Creation

Modification

VENDOR/CUSTOMER CREATION/MODIFICATION

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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