Bid_Package_Documents.pdf

Administration Division, Office of Business and Acquisition Services | State of California | Government Operations Agency | 707 3rd Street, MS 508 | West Sacramento, CA 95605 | t 916.375-4958 f 916.376-1778

ADDITIONAL BID INFORMATION

Bidders are advised to read the Instructions to Bidders, Document 00 21 00 and the Supplementary Instruction to Bidders, Document 00 22 00, of the Project Manual.

YOUR CALIFORNIA STATE CONTRACTOR’S LICENSE HAS NOT BEEN VERIFIED BY THE

DEPARTMENT OF GENERAL SERVICES. YOUR BID IS SUBJECT TO REJECTION AT THE

TIME OF BID OPENING IF:

1. Your license does not meet the requirements as set forth in the project manual.

2. Your license is suspended.

3. Your license is expired.

4. Your license has been cancelled.

5. Your company or any listed subcontractor is not currently registered with the

Department of Industrial Relations (DIR).

6. Your company did not attend a mandatory pre-bid site inspection or meeting, if required.

BIDDING INSTRUCTIONS

REGISTRATION WITH THE DIR

1. ALL Contractors and subcontractors for public works projects must register with DIR.

Check out http://www.dir.ca.gov/Public-Works/PublicWorks.html for complete information and the online registration site.

2. Beginning March 1, 2015, any contractor is not qualified to bid, be listed in a bid or engage in the performance of any contract for public work if they are not registered. Refer to Instructions to Bidders (00 21 00), Article 2 for more information.

PROPOSAL FORM REQUIREMENTS

1. Submit bids on the enclosed Bid Form.

2. Present bids under sealed cover, clearly identifying the project.

3. The Bid Form is not transferable.

BIDDER’S NAME

1. Submit the Bid Form under the same name as licensed.

BIDDER’S SECURITY (Does not apply to solicitations pursuant to GC 14838.7)

1. Bid Security is not required for bids under ten thousand dollars ($10,000).

2. Bid Security shall be a minimum of ten percent (10%) of the bid.

3. Bid Security may be bidder’s bond, cashiers check, certified check or cash. Personal checks will not be accepted.

4. Bid Security shall be made payable to: The Department of General Services.

5. When a Bidder’s Bond is used, it is required to be on the DGS Bid Bond form attached to the Bid Form. Attach the power of attorney for the attorney-in-fact and the signature must be notarized. Contact this office if another copy of the form is needed.

SIGNATURE

1. The Bidder, or Bidder’s authorized representative, is required to sign the bid.

2. Include the address of the Bidder or the authorized representative.

3. If the Bidder is a corporation, affix the corporate seal.

4. Sign the Bidder’s Bond (Does not apply to solicitations pursuant to GC 14838.7).

5. Include applicable documentation; see Instructions to Bidders (00 21 00), Article 9.2.

Governor Gavin Newsom http://www.dir.ca.gov/Public-Works/PublicWorks.html

ADDENDUM

Refer to the Instructions to Bidders for addendum information. Acknowledge the addendum on the appropriate page of the Bid Form.

WITHDRAWAL OF BID

A written notice to withdraw a bid is required prior to the bid opening. A notice not bearing an original signature will not be accepted.

IRREGULARITIES

1. The Bid may be rejected if the bid form is altered. Alterations are, but not limited to:

a. Additions or erasures not requested or required.

b. An incomplete bid.

c. A conditioned bid.

d. Irregularities of any kind.

e. Use of the term “N/A”.

2. If the bid amount or other items including the subcontractors list are changed after being inserted on the bid form, initial or sign the change.

3. Avoid the acronym “N/A” or the term ‘not applicable’ when filling out the bid form.

PAYEE DATA RECORD

Bidders are requested to complete and return the State’s Payee Data Record form, Std.

204, included with the Bid Forms. The Payee Data Record form is required in lieu of IRS W-9 when doing business with the State of California, and will be used by the State to prepare tax information returns as stated on the form. Failures to submit the completed form with the Bid will not be cause for rejection of a Bid, but will be required prior to Award of Contract if not on file.

