4-03. Submittal Form- Vendor Set Up Form.pdf
PDF 8 MB Posted
- Attached to
- UDOT IFB- Deicer Testing
- Solicitation number
- UDOT260177MP
- 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 an Invitation for Bid (IFB) for Deicer Testing services. The form serves as the vendor setup document required for businesses seeking to engage in contracting with the State of Utah. The solicitation intends to enter into a contract with a qualified supplier to provide Deicer Testing services in accordance with the associated Scope of Work requirements and specifications, issued under the Utah Procurement Code and applicable administrative rules of the Utah Administrative Code.
The vendor form requires submission of comprehensive business information including legal entity name, Doing Business As (DBA) designation, organization type classification (with LLC indicated in the sample), Tax Identification Number (TIN), preferred payment method selection (EFT, Check, or PayPlus virtual card), and multiple address entries for payment, billing, and ordering purposes. Vendors must attest that all provided information is accurate and that they are authorized representatives of their business. The form also requires disclosure regarding active contracts with the State, current receipt of Utah Retirement Systems (URS) retirement benefits, and 1099 tax reporting classification. Completed forms must be accompanied by a W-9 form and, if selecting PayPlus as the payment method, completion of Form FI 171. The information collected will be used to establish a valid vendor profile in the State's Accounting system and may be shared with other State agencies, financial institutions, and the Internal Revenue Service for transaction processing and 1099 reporting purposes.
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Other files
| File | Type | Posted |
|---|---|---|
| 3-04. Submittal Form- Business Confidentiality- check fields.doc | DOC document | |
| 7-01. IFB General Bid Information.doc | DOC document | |
| 1-05. Attachment A- Agency Terms and Conditions.docx | DOCX document | |
| 2-07. Submittal Form- Debarment or Suspension, Conflicts, Tax Lien, Responsiveness.docx | DOCX document | |
| 6-06. Submittal Form- Pricing Sheet- Deicer Testing.xlsx | XLSX spreadsheet | |
| 5-02. Scope of Work- Deicer testing.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: |
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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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