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Docusign Envelope ID:AA62266B-55B0-4103-ACBB-2EE04A18A333
<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 03/2021)
<br /> GENERAL INSTRUCTIONS
<br /> Type or print the information on the Payee Data Record,STD 204 form. Sign,date,and return to the state agency/department office address shown in Section 6.
<br /> Prompt return of this fully completed form will prevent delays when processing payments.
<br /> Information provided in this form will be used by California state agencies/departments to prepare Information Returns(Form1099).
<br /> NOTE:Completion of this form is optional for Government entities,i.e.federal,state,local,and special districts.
<br /> A completed Payee Data Record,STD 204 form,is required for all payees(non-governmental entities or individuals)entering into a transaction that may lead to a
<br /> payment from the state.Each state agency requires a completed,signed,and dated STD 204 on file:therefore,it is possible for you to receive this form from
<br /> multiple state agencies with which you do business.
<br /> Payees who do not wish to complete the STD 204 may elect not to do business with the state.If the payee does not complete the STD 204 and the required
<br /> payee data is not otherwise provided,payment may be reduced for federal and state backup withholding.Amounts reported on Information Returns(Form 1099)
<br /> are in accordance with the Internal Revenue Code(IRC)and the California Revenue and Taxation Code(R&TC).
<br /> Section 1 -Payee Information
<br /> Name—Enter the name that appears on the payee's federal tax return. The name provided shall be the tax liable party and is subject to IRS TIN matching(when
<br /> applicable).
<br /> • Sole Proprietor/Individual/Revocable Trusts—enter the name shown on your federal tax return.
<br /> • Single Member Limited Liability Companies(LLCs)that is disregarded as an entity separate from its owner for federal tax purposes-enter the name of the
<br /> individual or business entity that is tax liable for the business in section 1. Enter the DBA,LLC name,trade,or fictitious name under Business Name.
<br /> • Note:for the State of California tax purposes,a Single Member LLC is not disregarded from its owner,even if they may be disregarded at the Federal level.
<br /> • Partnerships,Estates/Trusts,or Corporations—enter the entity name as shown on the entity's federal tax return. The name provided in Section 1 must match
<br /> to the TIN provided in section 3. Enter any DBA,trade,or fictitious business names under Business Name.
<br /> Business Name—Enter the business name,DBA name,trade or fictitious name,or disregarded LLC name.
<br /> Mailing Address—The mailing address is the address where the payee will receive information returns. Use form STD 205, Payee Data Record Supplement
<br /> to provide a remittance address if different from the mailing address for information returns,or make subsequent changes to the remittance address.
<br /> Section 2-Entity Type
<br /> If the Payee in Section 1 is a(n)... THEN Select the Box for...
<br /> Individual•Sole Proprietorship•Grantor Revocable Living)Trust disregarded for federal tax purposes Sole Proprietor/individual
<br /> Limited Liability Company LLC owned by an individual and is disregarded for federal tax purposes Single Member LLC-owned by an individual
<br /> Partnerships• Limited Liability Partnerships LLP •and,LLC treated as a Partnership Partnerships
<br /> Estate•Trust other than disregarded Grantor Trust Estate or Trust
<br /> Corporation that is medical in nature(e.g., medical and healthcare services,physician care, nursery Corporation-Medical
<br /> care,dentistry,etc. • LLC that is to be taxed like a Corporation and is medical in nature
<br /> Corporation that is legal in nature(e.g..services of attorneys,arbitrators,notary publics involving legal Corporation-Legal
<br /> or law related matters,etc.) • LLC that is to be taxed like a Corporation and is legal in nature
<br /> Corporation that qualifies for an Exempt status,including 501 c 3 and domestic non-profit corporations. Corporation-Exempt
<br /> Corporation that does not meet the qualifications of any of the other corporation types listed above•LLC Corporation-All Other
<br /> that is to be taxed as a Corporation and does not meet any of the other corporation types listed above
<br /> Section 3-Tax Identification Number
<br /> The State of California requires that all parties entering into business transactions that may lead to payment(s)from the state provide their Taxpayer
<br /> Identification Number(TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of
<br /> Form 1099 and other information returns as required by the IRC section 6109(a)and R&TC section 18662 and its regulations.
<br /> Section 4-Payee Residency Status
<br /> Are you a California resident or nonresident?
<br /> • A corporation will be defined as a"resident"if it has a permanent place of business in California or is qualified through the Secretary of State to do business in
<br /> California.
<br /> • A partnership is considered a resident partnership if it has a permanent place of business in California.
<br /> • An estate is a resident if the decedent was a California resident at time of death.
<br /> • A trust is a resident if at least one trustee is a California resident.
<br /> o For individuals and sole proprietors,the term"resident"includes every individual who is in California for other than a temporary or transitory purpose and
<br /> any individual domiciled in California who is absent for a temporary or transitory purpose. Generally,an individual who comes to California for a purpose
<br /> that will extend over a long or indefinite period will be considered a resident. However,an individual who comes to perform a particular contract of short
<br /> duration will be considered a nonresident.
<br /> For information on Nonresident Withholding,contact the Franchise Tax Board at the numbers listed below:
<br /> Withholding Services and Compliance Section: 1-888-792-4900 E-mail address:wscs.gen@ftb.ca.gov
<br /> For hearing impaired with TDD,call: 1-800-822-6268 Website:www.ftb.ca.gov
<br /> Section 5-Certification
<br /> Provide the name,title,email address,signature.and telephone number of individual completing this form and date completed. In the event that a SSN or ITIN is
<br /> provided,the individual identified as the tax liable party must certify the form. Note:the signee may differ from the tax liable party in this situation if the signee can
<br /> provide a power of attorney documented for the individual.
<br /> Section 6-Paying State Agency
<br /> This section must be completed by the state agency/department requesting the STD 204.
<br /> Privacy Statement
<br /> Section 7(b)of the Privacy Act of 1974(Public Law 93-579)requires that any federal.state,or local governmental agency,which requests an individual to
<br /> disclose their social security account number,shall inform that individual whether that disclosure is mandatory or voluntary,by which statutory or other authority
<br /> such number is solicited,and what uses will be made of it. It is mandatory to furnish the information requested. Federal law requires that payment for which the
<br /> requested information is not provided is subject to federal backup withholding and state law imposes noncompliance penalties of up to$20,000. You have the
<br /> right to access records containing your personal information,such as your SSN.To exercise that right,please contact the business services unit or the
<br /> accounts payable unit of the state agency(ies)with which you transact that business.
<br /> All questions should be referred to the requesting state agency listed on the bottom front of this form.
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