DVBE REQUIREMENTS (Does not apply to solicitations pursuant to GC 14838.7) DVBE Requirements have recently changed (July 2009). You must meet the required percentage of DVBE participation in order for your bid to be considered responsive.

Please refer to the Instructions to Bidders (00 21 00) and the DVBE Program Requirements (00 22 10) of the Project Manual for additional information.

BID RESULTS

Bid results, bid rejections, awards and project start dates shall be made available via email.

The preliminary bid tabulation will be made available immediately after the bid opening is completed and it will be emailed to bidders. A final bid tabulation will be emailed in about 2-8 business days after bidding requirements, such as bonds, DIR Registration and DVBE, have been verified.

Rev. February 2016 Adt’l Bid Info Page 2 https://caleprocure.ca.gov/pages/bidder-vendor.aspx

BID FORM

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BID FORM

THE STATE OF CALIFORNIA FROM: ______________________________

DEPARTMENT OF GENERAL SERVICES (Name of Bidding Firm)

EXECUTIVE OFFICE OF SUSTAINABILITY

TRANSPORTATION UNIT

DELIVER TO: Jannice Castro Acquisition Analyst BEFORE 2:00 P.M., December 18, 2024 jannice.castro@dgs.ca.gov

FOR: DOT D6 - ELECTRIC VEHICLE SUPPLY EQUIPMENT - MADERA AND FRESNO

CALIFORNIA DEPARTMENT OF TRANSPORTATION (CALTRANS)

MADERA AND FRESNO COUNTY, CALIFORNIA

PROJECT NO. 000000000013151

Plainly mark outside of envelope with "Bid For”; followed by the above title and Project Number.

The undersigned hereby proposes and agrees to furnish all labor, materials, and equipment, and to perform all work required for the above-named Project in the manner and time prescribed in the Drawings and Project Manual, dated November 2024 and such addenda thereto as may be issued prior to bid opening date and in accordance with prevailing wage rates ascertained by the Department of Industrial Relations and set forth on the DIR web site (Prevailing Wage Requirements) for General Prevailing Wage Rates as determined by the August 2024 DIR prevailing wage published rates. The Bid Price, set forth below in clear legible figures, includes the cost of Bonds, insurance, sales tax, and every other item of expense, direct or indirect, incidental to the Bid Price.

IMPORTANT - READ BEFORE SIGNING: Bid Form must be executed in same name-style in which the bidder is licensed. Bidder bidding jointly or as a combination of several business organizations is specially cautioned that such bidder must be jointly licensed in the same form and style in which the bid is executed. If making a bid as a joint venture, each person submitting the bid shall provide the information required below with respect to his or her licensure. The undersigned Bidder certifies and agrees to provide the information and comply with the requirements contained in Articles 1 through 10 on the following pages of the Bid Form. By signing, Bidder swears under penalty of perjury that the conditions of Article 2; Article 4, Paragraph 4.2; Article 7 and Article 9, Paragraph 9.2.1 are true.

Legal Name of Bidder: Federal I.D. No.: ____________

Contractor's License No.: _________ License Expiration Date: ___________License Classification: _______________

Contractor’s Public Works Registration No. (Dept. of Industrial Relations): ___________________________________

Contractor’s DGS Small Business/DVBE Certification Number: ____________________________________________

Business Address: _______________________________________________________________________________ (Street and/or P.O. Box) (City) (State) (Zip)

E-Mail Address:

Business Telephone No.: ____________________________ Facsimile No.: _________________________________

SIGN HERE ------>____________________________________________________

Signature of Bidder

Print Name and Title of Bidder

Executed this day of ________________________, 20_________at ______________________, California.

