6._Supplement_Vendor_Payee_Data_Record_Form.pdf
PDF 242 KB Posted
- Attached to
- Electrocardiograph (ECG) Equipment and Cardiologist Over-Read and Interpretation Services SD23-00094
- Solicitation number
- 0000033006
- Issued by
- California
About this file
This document is a Supplement Vendor Payee Data Record Form from the California Department of Corrections and Rehabilitation. It requests vendors to provide information about their business, including legal name, DBA, federal tax ID or Social Security number, physical and remittance addresses, contact information, and service/commodity type. The form also includes sections for vendors to indicate certification status as a small business, micro business, disabled veteran business enterprise, or non-profit organization, as well as tax withholding information. Additionally, the form includes a section for vendors who have sold their receivables to a third-party factoring company.
The form does not provide details on a specific contract opportunity, but rather collects general vendor registration information that would be required for any contracting activities with the Department of Corrections and Rehabilitation. The information gathered is likely used to establish vendor accounts, facilitate payments, and verify certifications and tax status.
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Text version
STATE OF CALIFORNIA
DEPARTMENT OF CORRECTIONS AND REHABILITATION
Rev. 05/1/2021
SUPPLEMENT VENDOR PAYEE DATA RECORD FORM
Form to be completed by Vendor.
LEGAL NAME OF BUSINESS
DBA
FEIN OR SSN NUMBER
BUSINESS PHYSICAL ADDRESS
STREET
CITY
STATE ZIP
REMIT TO INFORMATION
(WHERE YOU WANT YOUR PAYMENTS SENT. ADDRESS MUST MATCH REMIT TO ADDRESS ON INVOICE.)
COMPANY NAME
STREET(P.O. Box)
CITY
STATE ZIP
CONTACT INFORMATION
SALES CONTACT PERSON ACCOUNTING CONTACT PERSON
TITLE TITLE
PHONE PHONE
FAX FAX
SALES E-MAIL ADDRESS
WEB-SITE ADDRESS:
PURCHASING INFORMATION
SERVICE TYPE OF SERVICE PROVIDED:
COMMODITY TYPE OF PRODUCT PROVIDED:
STATE OF CALIFORNIA
DEPARTMENT OF CORRECTIONS AND REHABILITATION
Rev. 05/1/2021
SUPPLEMENT VENDOR PAYEE DATA RECORD FORM
BUSINESS DESIGNATION
(Fill out only if registered with the Dept. of General Services)
SMALL BUSINESS (SB) CERTIFICATION # - EXPIRATION DATE
MICRO BUSINESS (MB) CERTIFICATION # - EXPIRATION DATE
DVBE BUSINESS CERTIFICATION # - EXPIRATION DATE
SMALL BUSINESS PUBLIC WORK CERTIFICATION # - EXPIRATION DATE
NP VETERAN SERVICE AGENCY CERTIFICATION # - EXPIRATION DATE
NON-PROFIT RECOGNITION CERTIFICATION # - EXPIRATION DATE
TAX INFORMATION
(Fill out if you expect a 1099 at the end of the year)
WITHHOLDING TAX INFORMATION
TYPE OF RECIPIENT (PLEASE SELECT ONE/ SHOULD
MATCH SECTION 3 OF STD 204)
RENTS CORPORATION (REGULAR)------------- (SELECT “ALL OTHERS” ON 204)
ROYALTIES MEDICAL CORPORATION---------- (SELECT “MEDICAL” ON 204)
OTHER INCOME (PRIZED, AWARDS) LEGAL CORPORATION----------------- (SELECT “LEGAL” ON 204)
FISHING BOAT PROCEEDS NON-PROFIT CORP.----- (SELECT “EXEMPT(N. PROF)” ON 204)
MEDICAL AND HEALTHCARE PAYMENTS LLC C-CORPORATION --------- (SELECT “ALL OTHERS” ON 204)
NONEMPLOYEE COMPENSATION LLC S-CORPORATION--------- (SELECT “ALL OTHERS” ON 204)
SUBSTITUTE PAYMENTS (DIVIDENDS/INTEREST) LLC PARTNERSHIP --------------------- (SELECT “PARTNERSHIP” ON 204)
DIRECT SALES SINGLE MEMBER LLC ----- (SELECT “SOLE PROP, INDIV LLC” ON 204)
CROP INSURANCE PROCEEDS TAX EXEMPT ORG. --------------------- (OTHER THAN NON PROFIT CORP.)
