2-7. Submittal Form- Vendor Set Up Form 2024-06-27 (4).pdf
PDF 8 MB Posted
- Attached to
- UDOT Region 3 Cover Material
- Solicitation number
- UDOT260233CN
- Issued by
- Utah
About this file
This is a Vendor/Customer Creation and Modification Form (Form FI170) issued by the State of Utah Department of Transportation (UDOT) Procurement Services Division in relation to the UDOT Region 3 Cover Material solicitation (UDOT260233CN). The form is used to establish or update vendor profiles in the State's accounting system to facilitate payments and invoicing. The related IFB solicitation seeks a single contract award to the lowest responsive and responsible bidder for the delivery of cover material to specified drop points, with delivery required before May 30, 2026. The solicitation is conducted under the State of Utah Procurement Code and Utah Administrative Code.
The vendor form requires submission of standard business information including legal entity name, address, contact details, tax identification number, organization type, and preferred payment method. Vendors must attest that all provided information is accurate and certify authorization to represent the business. The form collects data to enable state agencies to process payments and generate invoices, with information potentially shared among state agencies, financial institutions, and the IRS for payment processing and 1099 tax reporting. Vendors must complete this form along with a W-9 and may elect to receive payments via EFT, check, or PayPlus virtual card. Completion of the form is necessary for vendors to establish a valid profile and participate in state contract opportunities.
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Other files
| File | Type | Posted |
|---|---|---|
| 4-Attachment B SOW+Chips+Region+3+2026 v4.docx | DOCX document | |
| 1-Attachment-A-Agency-Terms-and-Conditions-GS.docx | DOCX document | |
| 3-Attachmnet C Bid sheet+Region+3+Cover+Material+Stockpile+Locations+C.Y.+2026 v4.xlsx | XLSX spreadsheet |
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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: |
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| SSN9: |
| EIN1: |
| EIN2: |
| EIN3: |
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| 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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