8._Payee_Data_Record_Supplement_(1).pdf
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- Attached to
- (1) Type II Ambulance
- Solicitation number
- 0000035536
- Issued by
- San Bernardino County, California
About this file
The document is a Supplement Vendor Payee Data Record Form issued by the California Department of Corrections and Rehabilitation (CDCR), revised on 05/1/2021. This two-page form is designed for vendors to provide comprehensive business and tax information when seeking to do business with the state agency. The form requires detailed vendor information including legal business name, physical and remit-to addresses, contact details, business designation, and tax classification.
The form includes sections for business designations such as Small Business, Micro Business, Disabled Veteran Business Enterprise (DVBE), and Non-Profit Recognition, which allows vendors to specify their certification status with the Department of General Services. The tax information section is particularly detailed, requiring vendors to select their specific type of business entity and recipient classification for tax purposes, including options for corporations, LLCs, partnerships, and individual/sole proprietorships. A special section is also included for vendors who have sold their receivables to another company, requiring additional documentation of the assignment.
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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
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)
CONTACT INFORMATION
SALES CONTACT PERSON
ACCOUNTING CONTACT PERSON
TITLE
TITLE
PHONE
PHONE
FAX
FAX
SALES E-MAIL ADDRESS
WEB SITE ADDRESS:
SERVICE TYPE OF SERVICE PROVIDED:
COMMODITY TYPE OF PRODUCT PROVIDED:
BUSINESS PHYSICAL ADDRESS
PURCHASING INFORMATION
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)
(Certified by DGS)
CERTIFICATION - #
EXPIRATION DATE
MICRO BUSINESS (MB)
(Certified by DGS)
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
WITHHOLDING TAX INFORMATION
TYPE OF RECIPIENT (PLEASE SELECT ONE/ SHOULD
MATCH SECTION 2 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)
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