2-7. Submittal Form- Vendor Set Up Form 2024-06-27 .pdf
PDF 8 MB Posted
- Attached to
- UDOT Brigham City MS4 Project Upgrade
- Solicitation number
- UDOT260198CN
- Issued by
- Utah
About this file
This is a Vendor/Customer Creation and Modification Form (FI 170) issued by the Utah Department of Transportation (UDOT) Procurement Department for the Brigham City MS4 Project Upgrade. The form is used to establish or update vendor profiles in the State of Utah's accounting system to facilitate payment and billing transactions. The related Invitation for Bid (IFB) solicitation UDOT260198CN seeks construction services for a comprehensive site upgrade at a UDOT facility in Brigham City, including demolition of existing structures (evaporative pond, wash rack, sander storage rack, and asphalt pavement) and construction of new facilities (asphalt paving, wash rack, material storage bin, sander storage rack, brine-mixing vault, and brine tank pad). The project also encompasses earthwork and utility work including stormwater infrastructure, water supply piping, sanitary sewer piping, and related structures. A mandatory virtual pre-bid meeting is scheduled for Tuesday, March 31, 2026, at 2:00 PM via Google Meet. The project completion deadline is June 15, 2026, and the contract will be awarded to the lowest responsive and responsible bidder.
UDOT reserves the right to evaluate bidder responsibility based on past MS4 project performance, specifically requiring that previously awarded MS4 projects be completed without excessive delays or warranty issues and before the substantial completion date, with no current MS4 projects in liquidated damage status. The successful contractor must submit a performance and payment bond upon contract award. Vendors submitting bids must complete the Vendor Set Up Form (FI 170) and W-9 form to establish a valid profile in the State's accounting system. The form requires standard business information including legal name, Tax Identification Number (TIN), organization type, address details, contact information, and certification that all information provided is true and accurate. Payment may be made via Electronic Funds Transfer (EFT) or check, and the State may share vendor information with other state agencies, financial institutions, and the IRS for payment processing and 1099 reporting purposes.
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Other files
| File | Type | Posted |
|---|---|---|
| 3-Attachmnet B Standard Specifications.pdf | ||
| 5-Attchment C Bid sheet.xlsx | XLSX spreadsheet | |
| 4-Attachment D Plans.pdf | ||
| 1-2. Attachment A- Standard Terms and Conditions- with check fields- 09-16-2024 2.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: |
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| 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 |
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| Other: Off |
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| Foreign Partners: Off |
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| EFT: Off |
| Contract Yes: Off |
| Contract No: Off |
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| Organization Type: [ ] |
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