EXCESS GOLDEN PARACHUTE PAYMENTS INDIVIDUAL/ SOLE PROP-- (SELECT “SOLE PROP, INDIV LLC” ON 204)
GROSS PROCEEDS PAID TO AN ATTORNEY ESTATE------------------------------------------------- (SELECT “ESTATE” ON 204)
STATE TAX WITHHELD QUALIFIED INTERMEDIARY
ARTIST OR ATHLETE
GOVERNMENT OR INT. ORGANIZATION
NOMINEE
FIDUCIARY
AUTHORIZES FOREIGN AGENT
TYPE OF RECIPIENT UNKNOWN
PRIVATE FOUNDATION
STOP! Only fill out this section if your company has sold their receivables to another company
FACTORING VENDOR (WHEN A VENDOR SELLS RECEIVABLES TO A THIRD PARTY) ATTACH COPY OF THE
LETTER FROM VENDOR NOTIFIYING CDCR OF THE ASSIGNMENT
COMPANY NAME
DBA
STREET(P.O. Box)
CITY
STATE ZIP
| LEGAL NAME OF BUSINESS: |
| STATE: |
| ZIP: |
| STATE_2: |
| ZIP_2: |
| SALES CONTACT PERSON: |
| ACCOUNTING CONTACT PERSON: |
| TITLE: |
| TITLE_2: |
| PHONE: |
| PHONE_2: |
| FAX: |
| FAX_2: |
| SMALL BUSINESS SB: Off |
| MICRO BUSINESS MB: Off |
| NONPROFIT RECOGNITION: Off |
| ROYALTIES: Off |
| OTHER INCOME PRIZED AWARDS: Off |
| FISHING BOAT PROCEEDS: Off |
| SUBSTITUTE PAYMENTS DIVIDENDSINTEREST: Off |
| DIRECT SALES: Off |
| TAX EXEMPT ORG: Off |
| INDIVIDUAL SOLE PROP: Off |
| STATE TAX WITHHELD: Off |
| QUALIFIED INTERMEDIARY: Off |
| ARTIST OR ATHLETE: Off |
| FIDUCIARY: Off |
| AUTHORIZES FOREIGN AGENT: Off |
| TYPE OF RECIPIENT UNKNOWN: Off |
| PRIVATE FOUNDATION: Off |
| DBA: |
| FEIN OR SSN: |
| STREET: |
| CITY: |
| CERTIFICATION NUMBER2: |
| CERTIFICATION NUMBER3: |
| CERTIFICATION NUMBER4: |
| CERTIFICATION NUMBER5: |
| CERTIFICATION NUMBER6: |
| EXP Date: |
| EXP Date2: |
| EXP Date3: |
| EXP Date4: |
| EXP Date5: |
| EXP Date6: |
| CHECK HERE IF SERVICE PURCHASE: Off |
| CHECK HERE IF COMMODITY PURCHASE: Off |
| DVBE BUSINESS: Off |
| CROP INSURANCE PROCEEDS: Off |
| EXCESS GOLDEN: Off |
| EXCESS PROCEEDS: Off |
| RENTS: Off |
| REG: Off |
| MED: Off |
| LEG: Off |
| NON-P: Off |
| LLC C: Off |
| LLC S: Off |
| LLC P: Off |
| Single: Off |
| Estate: Off |
| GOVERNMENT OR INT ORGANIZATION: Off |
| NOMINEE: Off |
| SMALL BUSINESS: Off |
| NP VET: Off |
| MEDICAL AND HEALTHCARE PAYMENTS: Off |
| NONEMP: Off |
| COMPANY NAME: |
| STREET(P: |
| O: |
| Box)_3: |
| Box)_2: |
| SALES EMAIL ADDRESS: |
| WEB-SITE ADDRESS: |
| ENTER TYPE OF SERVICE PROVIDED: |
| ENTER TYPE OF PRODUCT PROVIDED: |
| CITY_2: |
| CERTIFICATION NUMBER1: |
| CITY_3: |
| ZIP_3: |
| STATE_3: |
| DBA_3: |
| COMPANY NAME_3: |
File details come from the government source that posted it. Updated .