COMPLETE WORK For the Lump Sum of: $__________________________ mailto:jannice.castro@dgs.ca.gov https://www.dir.ca.gov/Public-Works/Prevailing-Wage.html

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ARTICLE 1 – BIDDER’S BUSINESS IDENTIFICATION

THIS BID IS SUBMITTED BY (check one):

Individual Partnership

Joint Venture Corporation State in which Incorporated NOTE: If Bidder is a corporation, the State in which incorporated shall be inserted above and the legal name of the corporation shall be set forth on Page 1, together with the signature of the officer or officers authorized to sign contracts on behalf of the corporation; if Bidder is a partnership, the true name of the firm shall be set forth on Page 1, together with the signature of a partner authorized to sign contract in behalf of the partnership; and if Bidder is an individual, that person’s signature shall be placed on Page 1. If signature is by an agent, other than an officer of a corporation or a member of a partnership, a Power of Attorney must be on file with the Department prior to opening bids or submitted with the bid; otherwise, the bid will be regarded as irregular and unauthorized. If bid is submitted by partnership or joint venture, the members are:

ARTICLE 2 – PREFERENCES AND INCENTIVES REMOVED IN ITS ENTIRETY

ARTICLE 3 – BONDING ASSISTANCE

In the event Bidder has received assistance in obtaining bonding for this Project, Bidder shall set forth name and nature of firm providing such assistance. Should that firm be listed as subcontractor, Bidder shall set forth the percentage of contract to be performed by that subcontractor.

Firm Providing Assistance and Nature of Assistance

Subcontractor: Yes No Percentage _____________

ARTICLE 4 – CERTIFICATIONS - BID DEPOSITORY AND FEDERAL COURT FINDINGS

4.1 By signing this Bid Form, Bidder certifies that in preparation of this Bid Form, no bid was received by the bidder from a bid depository, which depository (as to any portion of the work) prohibits or imposes sanctions for the obtaining by bidder, or the submission to bidder by any subcontractor or vendor or supplier of goods and services, of a bid outside the bid depository.

This certification shall constitute a warranty, the falsity of which shall entitle the State to pursue any remedy authorized by law, and shall include the right, at the option of the State, of declaring any contract made as a result thereof to be void.

4.2 By signing this Bid Form, Bidder swears under penalty of perjury that representations of the bid with respect to bidder's license are true and that no more than one final un-appealable finding of contempt of court by a Federal Court has been issued against the Contractor within the immediately preceding two-year period because of the Contractor's failure to comply with an order of a Federal Court which orders the Contractor to comply with an order of the National Labor Relations Board.

4.3 By signing this Bid Form, Bidder acknowledges that in in accordance with the provisions of Section 3700 of the Labor Code, every contractor will be required to secure the payment of compensation to his employees. The Bidder agrees that they are aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and will comply with such provisions before commencing the performance of the work of this contract.

4.4 By signing this Bid Form, Bidder certifies they will not ask an applicant for onsite construction-related employment to disclose orally or in writing information concerning the conviction history of the applicant on or at the time of an initial employment application.

This section shall not apply to a position for which the person or the state is otherwise required by state or federal law to conduct a conviction history background check or to any contract position with a criminal justice agency, as that term is defined in Section 13101 of the Penal Code.

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This section shall not apply to a person to the extent that he or she obtains workers from a hiring hall pursuant to a bona fide collective bargaining agreement.

ARTICLE 5 – STATEMENT OF COMPLIANCE - NONDISCRIMINATION

Bidder (hereinafter referred to as "prospective contractor" in this Statement), by signing this Bid Form, hereby certifies, unless specifically exempted, compliance with Government Code Section 12990 (a-f), and CCR, Title 2, Division 4.1, Chapter 5 and Subchapter 5, Section 11102, in matters relating to reporting requirements and the development, implementation and maintenance of a Nondiscrimination Program; as set forth in the General Conditions of the Contract for Construction.

Prospective contractor agrees not to unlawfully discriminate, harass or allow harassment against any employee or applicants for employment because of sex, race, color, ancestry, religious creed, national origin, physical disability (including HIV and AIDS), medical disability (cancer), age (over 40), marital status, and denial of family care leave.

ARTICLE 6 – QUESTIONNAIRE

6.1 In accordance with Public Contract Code, Section 10162, the Bidder shall complete the following questionnaire:

6.1.1 Has the Bidder, any officer of the Bidder, or any employee of the Bidder who has a proprietary interest in the Bidder, ever been disqualified, removed, or otherwise prevented from bidding on, or completing a Federal, State or Local government project because of a violation of law or a safety regulation?

