3-4. Submittal Form- Vendor Set Up Form 2024-06-27.pdf
PDF 8 MB Posted
- Attached to
- UDOT- Snowplow Cover Blades
- Solicitation number
- UDOT270054JB
- Issued by
- Utah
About this file
This is a Vendor/Customer Creation and Modification Form (FI170) issued by the Utah Department of Transportation (UDOT) Procurement Department in support of Solicitation #UDOT270054JB for Snowplow Cover Blades. The form serves as the official vendor setup documentation required for businesses to establish or modify their profile in the State of Utah's accounting system to facilitate payment processing and invoicing. Vendors responding to the UDOT snowplow cover blades invitation for bid must complete this form to ensure their business entity can receive payment upon contract award. The form requests comprehensive vendor information including business legal name, doing business as (DBA) name, organization type, tax identification number (TIN), and multiple address designations for payment, billing, and ordering purposes.
The form requires vendors to provide contact information, specify preferred payment methods (electronic funds transfer or check), and complete a URS attestation regarding retirement benefits from Utah Retirement Systems. All information submitted must be certified as true and accurate by an authorized representative of the vendor business. Failure to provide complete and accurate information will prevent the vendor profile from being validated in the State's accounting system, resulting in inability to process payments or invoices. The form includes provisions for 1099 tax reporting classification and may require completion of additional documentation including IRS Form W-9. Vendors must also indicate whether they currently have an active contract with the State and provide the contract number if applicable. This vendor setup process is a prerequisite to bid consideration and contract award for the UDOT snowplow cover blades procurement.
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Other files
| File | Type | Posted |
|---|---|---|
| 4-1. IFB-General Bid Information UDOT270054B.doc | DOC document | |
| 2-5. Submittal Form- Business Confidentiality- check fields (3).doc | DOC document | |
| 5-2. Attachment B Scope - Snowplow Cover Blades.docx | DOCX document | |
| 1-6. Submittal Form- Standard PO Terms and Conditions- with Check Fields (2).docx | DOCX document | |
| 7-7. Att.-A-Agency-Terms-and-Conditions.docx | DOCX document | |
| 6-3. Attachment C Cost Submittal - Various size SNP Cover Blades.xlsx | XLSX spreadsheet |
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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: Jeffery Barnes |
| 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: |
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| EIN1: |
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| 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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