2-7. Submittal Form- Vendor Set Up Form 2024-06-27 .pdf
PDF 8 MB Posted
- Attached to
- UDOT Region 3 Tree Trimming
- Solicitation number
- UDOT260148CN
- Issued by
- Utah
About this file
This is a Vendor/Customer Creation/Modification Form (FI170) issued by the Utah Department of Transportation (UDOT) Procurement Department in conjunction with the UDOT Region 3 Tree Trimming Project solicitation (UDOT260148CN). The form is a standard vendor setup document required for businesses to establish or modify their profile in the State of Utah's accounting system to enable payment processing and invoicing. The form collects essential vendor information including business name, addresses, contact details, tax identification numbers, and organizational structure to facilitate transactions between the vendor and state agencies.
The form requires vendors to provide attestation that all submitted information is accurate and complete, with authorization from a designated representative of the business. Vendors must indicate their preferred payment method (Electronic Funds Transfer or check), provide their Tax Identification Number (TIN), specify their organization type (such as LLC, Corporation, or Partnership), and confirm whether they hold an active contract with the state. Additional requirements include disclosure of retirement benefits status under the Utah Retirement Systems Post Retirement Reemployment Restrictions Act and completion of a W-9 form for federal tax reporting purposes. The information collected is used by the State of Utah and potentially shared with other state agencies and financial institutions for payment processing and IRS 1099 reporting. Failure to provide requested information will result in an invalid vendor profile and prevent payment or invoice generation.
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Other files
| File | Type | Posted |
|---|---|---|
| 1-2. Attachment A- Standard Terms and Conditions- with check fields- 09-16-2024 2.docx | DOCX document | |
| 4-Attachment C R3 Tree Cost Schedule.xlsx | XLSX spreadsheet | |
| 3-Attachment B R3 Scope of Work Tree Trimming.docx | DOCX document |
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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: |
| SSN7: |
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| SSN9: |
| EIN1: |
| EIN2: |
| EIN3: |
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| 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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