1-7. Submittal Form- Vendor Set Up Form 2024-06-27 .pdf
PDF 8 MB Posted
- Attached to
- UDOT Region 1 Wetland Vegetation Control -
- Solicitation number
- UDOT260185CN
- Issued by
- Davis County, Utah
About this file
This is a Vendor/Customer Creation and Modification Form (FI170) used by the State of Utah, specifically the Utah Department of Transportation (UDOT) Procurement Department, for establishing vendor profiles in the state's accounting system. The form is designed to collect essential vendor information including business registration details, tax identification numbers, organizational structure, and contact information necessary to process payments and invoices. The related solicitation is an Invitation for Bid (IFB) issued by UDOT Region 1 for Wetland Vegetation Control services at two sites located in Davis and Weber County, with solicitation number UDOT260185CN. The contract scope encompasses ongoing wetland mitigation maintenance activities, including noxious and invasive weed control, with potential additional work items such as mowing, tree and shrub removal, reseeding, and riparian plant replacement. A mandatory site visit is scheduled for Thursday, March 19, 2026, from 11:00 am to 2:00 pm, beginning at the Huntsville site (MS0055) in Weber County at 41.261137, -111.760303 and proceeding to the Snow Creek site (MS0052) in Layton, Davis County at 41.077615, -111.910014. Bidders who arrive late may be prohibited from participating in the site visit and submitting a bid. The contract may result in multiple five-year awards given to the lowest responsive and responsible bidder based on the Cost sheet Attachment C.
The Vendor Set Up Form requires completion of critical administrative elements including business legal name, DBA if applicable, tax identification number, organizational type (such as LLC designation noted in the sample), preferred payment method (EFT or check), and 1099 reporting classification. The form must be accompanied by a completed W-9 form and, if applicable, Form FI 171 for PaymentPlus virtual card payments. Vendors must attest that all information provided is accurate and certify they are authorized representatives of their business. The form addresses Utah Retirement Systems (URS) post-retirement reemployment restrictions and indicates that collected information will be shared with other state agencies, financial institutions, and the IRS for transaction processing and 1099 reporting purposes. All vendors seeking to contract with the State of Utah must establish a valid profile through this form before payment or invoicing can be generated.
View the file
Other files
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 .