1-7. Submittal Form- Vendor Set Up Form 2024-06-27 .pdf
PDF 8 MB Posted
- Attached to
- UDOT Rapid Set Volumetric Truck
- Solicitation number
- UDOT270079CN
- Issued by
- Utah
About this file
This is a Vendor/Customer Creation and Modification Form (FI170) submitted to the Utah Department of Transportation (UDOT) Procurement Services Division in support of the UDOT Rapid Set Volumetric Truck solicitation (UDOT270079CN). The form serves as the vendor setup documentation required for a vendor to establish a valid profile in the State of Utah's accounting system. The solicitation seeks a contractor to deliver approximately 53 cubic yards of rapid set material to two UDOT job sites on separate occasions: 25 cubic yards on October 23rd at midnight to I-215 at 2100 North (northbound and southbound), and 28 cubic yards on October 25th at 1:00 AM to State Route 201 at mile post 16. The contract is issued as an Invitation for Bid (IFB) in accordance with the State of Utah Procurement Code and Utah Administrative Code, with UDOT Region 2 serving as the conducting procurement unit.
The form requires vendors to provide complete business information including legal name, Tax Identification Number (TIN), business structure classification (in this case, LLC is indicated), address details for payment, billing, and ordering purposes, contact information, and preferred payment method. Vendors must attest that all provided information is accurate and certify they are authorized representatives of their business. The State will use this information to generate payment profiles and may share data with other state agencies, financial institutions, and the IRS for 1099 reporting purposes. Additionally, vendors must declare whether they are currently receiving retirement benefits from the Utah Retirement Systems (URS) as required under UCA 49-11-12 Post Retirement Reemployment Restrictions Act. Failure to complete and submit this form prevents vendor profile validation and payment processing.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 3-Attachment C cost sheet.xlsx | XLSX spreadsheet | |
| 2-Agency-Contract-GoodsServices-Combined-9.16.24 (2).docx | DOCX document |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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: |
| SSN2: |
| SSN3: |
| SSN4: |
| SSN5: |
| SSN6: |
| SSN7: |
| SSN8: |
| SSN9: |
| EIN1: |
| EIN2: |
| EIN3: |
| EIN4: |
| EIN5: |
| EIN6: |
| EIN7: |
| EIN8: |
| EIN9: |
| 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: |
File details come from the government source that posted it. Updated .