1-7. Submittal Form- Vendor Set Up Form 2024-06-27 .pdf
PDF 8 MB Posted
- Attached to
- UDOT Region 2 Temporary Traffic Control
- Solicitation number
- UDOT260175CN -
- Issued by
- Utah
About this file
This is a Vendor/Customer Creation and Modification Form (FI170) for the State of Utah, specifically related to the Utah Department of Transportation (UDOT) Region 2 Temporary Traffic Control solicitation (UDOT260175CN). The form is designed to establish or update vendor profiles in the State's accounting system to enable payment processing and billing transactions. Vendors completing this form must provide comprehensive business information including legal name, Doing Business As (DBA) name, organization type, Tax Identification Number (TIN), multiple addresses for payment, billing, and ordering purposes, primary contact information, and preferred payment method. The associated contract opportunity is an Invitation for Bid (IFB) issued by UDOT Procurement Services Division for providing Temporary Traffic Control services in Region 2, which may result in a five-year contract with potential primary and secondary awards covering multiple counties across three designated areas.
Vendors must attest that all information provided is accurate and authorize their use by the State of Utah and other state agencies for payment processing, invoicing, and IRS 1099 reporting purposes. The form requires vendors to specify their organization structure (sole proprietor, C-Corporation, S-Corporation, Partnership, Trust/Estate, or LLC), indicate whether they currently hold an active contract with the State, and disclose any current retirement benefits received from Utah Retirement Systems (URS). Vendors may elect to receive payments via Electronic Funds Transfer (EFT), check, or PayPlus virtual card. The form also includes verification of citizenship status through FATCA exemption certification and requires vendors to acknowledge data sharing practices with financial institutions and the IRS. No specific pricing information, set-aside requirements, or funding amounts are detailed in this vendor setup documentation, as it serves solely as an administrative registration tool for qualified bidders on the UDOT Region 2 contract opportunity.
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Other files
| File | Type | Posted |
|---|---|---|
| 4-Attachment C Cost submittal-Temporary Traffic Control Services UDOT Region Two.xlsx | XLSX spreadsheet | |
| 2-Agency-Contract-GoodsServices-Combined-9.16.24 (2).docx | DOCX document | |
| 3-Attachment B ScopeTemporary Traffic Control-.docx | DOCX document |
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Text version
Creation
Modification
VENDOR/CUSTOMER CREATION/MODIFICATION
Note: Some features may not work when completing the form in the browser. Please download forms to a PDF before entering information. All forms are downloadable PDFs.
Vendor
Customer
No Yes
Address Information
Address 1 City, State, ZIP Address Type Payment Billing Ordering
Payment Billing Ordering
Address 2 City, State, ZIP Address Type Address 3 City, State, ZIP Address Type Payment Billing Ordering Contact
Email Primary Contact Phone Number Email for EFT Remittance, if applicable
Attestation
All of the information contained in this form is true and accurate to the best of my knowledge. I hereby certify that I am an authorized representative of the business and am acting in that authority and on behalf of the vendor listed above.
You are asked to provide this information to generate a valid profile in the State's Accounting system so agencies of the State can create payments or billing requests for your business.
Intended Uses of the Information The State of Utah will use this information to create a profile in our accounting system so payment or invoices can be made for your business.
Consequences for Refusing to Provide the Information
Failure to provide the requested information will prevent your profile from being valid and payment/invoices will not be generated resulting in loss of income or other collection methods to be used
Data Sharing
This information may be shared with other State Agencies to allow transactions to be processed. This information may be shared with financial institutions to generate payment and the IRS to record 1099 reporting
Preferred Payment Method EFT Check
TIN Type
Legal/Individual Name DBA if Applicable Does the Vendor have an Active Contract? Yes Tax Reporting
No If yes, enter a contract number
Tax ID Number (TIN) Organization Type
1099 Classification 1099 Reportable
Reason for Data Collection
Notice of Personal Information Data Collection UCA 63G-2-601(2)
The data collected by this form is part of record series VEND/CUST FINET, FINET Vend Cust Table, 30547 and 30546
Signature DateSigner Name
Agency Information
Agency Contact
Department Name
Department Number
URS Attestation
Is the vendor currently receiving retirement benefits from Utah Retirement Systems (URS)?
(UCA 49-11-12 Post Retirement Reemployment Restrictions Act)
PaymentPlus (Virtual Card)*If Selected Complete Form FI 171 tadarrington Underline tadarrington Underline tadarrington Underline tadarrington Line tadarrington Line
| Vendor Creation Modification Form FI170.pdf |
| W-9.pdf |
| Select One:: Yes |
| Title: |
| Button: |
| Clear: |
| Contact Phone: |
| E-Mail Address: |
| Generic Email: |
| Date28_af_date: |
| Vendor: Yes |
| Customer: Off |
| No: Yes |
| Yes: Off |
| Check: Off |
| PayPlus: Off |
| Payment: Off |
| Billing: Off |
| Ordering: Off |
| Date3_af_date: |
| Sig Name: |
| Agency Contact: Mark R Parry |
| Department Name: UDOT Procurement |
| Department Number: 810 |
| Legal Name: |
| Registered DBA: |
| Individual/Sole Prop: Off |
| C Corp: Off |
| S Corp: Off |
| Partnership: Off |
| Trust/Estate: Off |
| LLC: Yes |
| LLC Type: |
| Other: Off |
| Other Text: |
| Foreign Partners: Off |
| Exempt Payee: |
| FATCA: |
| IRS Address: |
| IRS City, State, ZIP: |
| Acct Numbers: |
| Requestor Name/Add: |
| SSN1: |
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| EFT: Off |
| Contract Yes: Off |
| Contract No: Off |
| Entity: |
| DBA: |
| Contract Numbers: |
| Organization Type: [ ] |
| TIN Type: [ ] |
| TIN: |
| 1099 Classification: [ ] |
| 1099 Reportable: [ ] |
| Address 1: |
| Address 1 City, State, Zip: |
| Address 2: |
| Address 2 City, State, ZIP: |
| Address 3: |
| Address 3 City, State, ZIP: |
| Contact Name: |
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