2-7. Submittal Form- Vendor Set Up Form 2024-06-27 .pdf
PDF 8 MB Posted
- Attached to
- UDOT Panguitch MS4 Project
- Solicitation number
- UDOT260204CN
- Issued by
- Carbon County, Utah
About this file
This Vendor/Customer Creation/Modification Form (Form FI170) is used by the State of Utah, specifically the Utah Department of Transportation (UDOT) Procurement Department, to establish vendor profiles in the state's accounting system. The form requires vendors to provide comprehensive business information including legal name, address details, contact information, tax identification numbers, organization type, and payment preferences to enable the state to process payments and invoices. Vendors must complete this form to participate in UDOT contracts, such as the Panguitch MS4 Project (Solicitation #UDOT260204CN), which involves reconstruction of a detention pond with liners and concrete. The mandatory site visit for the Panguitch MS4 Project is scheduled for Wednesday, April 1st, 2026, at 1:30 PM at the UDOT maintenance facility located at 1200 South HWY 143 in Panguitch, Utah. The project must be completed by June 15th, 2026, and attendance at the site visit is mandatory; late arrival may result in exclusion from bid submission.
The form collects essential vendor information for tax reporting purposes, including W-9 documentation, TIN classification, and 1099 reporting status. Vendors must attest under penalty of perjury that all information is true and accurate, and they must be authorized representatives of their business. Payment methods include Electronic Funds Transfer (EFT), check, or PayPlus virtual card options. The state will share vendor information with other state agencies, financial institutions, and the IRS as necessary to process transactions and generate 1099 reports. The form also includes a URS (Utah Retirement Systems) attestation to ensure compliance with post-retirement reemployment restrictions. UDOT reserves the right to evaluate bidder responsibility based on past MS4 project performance, requiring that previous projects be completed without excessive delays or warranty issues and that current MS4 projects not be in a liquidated damages state. The awarded contractor must submit a performance and payment bond upon contract award.
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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 Bid Schedule.xlsx | XLSX spreadsheet | |
| 6-Optional Pond Liner Installation.pdf | ||
| 3-Attachment C Bid Schedule.xlsx | XLSX spreadsheet | |
| 5-Attachment B Standard Provisions.pdf |
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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: |
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| 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: |
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| 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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