Yes No

6.1.2 Has the Bidder, any officer of the Bidder, or any employee of the Bidder who has a proprietary interest in the Bidder, ever received a safety violation or failed to file notifications to the Cal-OSHA, Federal OSHA, or EPA Agencies for employee records as required by CCR, Title 8, Section 5208 and CFR 40, Part 61?

If the answer to either 6.1.1 or 6.1.2 above is “Yes”, then give the date(s) of the citation(s) or failure to make notifications, and explain the circumstances by attachment to this Bid Form.

6.2 In order to verify compliance with California Air Resources Board In-Use Off-Road Diesel Fueled Fleets Regulation, Section 2449(i), Title 13, California Code of Regulations, the Bidder shall complete the following questionnaire:

6.2.1. Does the work for the above-named Project involve use of vehicles subject to California Air Resources Board In-Use Off-Road Diesel Fueled Fleets Regulation?

If the answer to 6.2.1 above is “Yes”, successful low Bidder shall, prior to the execution of a contract, submit copies of the valid Certificates of Reported Compliance, issued by the California Air Resources Board, for the fleet selected for the contract and listed subcontractors.

ARTICLE 7 – NON-COLLUSION DECLARATION TO BE EXECUTED BY BIDDER AND SUBMITTED WITH BID

By signing this Bid Form, Bidder, being first duly sworn, deposes and says that he or she is the authorized representative of the Bidder, the party making the foregoing bid, that the bid is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation; that the bid is genuine and is not collusive or sham;

that the Bidder has not directly or indirectly induced or solicited any other Bidder to put in a false or sham bid, and has not directly or indirectly colluded, conspired, connived, or agreed with any Bidder or anyone else to put in a sham bid, or that anyone shall refrain from bidding; that the Bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of the Bidder or any other Bidder, or to fix any overhead, profit, or cost element of the bid price, or that of any other Bidder, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract; that all statements contained in the bid are true; and, further, that the Bidder has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any corporation, partnership, company association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid.

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ARTICLE 8 – ADDENDA

In submitting this bid, Bidder represents that Bidder has examined copies of all the Contract Documents and acknowledges receipt of the following addenda:

Addendum No.: __________ Date: ___________ Addendum No.: __________ Date: ____________

Addendum No.: __________ Date: ___________ Addendum No.: __________ Date: ____________

Addendum No.: __________ Date: ___________ Addendum No.: __________ Date: ____________

Failure to acknowledge on the Bid Form receipt of an addendum shall not in itself be cause for withdrawal or rejection of bids, if it can be shown that bidder did, in fact, receive such addendum prior to bid opening.

ARTICLE 9 – DVBE COMPLIANCE & PARTICIPATION SUMMARY REMOVED IN ITS ENTIRETY

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NAME OF BIDDER: ______________________________

ARTICLE 10 – LIST OF PROPOSED SUBCONTRACTORS

Listed hereinafter are the name, location, license number, and registration number of all subcontractors who will be employed, and the kind of work which each will perform if the contract is awarded to the undersigned. I understand that under Public Contract Code Section 4100, et. seq., I must here clearly set forth the name and location of each subcontractor who will perform work or labor or render service to me in or about the construction of the work in an amount in excess of one-half of one percent (1/2 of 1%), of my total bid, and that as to any work in which I fail to do so, I agree to perform that portion myself or be subject to penalty under the act.

(Note: In case more than one subcontractor is named for the same kind of work, state the portion that each will perform.) I also understand that listed subcontractors must be registered with the Department of Industrial Relations in order to be listed for and to engage in the performance of work on Public Works projects.

Notwithstanding General Conditions Paragraph 1.1, the definition of a SUBCONTRACTOR for the purposes of the Subletting and Subcontracting law is as follows: A trade Contractor who is licensed with the Contractors’ State License Board with an A, B, C or D classification, as defined pursuant to PCC Section 4113.

• Vendors or suppliers of materials only need not be listed.

• Any DVBE subcontractor performing work in excess of ½ of 1% of the bid amount MUST be listed below AND under ARTICLE 9.2.1 - DVBE PARTICIPATION

SUMMARY.

