3-10. Submittal Form- Vendor Setup Form.pdf
PDF 8 MB Posted
- Solicitation number
- UDOT260065MP
- Issued by
- Utah
About this file
This is a Vendor/Customer Creation/Modification Form (Form FI170) issued by the State of Utah for establishing vendor profiles in the state's accounting system. The form is designed to enable state agencies to process payments and billing requests for vendors conducting business with Utah. Vendors must complete this form to create a valid profile that allows transactions to be processed, including payment generation and invoice creation. The form captures essential business information including vendor contact details, address information for payment, billing, and ordering purposes, tax identification numbers, organization type, and preferred payment methods. Vendors must attest that all information provided is true and accurate, and they must certify that they are an authorized representative of the business.
The form requires vendors to provide critical data elements including Tax Identification Numbers (TIN), organization classification (such as LLC, C Corporation, S Corporation, Partnership, or Trust/Estate), 1099 reporting classification, and contract information if applicable. Vendors may select preferred payment methods including Electronic Funds Transfer (EFT), check, or PayPlus virtual card options. The form also includes a Utah Retirement Systems (URS) attestation section to confirm compliance with post-retirement reemployment restrictions under UCA 49-11-12. The state indicates that collected information may be shared with other state agencies, financial institutions, and the IRS for payment processing and tax reporting purposes. This form is a prerequisite for any vendor seeking to engage with the State of Utah, including those responding to the UDOT Toll Back Office System and Customer Service Center Support solicitation.
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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 |
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