unonvvnn o/ o??,?„ - <br />completed form will prevent delays when prooessing payments. Information provided in <br />t return of this full <br />Prom <br />e <br />f thi <br />b <br />tt <br />y <br />. <br />p <br />om o <br />s pag <br />o <br />the <br />this form will be used by State agencies to prepare Information Returns (1099).. See reverse side for more information and Privacy <br />Statement. <br />NOTE: Governmental entities, federal, State, and local (including school districts), are not r uired to submit this fort. <br /> PAYEE'S LEGAL BUSINESS NAME (Type or Print) <br />a SOLE PROPRIETOR - ENTER NAME AS SHOWN ON SSN (Last, First, M.I.) E-MAIL ADDRESS <br /> MAILING ADDRESS BUSINESS ADDRESS <br /> CITY, STATE, ZIP CODE CITY, STATE, ZIP CODE <br /> ENTER FEDERAL. EMPLOYER IDENTIFICATION NUMBER (FEIN): I I I -III I I I I I NOTE: <br />? Payment will not <br /> [] PARTNERSHIP CORPORATION: be processed <br />without an <br />PAYEE ? MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.) accompanying <br />ENTITY ESTATE OR TRUST ? LEGAL (e.g., attorney services) <br />Q taxpayer I.D. <br />TYPE D EXEMPT (nonprord) number, <br /> ? ALL OTHERS <br />CHECK <br /> <br />ONE BOX l <br />0 INDIVIDUAL OR SOLE PROPRIETOR <br />I I I I -I I I ^ I I I i <br />ONLY <br />ENTER SOCIAL SECURITY NUMBER: <br /> SSN required authority of Califomia Revenue and Tax Code Section 19846 <br /> California resident - Qualified to do business in California or maintains a pemtanent place of business in California. <br /> 0 California nonresident (see reverse side) - Payments to nonresidents for services may be subject to State income tax <br />PAYEE withholding. <br />RESIDENCY ? No services performed in California. <br />STATUS ? Copy of Franchise Tax Board waiver of State withholding attached. <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 agency below. <br /> AUTHORIZED PAYEE REPRESENTATIVE'S NAME (Type or Print) TITLE <br /> SIGNATURE DATE TELEPHONE <br /> Please return completed form to: <br />a Department/Office: <br /> UniVSection: <br /> Mailing Address: <br /> C itylStatelZip: <br /> Telephone: ___) Fax: (_) <br /> E-mail Address: <br />55A-41