Failure to list Kind of Work, Name, Location or License Number shall cause the bid to be rejected as non-responsive.

Kind of Work Name Location (City) CSLB License No. DIR Registration No.

If further space is required below, copy this page and attached hereto to be made a part of the Bid Form. Sub List Page _________of __________

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STATE OF CALIFORNIA DEPARTMENT OF GENERAL SERVICES

CALIFORNIA CIVIL RIGHTS LAWS ATTACHMENT OFFICE OF LEGAL SERVICES

DGSOLS 04 (Rev. 01/17)

Pursuant to Public Contract Code section 2010, a person that submits a bid or proposal to, or otherwise proposes to enter into or renew a contract with, a state agency with respect to any contract in the amount of $100,000 or above shall certify, under penalty of perjury, at the time the bid or proposal is submitted or the contract is renewed, all of the following:

1. CALIFORNIA CIVIL RIGHTS LAWS: For contracts executed or renewed after January 1, 2017, the contractor certifies compliance with the Unruh Civil Rights Act (Section 51 of the Civil Code) and the Fair Employment and Housing Act (Section 12960 of the Government Code); and

2. EMPLOYER DISCRIMINATORY POLICIES: For contracts executed or renewed after January

1, 2017, if a Contractor has an internal policy against a sovereign nation or peoples recognized by the United States government, the Contractor certifies that such policies are not used in violation of the Unruh Civil Rights Act (Section 51 of the Civil Code) or the Fair Employment and Housing Act (Section 12960 of the Government Code).

CERTIFICATION

I, the official named below, certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Proposer/Bidder Firm Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title of Person Signing

Executed in the County of Executed in the State of

Date Executed

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NONCOLLUSION DECLARATION TO BE EXECUTED BY BIDDER AND SUBMITTED WITH

BID

The undersigned declares:

I am the ___________________ of ___________________, the party making the foregoing bid.

The bid is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation. The bid is genuine and not collusive or sham.

The bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham bid. The bidder has not directly or indirectly colluded, conspired, connived, or agreed with any bidder or anyone else to put in a sham bid, or to refrain from bidding. The bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of the bidder or any other bidder, or to fix any overhead, profit, or cost element of the bid price, or of that of any other bidder. All statements contained in the bid are true.

The bidder has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof, to effectuate a collusive or sham bid, and has not paid, and will not pay, any person or entity for such purpose.

Any person executing this declaration on behalf of a bidder that is a corporation, partnership, joint venture, limited liability company, limited liability partnership, or any other entity, hereby represents that he or she has full power to execute, and does execute, this declaration on behalf of the bidder.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct and that this declaration is executed on ___________________ [date], at ___________________ [city], ___________________ [state].”

Signed

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END OF DOCUMENT

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

Section 1 – Payee Information NAME (This is required. Do not leave this line blank. Must match the payee’s federal tax return)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2)

CITY, STATE, ZIP CODE E-MAIL ADDRESS

Section 2 – Entity Type Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2)

CORPORATION (see instructions on page 2)SOLE PROPRIETOR / INDIVIDUAL MEDICAL (e.g., dentistry, chiropractic, etc.)SINGLE MEMBER LLC Disregarded Entity owned by an individual

PARTNERSHIP

ESTATE OR TRUST

LEGAL (e.g., attorney services)

EXEMPT (e.g., nonprofit)

ALL OTHERS

Section 3 – Tax Identification Number Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN.

The TIN is a 9-digit number. Note: Payment will not be processed without a TIN.

For Individuals, enter SSN.

If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.

Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may not have a separate FEIN. Those trusts must enter the individual grantor’s SSN.

For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).

For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity’s FEIN. Do not use the disregarded entity’s FEIN.

For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity’s FEIN.

Social Security Number (SSN) or Individual Tax Identification Number (ITIN)

OR

Federal Employer Identification Number

(FEIN)

Section 4 – Payee Residency Status (See instructions)

CALIFORNIA RESIDENT – Qualified to do business in California or maintains a permanent place of business in California.

CALIFORNIA NONRESIDENT – Payments to nonresidents for services may be subject to state income tax withholding.

