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<br /> <br /> <br /> 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 /> INSTRUCTIONS: Complete all information on this form. Sign, date, and return to the State agency (department/office) address shown at <br /> the bottom of this page. Prompt return of this fully completed form will prevent delays when prooessing payments. Information provided In <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 aired 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 BU51NES5 ADDRESS <br /> <br /> CITY, STATE, ZIP CODE CITY, STATE, ZIP CODE <br /> <br /> <br /> [3] 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 /> PAYEE ? MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.) without an <br /> ENTITY Q accompanying <br /> ESTATE OR TRUST ? LEGAL (e.g., attorney services) taxpayer I.D. <br /> TYPE D EXEMPT (nonprord) number, <br /> ? ALL OTHERS <br /> CHECK l <br /> ONE BOX 0 INDIVIDUAL OR SOLE PROPRIETOR <br /> I I I I -I I I ^ I I I i <br /> ONLY <br /> ENTER SOCIAL SECURITY NUMBER: SSN required authorhy 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 <br /> I hereby certify under penalty of perjury that the information provided on this document is hue 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 /> CitylStatelZip: <br /> Telephone: Fax: O <br /> E-mail Address: <br /> <br /> <br /> <br /> <br /> <br /> 55A-41 <br />