4-8. FI170 (1).pdf

Creation

Modification

FI 170

06/2024 Division of Finance

Vendor Should Complete Form with Agency Input

Attach Completed form to VCC/VCM transaction

For questions, call:(801) 957-7703

DIVISION OF FINANCE 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.

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

Signature DateSigner Name

Agency Information

Agency Contact

Department Name

Department Number

URS Attestation Under UCA 49-11-12, (Post-Retirement Reemployment Restrictions Act), it is the responsibility of the State to identify and certify that a post-retired employee is working/providing services to the State of Utah.

Violations of this act and failing to certify post-retirees with URS will result in a liability to the State for repayment of retirement benefits. Visit URS for more information (urs.org/employerguide)

PaymentPlus (Single Use Virtual Card)*If Selected Complete Form FI 171

Is the vendor currently receiving retirement benefits from Utah Retirement Systems (URS)?

Notice of Personal Information Data Collection (UCA 63-G-2-601(2)) The data collected by this form is part of general record series 30900, 30901, 30546 and 30547 Reason for Data Collection You are asked to provide this information to generate a valid profile for 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 payments/invoices will not be generated resulting in loss of income or other collections methods.

Data Sharing This information may be shared with other State Agencies of the State of Utah to allow transaction processing.

This information may be shared with financial institutions to generate payments This information may be shared with the Internal Revenue Service (IRS) to record 1099 reporting.

*Only Applicable when using an SSN for tax ID number tadarrington Underline tadarrington Underline tadarrington Underline tadarrington Line