1-7. Submittal Form- Vendor Set Up Form 2024-06-27 .pdf
PDF 8 MB Posted
- Solicitation number
- UDOT260127CN
- Issued by
- Utah
About this file
This is a Vendor/Customer Creation and Modification Form (FI170) from the State of Utah, specifically processed through the Utah Department of Transportation (UDOT) Procurement Department, designed to establish vendor profiles in the State's accounting system. The form is utilized for the Invitation for Bid (IFB) Solicitation #UDOT260127CN, which seeks pricing for Segmental Thermoplastic Liners for pipe relining installation and use by UDOT. The IFB may result in a multiple 5-year contract awarded to the lowest responsive and responsible bidder. The form collects essential vendor information including business registration details, tax identification numbers, payment preferences, and authorized representative certification to enable the State to process payments and invoices.
Vendors submitting bids must complete this form along with supporting documentation (W-9 form and Form FI 171 if selecting PayPlus virtual card payment) to establish a valid vendor profile prior to contract award. The form requires vendors to specify their business entity type (LLC, Corporation, Partnership, etc.), provide multiple address options for payment, billing, and ordering purposes, designate preferred payment method (Electronic Funds Transfer or check), and attest to the accuracy of provided information. Data collected through this form is shared among State agencies, financial institutions, and the IRS for transaction processing and 1099 reporting purposes. Vendors currently receiving retirement benefits from Utah Retirement Systems must disclose this information per UCA 49-11-12 Post Retirement Reemployment Restrictions Act, and the form serves as a critical prerequisite for UDOT to process contract payments or billing requests.
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Other files
| File | Type | Posted |
|---|---|---|
| 5-Attachment D 2026 Standard Specifications Pipe Liner (1) (2).pdf | ||
| 3-Attachment B- Scope of Work.pdf | ||
| 4-Attachment C Price List- Segment Pipe (1) (2).xlsx | XLSX spreadsheet | |
| 2-Agency-Contract-GoodsServices-Combined-9.16.24 (2).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: |
| 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: |
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