Attachment A21.doc

Jet Propulsion Laboratory

California Institute of Technology

Jet Propulsion Laboratory

California Institute of Technology

Supplier Information Request Form (RFP/RFQ/ITB Attachment A-21)

Supplier Identification Information

Legal Business Name (name entered on tax return):

For Primary Business Activity To find your NAICS code by key word please go to https://www.census.gov/eos/www/naics/

SAM Database (System for Award Management)

The System for Award Management is free to use. SAM is a primary source for federal government agencies to find potential vendors. Register at www.sam.gov.

FORMCHECKBOX

By checking this box the supplier confirms they are registered in sam.gov/. (Optional)

same as location addr.)

Zip Code (xxxxx-xxxx):

https://www.usps.com

https://www.usps.com

Congressional District:

www.house.gov/representatives/find-your-representative

www.house.gov/representatives/find-your-representative

Organization Type (please check the appropriate type):

For Information about Organization Type please go to https://www.sba.gov/business-guide/launch-your-business/choose-business-structure

FORMCHECKBOX

Individual/Sole proprietor

FORMCHECKBOX

Non-profit

Tax Exempt payee

Partnership

Government

Corporation; incorporated under the laws of the state of

Limited Liability Company (LLC) --- If “LLC” is checked, you must also select one of the following tax classifications: FORMCHECKBOX D=disregarded FORMCHECKBOX C=corporation FORMCHECKBOX P=partnership

Business Classification (check all appropriate boxes in the left OR right column) For Information about Business Classification please go to https://www.sba.gov/size-standards/

FORMCHECKBOX

Large Business

FORMCHECKBOX

Nonprofit Organization

FORMCHECKBOX

Foreign Business/Institution

FORMCHECKBOX

Government

FORMCHECKBOX

Educational Institution

FORMCHECKBOX

Historically Black Colleges & Universities/ Other Minority Institutions (HBCU/MI)

FORMCHECKBOX

Small Business (SB)

(plus any of the below, if appropriate)

FORMCHECKBOX

Small Disadvantaged Business (SDB)

FORMCHECKBOX

Woman-Owned (WO)

FORMCHECKBOX

HUBZone (HUBZ)

FORMCHECKBOX

Veteran-Owned (VO)

Service-Disabled VO (SDVO)

Notice of Potential Tax Withholding

To comply with CA Revenue and Taxation Code 18662 and CA Franchise Tax Board FTB Publ. 1023, and Internal Revenue Code 1441, JPL must determine if any tax reporting and tax withholding requirements are applicable. See Notice of Potential Tax Withholding (Form 7258) located at: http://www.jpl.nasa.gov/acquisition/terms-conditions/ under the Other Supporting Documents tile for additional information.

Supplier Certification of Information Provided

Subcontractor Name:

Authorized Signature:

Date:

Type/Print Name:

Type/Print Title:

See Page 3 below for Authorization for Electronic Invoice Payments

Authorization for Electronic Invoice Payments

Completion of this form authorizes the Jet Propulsion Laboratory to deposit payments due or that become due into the following bank account.

Name (As shown on the bank account):

Address:

Email Address: (For Remittance Advice)

Name of Financial Institution:

Financial Institution Address:

Account Number:

Bank’s ACH Routing Number:

Additional information necessary for International wire transfers. Wire transfers will be issued in either US dollars or foreign currency per invoice instructions.

Beneficiary BIC or SWIFT Code: __________________________________________________________________ IBAN Number: ___________________________________________________________

Intermediary Bank: (if Required): ___________________________________________________________

Intermediary Bank ABA: ___________________________________________________________ I understand and acknowledge that if the name on the electronic funds transfer (EFT) account is different than as shown on the Caltech-JPL Vendor Master File and as stated above, the financial institution’s procedures may cause a delay in the crediting of said account with my payments, and I hereby expressly relieve Caltech-JPL of any liability I may incur because of a delay caused by the application of a financial institution’s procedures and I agree to hold Caltech-JPL harmless.

I further acknowledge and understand that I must take all steps necessary to change or revoke this EFT authorization in the event I desire to change or revoke this authorization. I understand that any change or revocation must be given to Caltech-JPL at least 30 days prior to the desired effective date of such change or revocation.

I understand and acknowledge that upon the effective date of termination of the JPL contract/purchase order/Agreement, for any reason, from Caltech-JPL this authorization for EFT shall be deemed terminated and that the provisions of the California Code, relating to payment of vendors termination of services, shall apply.

Date Name of Company as it appears on JPL Subcontract or Purchase Order/BPA

Phone Number

Signature of Authorizing Person

JPL 7255-A21, 10/14

JPL 7255-A21, R 7/19 <>