No services performed in California

Copy of Franchise Tax Board waiver of state withholding is attached.

Section 5 – Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Should my residency status change, I will promptly notify the state agency below.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS

SIGNATURE DATE TELEPHONE (include area code)

Section 6 – Paying State Agency Please return completed form to:

STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION

MAILING ADDRESS FAX TELEPHONE (include area code)

CITY STATE ZIP CODE E-MAIL ADDRESS

Print Form Reset Form

Department of General Services, Administration Division Office of Business Acquisition Services, Contract Services Section

707 Third Street, MS 508 n/a (916) 376-1768

West Sacramento CA 95605 n/a

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record, STD 204 form. Sign, date, and return to the state agency/department office address shown in Section 6.

Prompt return of this fully completed form will prevent delays when processing payments.

Information provided in this form will be used by California state agencies/departments to prepare Information Returns (Form1099).

NOTE: Completion of this form is optional for Government entities, i.e. federal, state, local, and special districts.

A completed Payee Data Record, STD 204 form, is required for all payees (non-governmental entities or individuals) entering into a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.

Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and the California Revenue and Taxation Code (R&TC).

Section 1 – Payee Information Name – Enter the name that appears on the payee's federal tax return. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).

Sole Proprietor/Individual/Revocable Trusts – enter the name shown on your federal tax return.

Single Member Limited Liability Companies (LLCs) that is disregarded as an entity separate from its owner for federal tax purposes - enter the name of the individual or business entity that is tax liable for the business in section 1. Enter the DBA, LLC name, trade, or fictitious name under Business Name.

Note: for the State of California tax purposes, a Single Member LLC is not disregarded from its owner, even if they may be disregarded at the Federal level.

Partnerships, Estates/Trusts, or Corporations – enter the entity name as shown on the entity’s federal tax return. The name provided in Section 1 must match to the TIN provided in section 3. Enter any DBA, trade, or fictitious business names under Business Name.

Business Name – Enter the business name, DBA name, trade or fictitious name, or disregarded LLC name.

Mailing Address – The mailing address is the address where the payee will receive information returns. Use form STD 205, Payee Data Record Supplement to provide a remittance address if different from the mailing address for information returns, or make subsequent changes to the remittance address.

Section 2 – Entity Type If the Payee in Section 1 is a(n)… THEN Select the Box for…

Grantor (Revocable Living) Trust disregarded for federal tax purposes Sole Proprietor/Individual Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes Single Member LLC-owned by an individual Partnerships Limited Liability Partnerships (LLP) and, LLC treated as a Partnership Partnerships Estate Trust (other than disregarded Grantor Trust) Estate or Trust Corporation that is medical in nature (e.g., medical and healthcare services, physician care, nursery care, dentistry, etc. LLC that is to be taxed like a Corporation and is medical in nature

Corporation-Medical

Corporation that is legal in nature (e.g., services of attorneys, arbitrators, notary publics involving legal or law related matters, etc.) LLC that is to be taxed like a Corporation and is legal in nature

Corporation-Legal

Corporation that qualifies for an Exempt status, including 501(c) 3 and domestic non-profit corporations. Corporation-Exempt Corporation that does not meet the qualifications of any of the other corporation types listed above LLC that is to be taxed as a Corporation and does not meet any of the other corporation types listed above

Corporation-All Other

Section 3 – Tax Identification Number The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Section 4 – Payee Residency Status Are you a California resident or nonresident?

A corporation will be defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California.

A partnership is considered a resident partnership if it has a permanent place of business in California.

An estate is a resident if the decedent was a California resident at time of death.

A trust is a resident if at least one trustee is a California resident.

o For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose that will extend over a long or indefinite period will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.

For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:

Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov

Section 5 – Certification Provide the name, title, email address, signature, and telephone number of individual completing this form and date completed. In the event that a SSN or ITIN is provided, the individual identified as the tax liable party must certify the form. Note: the signee may differ from the tax liable party in this situation if the signee can provide a power of attorney documented for the individual.

Section 6 – Paying State Agency This section must be completed by the state agency/department requesting the STD 204.

