ATTACHMENT 4 - Supplement Vendor Payee Data Record Form_Fillable.pdf

135 KB Posted

Attached to
RFP C5612999
Solicitation number
C5612999
Issued by
California

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This is a Supplement Vendor Payee Data Record Form issued by the State of California Department of Corrections and Rehabilitation (CDCR) for use by vendors seeking to conduct business with the state agency. The form serves as a vendor registration and qualification document and does not contain specific details regarding products, services, quantities, response dates, or contract terms. Instead, it functions as a standardized data collection instrument requiring vendors to provide comprehensive business information including legal business name, Federal Employer Identification Number (FEIN) or Social Security Number (SSN), physical business address, and remittance payment information. Vendors must also designate whether they are providing services or commodities and identify their primary contact personnel for sales and accounting matters.

The form requires vendors to disclose their business designation status, including certifications such as Small Business (SB), Micro Business (MB), Disabled Veteran Business Enterprise (DVBE), Small Business Public Works, Non-Profit Veteran Service Agency, and Non-Profit Recognition status, along with corresponding certification numbers and expiration dates. Additionally, vendors must complete tax information sections specifying the type of business entity (corporation, LLC, partnership, sole proprietor, non-profit, estate, government organization, or other classifications) to ensure proper 1099 tax reporting and withholding compliance. The form includes provisions for vendors who have factored their receivables to a third party, requiring notification to CDCR with supporting documentation. This document is a prerequisite administrative requirement for vendor qualification and payment processing with the State of California Department of Corrections and Rehabilitation.

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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. 6/2/20

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:

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