15._Supplement_Vendor_Payee_Data_Record_Form.pdf

STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS AND REHABILITATION

Rev. 05/1/2021

SUPPLEMENT VENDOR PAYEE DATA RECORD FORM

Form to be completed by Vendor.

LEGAL NAME OF BUSINESS

DBA

FEIN OR SSN NUMBER

BUSINESS PHYSICAL ADDRESS

STREET

CITY

STATE ZIP

REMIT TO INFORMATION

(WHERE YOU WANT YOUR PAYMENTS SENT. ADDRESS MUST MATCH REMIT TO ADDRESS ON INVOICE.)

COMPANY NAME

STREET(P.O. Box)

CITY

STATE ZIP

CONTACT INFORMATION

SALES CONTACT PERSON ACCOUNTING CONTACT PERSON

TITLE TITLE

PHONE PHONE

FAX FAX

SALES E-MAIL ADDRESS

WEB-SITE ADDRESS:

PURCHASING INFORMATION

SERVICE TYPE OF SERVICE PROVIDED:

COMMODITY TYPE OF PRODUCT PROVIDED:

STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS AND REHABILITATION

Rev. 05/1/2021

SUPPLEMENT VENDOR PAYEE DATA RECORD FORM

BUSINESS DESIGNATION

(Fill out only if registered with the Dept. of General Services)

SMALL BUSINESS (SB) CERTIFICATION # - EXPIRATION DATE

MICRO BUSINESS (MB) CERTIFICATION # - EXPIRATION DATE

DVBE BUSINESS CERTIFICATION # - EXPIRATION DATE

SMALL BUSINESS PUBLIC WORK CERTIFICATION # - EXPIRATION DATE

NP VETERAN SERVICE AGENCY CERTIFICATION # - EXPIRATION DATE

NON-PROFIT RECOGNITION CERTIFICATION # - EXPIRATION DATE

TAX INFORMATION

(Fill out if you expect a 1099 at the end of the year)

WITHHOLDING TAX INFORMATION

TYPE OF RECIPIENT (PLEASE SELECT ONE/ SHOULD

MATCH SECTION 3 OF STD 204)

RENTS CORPORATION (REGULAR)------------- (SELECT “ALL OTHERS” ON 204)

ROYALTIES MEDICAL CORPORATION---------- (SELECT “MEDICAL” ON 204)

OTHER INCOME (PRIZED, AWARDS) LEGAL CORPORATION----------------- (SELECT “LEGAL” ON 204)

FISHING BOAT PROCEEDS NON-PROFIT CORP.----- (SELECT “EXEMPT(N. PROF)” ON 204)

MEDICAL AND HEALTHCARE PAYMENTS LLC C-CORPORATION --------- (SELECT “ALL OTHERS” ON 204)

NONEMPLOYEE COMPENSATION LLC S-CORPORATION--------- (SELECT “ALL OTHERS” ON 204)

SUBSTITUTE PAYMENTS (DIVIDENDS/INTEREST) LLC PARTNERSHIP --------------------- (SELECT “PARTNERSHIP” ON 204)

DIRECT SALES SINGLE MEMBER LLC ----- (SELECT “SOLE PROP, INDIV LLC” ON 204)

CROP INSURANCE PROCEEDS TAX EXEMPT ORG. --------------------- (OTHER THAN NON PROFIT CORP.)

EXCESS GOLDEN PARACHUTE PAYMENTS INDIVIDUAL/ SOLE PROP-- (SELECT “SOLE PROP, INDIV LLC” ON 204)

GROSS PROCEEDS PAID TO AN ATTORNEY ESTATE------------------------------------------------- (SELECT “ESTATE” ON 204)

STATE TAX WITHHELD QUALIFIED INTERMEDIARY

ARTIST OR ATHLETE

GOVERNMENT OR INT. ORGANIZATION

NOMINEE

FIDUCIARY

AUTHORIZES FOREIGN AGENT

TYPE OF RECIPIENT UNKNOWN

PRIVATE FOUNDATION

STOP! Only fill out this section if your company has sold their receivables to another company

FACTORING VENDOR (WHEN A VENDOR SELLS RECEIVABLES TO A THIRD PARTY) ATTACH COPY OF THE

LETTER FROM VENDOR NOTIFIYING CDCR OF THE ASSIGNMENT

COMPANY NAME

DBA

STREET(P.O. Box)

CITY

STATE ZIP