PR_10845965_-_BID_PACKAGE___FORMS__IFB__-_Attachment_3.pdf

STATE OF CALIFORNIA

(REV 08/21)

DEPARTMENT OF CORRECTIONS AND REHABILITATION

ATTACHMENT

CDCR Special Terms and Conditions

1. Clothing Restrictions: For security reasons, while on institution grounds, suppliers and all its agents and/or representatives must not wear clothing that in any way resembles state issued inmate or ward clothing. Specifically, blue denim pants and blue chambray shirts, orange/yellow/white/chartreuse jumpsuits and/or yellow rainwear. Suppliers should contact the institution regarding clothing restrictions prior to requiring access to the institution to assure the supplier and their employees are in compliance.

2. Prison Rape Elimination Policy: CDCR maintains a zero tolerance for sexual misconduct in its institutions, community correctional facilities, camps, and for all offenders under its jurisdiction. All sexual misconduct is strictly prohibited. CDCR is committed to providing a safe, humane, secure environment, free from sexual misconduct. This will be accomplished by maintaining a program to ensure education/prevention, detection, response, investigation, and tracking of sexual misconduct. All suppliers are expected to ensure compliance with this policy as described in Department Operations Manual, Chapter 5, Article 44 which can be located at:

www.cdcr.ca.gov/regulations/cdcr-regulations/dom-toc/. As a supplier, you and your staff are required to adopt and comply with the PREA standards, 28 Code of Federal Regulations Part 115. As a supplier for CDCR, you shall not assign an employee to a CDCR facility or assign an employee to duties if that employee will have contact with CDCR inmates, if that employee has 1) engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C.

1997); 2) been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse; or 3) has been civilly or administratively adjudicated to have engaged in the activity described herein. By signing below the supplier agrees to ensure that all of the mandates referenced herein are complied with.

3. Security Regulations: Suppliers shall observe all security rules and regulations and comply with all instructions given by institutional authorities while on institution grounds.

a. Due to security procedures, suppliers may by delayed at vehicle/pedestrian gates and sally ports. Any loss of time checking in and out of the institution grounds shall be borne by the supplier.

b. Delivery drivers may be required to obtain gate clearance prior to entry. Suppliers shall contact the institution regarding specific gate clearance regulations prior to attempting deliveries. If gate clearance is required, the supplier will be required to complete a Request for Gate Clearance for all persons entering the facility a minimum of ten (10) working days prior to commencement of delivery and/or service. The gate clearance check will include Department of Motor Vehicles check, Wants and Warrants check, and Criminal History Check. All persons entering the facilities must have a valid state driver’s license or photo identification card on their person.

c. Per PC Sections 5054 and 5058; CCR, Title 15, Section 3304 and 4603; and WIC Section 1712, CDCR does not recognize hostages for bargaining purposes. CDCR has a “NO HOSTAGE” policy.

d. All persons entering onto institution/facility/camp grounds consent to search of their person, property, or vehicle at any time. Refusal by individuals to submit to a search may be cause for denial of access to the premises.

e. It is illegal for an individual who has been previously convicted of a felony offense and confined in any State prison in this state to enter into CDCR adult institutions/facilities or camps, or youth institutions/facilities or camps, without the prior approval of the Warden or officer in charge. It is also illegal for an individual to enter onto these premises for unauthorized purposes or to refuse to leave said premises when requested to do so. Failure to comply with this provision could lead to prosecution.

f. Encouraging and/or assisting prison inmates to escape, is a crime. It is illegal to bring firearms, deadly weapons, explosives, tear gas, drugs or drug paraphernalia on CDCR institutions/facilities or camp premises. It is illegal to give prison inmates or wards firearms, explosives, alcoholic beverages, narcotics, or any drug or drug paraphernalia, including cocaine or marijuana.

It is illegal to give wards sex oriented objects or devices, and written materials and pictures whose sale is prohibited to minors.

g. It is illegal to give or take letters from inmates or wards without the authorization of the Warden or officer in charge. It is also illegal to give or receive any type of gift and/or gratuities from prison inmates or wards.

h. Electronic and communicative devices such as pagers, cell phones and cameras/micro cameras are not permitted on institution grounds.

i. Unless otherwise directed by the entrance gate officer and/or contact manager, suppliers shall enter the premises through the main entrance gate. Keys shall be removed from the ignition when outside the vehicle and all unattended vehicles shall be locked and secured while on institution grounds.

CERTIFICATION: By signing the bid response, supplier acknowledges the receipt and understanding of the CDCR Special Terms and Conditions list above.

http://www.cdcr.ca.gov/regulations/adult_operations/DOM_TOC.html www.cdcr.ca.gov/regulations/cdcr-regulations/dom-toc/

Department of Resources Recycling and Recovery (CalRecycle) CalRecycle 74 (Revised 01/23)

Postconsumer Recycled-Content Certification

To be completed by the State agency

State Agency:

Purchasing Agent: PO #:

Phone: E-mail:

The State Agency Buy Recycled Campaign (SABRC) is a state mandated program that requires the reporting of all purchases made within 16 specified product categories. All state agencies are required to verify the recycled-content of all products purchased within each of these categories.

