2-7. Submittal Form- Vendor Set Up Form 2024-06-27 (5).pdf

8 MB Posted

Attached to
UDOT Cattle Guard Fabrication Scipio
Solicitation number
UDOT260224CN
Issued by
Duchesne County, Utah

About this file

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This is a Vendor/Customer Creation and Modification Form (FI170) for the State of Utah, specifically processed through the Utah Department of Transportation (UDOT) Procurement Department. The form is designed to establish or update vendor profiles in the State's accounting system to facilitate payment and billing transactions. The document requires vendors to provide comprehensive business information including legal entity name, address details, tax identification numbers, organization type, contact information, and payment preferences. All information submitted must be attested to as true and accurate by an authorized representative of the business.

The form serves as the foundational documentation required for vendor registration prior to contract execution and payment processing. Vendors must complete mandatory fields including tax ID number (TIN), organization classification (such as LLC, Corporation, Partnership, or Sole Proprietorship), 1099 reporting status, and preferred payment method (electronic funds transfer or check). Additionally, vendors must disclose whether they are receiving retirement benefits from Utah Retirement Systems and whether they have active contracts with the State. Failure to provide complete and accurate information will prevent profile validation and result in the inability to process payments or invoices. The form explicitly notes that collected information may be shared with other state agencies, financial institutions, and the IRS for payment processing and tax reporting purposes in accordance with Utah Code Annotated Section 63G-2-601(2).

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Other files

File Type Posted
1-Attachment-A-Agency-Terms-and-Conditions-GS.docx DOCX document
5-Attachment D 8 Wide Std Dwgs.pdf PDF
4-Attachment C Bid Sheet.docx DOCX document
3-Attachment B Scope of Work.pdf PDF

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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)

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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 .