Privacy Statement Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it. It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and state law imposes noncompliance penalties of up to $20,000. You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.

All questions should be referred to the requesting state agency listed on the bottom front of this form.

STATE OF CALIFORNIA – STATE CONTROLLERS OFFICE

PAYEE DATA RECORD SUPPLEMENT

(This form is optional. Form is used to provide remittance address information if different than the mailing address on the STD 204 – Payee Data Record.

Use this form to provide additional remittance addresses and additional Authorized Representatives of the Payee not identified on the STD 204.)

Payee Information (must match the STD 204) NAME (Required. Do not leave blank.)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

TAX ID NUMBER (Required)

SSN, ITIN, or FEIN that matches Tax ID number provided on STD 204

Additional Remittance Address Information Use the fields below to provide remittance addresses for payee if different from the mailing address on the STD 204.

The addresses provided below are for remittance purposes only. 1099 information returns will be sent to the mailing address specified on the STD 204.

REMITTANCE ADDRESS (number, street, apt or suite no.)

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

REMITTANCE ADDRESS

CITY STATE ZIP CODE

Additional Contact Information Use the fields below to provide additional Authorized Representatives for the Payee if applicable.

CONTACT NAME

TELEPHONE (Include area code) EMAIL

CONTACT NAME

TELEPHONE EMAIL

CONTACT NAME

TELEPHONE EMAIL

Certification I hereby certify under penalty of perjury that the information provided on this supplemental document is true and correct.

By signing this document, I authorize the State of California to remit payment to the addresses specified on this supplemental form (STD 205) and certify that all persons identified on this form are authorized representatives of this payee. Payments remitted to any of the listed addresses may be reported on 1099 information returns to the tax liable entity identified on the accompanying Payee Data Record - STD 204.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE

(Print or Type name)

TITLE E-MAIL ADDRESS

SIGNATURE

X___________________________________________

DATE TELEPHONE (Include area code)

Print Form Reset Form

STATE OF CALIFORNIA – STATE CONTROLLERS OFFICE

PAYEE DATA RECORD SUPPLEMENT

(This form is optional. Form is used to provide remittance address information if different than the mailing address on the STD 204 – Payee Data Record.

Use this form to provide additional remittance addresses and additional Authorized Representatives of the Payee not identified on the STD 204.)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record Supplement, STD 205. Sign, date, and return to the state agency/department with a completed STD 204. Prompt return of the fully completed forms will prevent delays when processing payments.

Purpose – Completion of this form (STD 205) is optional. Payees may use this form to provide remittance addresses or contact information in addition to the 1099 information return mailing address provided on the STD 204. This form shall only be used in conjunction with the STD 204, and will not be accepted without a STD 204.

Please note: The State of California Government will issue 1099 information returns to the mailing address provided on the most recently dated form STD 204 validated by the Payee. Addresses provided on this form (STD 205) will be used for remittance purposes only. If the payee would like to update the address for receiving 1099 information returns, please complete the STD 204.

Payee Information: The Payee’s Tax ID number (TIN) and Name (including any Business, DBA, or Disregarded LLC names) are required. This information is subject to TIN matching via the IRS database for validation. Payee Information provided in this section must clearly match the STD 204. Any discrepancies may result in delays of payment, up to and including denial of the request.

Name – Enter the name of the Payee. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).

Business Name – Enter the business name, DBA name, trade or fictitious name, or disregarded LLC name.

Tax ID Number-The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Additional Remittance Address Information - Enter the Payee’s additional remittance address(s) that are not listed on STD 204. Up to five (5) addresses may be provided on this form. The Payee may provide additional remittance addresses on a second STD 205 form if needed.

Additional Contact Information - Enter the Payee’s additional or updated contact information. Up to three contacts may be identified on this form. Payee may provide additional contacts on a second STD 205 if needed.

PRIVACY STATEMENT

Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an individual to disclose their social security account number, shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it.

It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup withholding and state law imposes noncompliance penalties of up to $20,000.

You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact the business services unit or the accounts payable unit of the state agency(ies) with which you transact that business.

All questions should be referred to the requesting state agency listed on the bottom front of the STD 204 form.