1-7. Submittal Form- Vendor Set Up Form 2024-06-27 .pdf
PDF 8 MB Posted
- Attached to
- UDOT Liquid Asphalt Oil Region 1
- Solicitation number
- UDOT260201CN
- Issued by
- Utah
About this file
This is a Vendor/Customer Creation and Modification Form (FI170) issued by the Utah Department of Transportation (UDOT) Procurement Services Division in conjunction with an Invitation for Bid (IFB) for Liquid Asphalt Oil Region 1 (Solicitation #UDOT260201CN). The IFB seeks a one-year contract with the lowest responsive and responsible bidder to supply liquid asphalt to specified locations within UDOT Region 1. Product delivery must be completed before May 21, 2026. The form requires vendors to submit comprehensive business information including legal entity details, Tax Identification Numbers, address information for payment, billing, and ordering purposes, and primary contact information to establish a valid vendor profile in the State of Utah's accounting system.
Vendors must complete the submission form to enable UDOT and other state agencies to process payments and invoices. The form requires attestation that all provided information is accurate and authorizes the vendor as a legitimate business representative. Vendor information will be shared with other state agencies, financial institutions for payment processing, and the Internal Revenue Service for 1099 reporting purposes. Vendors must indicate preferred payment methods (Electronic Funds Transfer or check), provide their organization type (such as LLC, Corporation, or Sole Proprietorship), confirm whether they currently hold an active state contract, and disclose any current receipt of retirement benefits from Utah Retirement Systems. The form serves as the foundational documentation required for vendor registration and eligibility to bid on state contracts.
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Other files
| File | Type | Posted |
|---|---|---|
| 3-Attachment B Liquid Asphalt SOW.pdf | ||
| 2-Attachment-A-Agency-Terms-and-Conditions-GS.docx | DOCX document | |
| 4-Attachment CLiquid Asphalt Bid Sheet.pdf |
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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: |
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| 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 |
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| Other: Off |
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| Foreign Partners: Off |
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| EFT: Off |
| Contract Yes: Off |
| Contract No: Off |
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| Organization Type: [ ] |
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File details come from the government source that posted it. Updated .