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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. 204 (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 processing payments. Information provided in <br /> this form will be used by Stale agencies to prepare Information Returns (1099). See reverse side for more information and Privacy <br /> Statement. <br /> NOTE: Governmental entities, federal, State, and local (includi school districts), are not required to submit this form. <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 /> <br /> <br /> ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): I I I- I I I I I NOTE: <br /> <br /> D Payment will not <br /> Q PARTNERSHIP CORPORATION: be processed <br /> PAYEE ? MEDICAL (e.g., dentistry, psychotherapy, chiropractic, eta) without an <br /> ENTITY Q ESTATE OR TRUST ? LEGAL (e.g., attorney services) accompanying <br /> TYPE ? EXEMPT (nonprofit) taxpayer 1. D. <br /> ? ALL OTHERS number. <br /> CHECK <br /> ONE BOX 0 INDIVIDUAL OR SOLE PROPRIETOR 1 I I_ I 4 <br /> ONLY ENTER SOCIAL SECURITY NUMBER: 1 1 I t <br /> SSN required authority of California Revenue and Tax Code Section 1B846 <br /> Q Califomia resident - Qualified to do business in California or maintains a permanent place of business in California. <br /> Q Califomia 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 /> 151 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) TIT LE <br /> SIGNATURE DATE TELEPHONE <br /> Please return completed form to: <br /> Department/Office: <br /> <br /> Unit/Section: <br /> Mailing Address: <br /> <br /> City/State/Zip: <br /> Telephone: Fax: L_) <br /> E-mail Address: <br /> <br /> <br /> <br /> <br /> <br /> <br /> 55B-41 <br />