All businesses shall certify the minimum percentage in writing to the contracting officer or his or her representative, if not the exact percentage, of postconsumer recycled-content (PCRC) material in the products, materials, goods, or supplies offered or sold to the State regardless of whether the product meets the minimum content requirements specified in law (see reverse side). The certification shall be furnished under penalty of perjury. The certification shall be provided regardless of content, even if the product contains no recycled material. A State agency may waive the certification requirement if the percentage of postconsumer material in the products, materials, goods, or supplies can be verified in a written advertisement, including, but not limited to, a product label, a catalog, or a manufacturer or vendor Internet website.

Public Contract Code sections 12205(a)(1), (2), (3) and (b)(1), (2), and (3)

Contractor/Company Name_________________________________________________________________________________

Address_____________________________________________________________________Phone_____________________

Purchase Order #

RFQ #

RFP #

IFB #

Cal Card Order #

Item # Product or Services Description 1Percent Postconsumer Recycled- Content Material

2SABRC

Product Category Code

M eets SA

B R

C

Pursuant to Public Contract Code 12205(b)(1), I certify under penalty of perjury under the laws of the State of California that the above information is true and correct.

Print Name Signature Title Date

FOOTNOTES:

1. “Postconsumer recycled-content material” is defined as products that were bought, used, and recycled by consumers. For example, a newspaper that has been purchased, recycled, and used to make another product would be considered postconsumer material.

2. “Product category” refers to one of the categories listed below, into which the reportable purchase is best placed.

3. If the product does not belong in any of the product categories, enter “N/A.” Common “N/A” products include wood products, aggregate, concrete, and electronics such as computers, TV, software on a disk or CD, and telephones.

4. For reused or refurbished products, there is no minimum content requirement. (PCC 12209(l))

California Department of Resources Recycling and Recovery (CalRecycle)

State Agency Buy Recycled Campaign (SABRC) - SABRC@CalRecycle.ca.gov

Code* Product Categories Product Subcategories Product Examples in each SABRC Category (PCC 12207 ) Examples include, but are not limited to, these individual products/materials.

Minimum Post-Consumer Content Requirement per Statute (PCC 12209 )

1A Paper Products Toilet Paper Toilet paper. 45 percent by fiber weight post-consumer fiber.

1B Paper Products Paper Towels Paper towels. 40 percent by fiber weight post-consumer fiber.

1C Paper Products Facial Tissues Facial tissue. 10 percent by fiber weight post-consumer fiber.

1D Paper Products Toilet Seat Covers Toilet seat covers. 20 percent by fiber weight post-consumer fiber.

1E Paper Products General Purpose Paper Wipes General purpose paper wipes. 40 percent by fiber weight post-consumer fiber.

1F Paper Products Food Serviceware Napkins, plates, bowls, food trays, takeout boxes, and placemats. 40 percent by fiber weight post-consumer fiber.

1G Paper Products Miscellaneous Paper Products Cartons, wrapping, packaging, file folders, hanging folders, building insulation and panels, corrugated boxes.

30 percent by fiber weight post-consumer fiber.

2 Printing and Writing Papers

Printing and Writing Papers Copy, xerographic, watermark, cotton fiber, offset, forms, computer printout paper, white wove envelopes, manila envelopes, book paper, note pads, writing tablets, newsprint, and other uncoated writing papers, posters, index cards, calendars, brochures, reports, magazines, and publications.

30 percent by fiber weight post-consumer fiber.

3A Soil Amendments and Toppings

Compost Soil amendments, soil conditioner for potting or plant mix, organic materials used for water conservation; organic materials such as biosolids or other comparable substitutes such as livestock, horse, or other animal manure, food residues or fish processing byproducts; mechanical breakdown of materials.

80 percent recovered material that would otherwise be normally disposed of in a landfill.

3B Soil Amendments and Toppings

Mulch Ground covers, weed suppressants. 80 percent recovered material that would otherwise be normally disposed of in a landfill.

4A Glass Products Glass Products Windows, test tubes, beakers, laboratory or hospital supplies, reflective beads, tiles, construction blocks, desktop accessories, flat glass sheets, loose- grain abrasives, deburring media, liquid filter media, and containers.

25 percent post-consumer, by weight.

4B Glass Products Fiberglass Fiberglass (insulation), 30 percent post-consumer, by weight.

5 Lubricating Oils Intended for use in a crankcase, transmission, engine, power steering, gearbox, differential chainsaw, transformer dielectric, fluid, cutting, hydraulic, industrial, or automobile, bus, truck, vessel, plane, train, heavy equipment, or machinery powered by an internal combustion engine.

70 percent re-refined base oil.

6 Plastic Products Printer or duplication cartridges, diskette, carpet, office products, plastic lumber, buckets, wastebaskets, containers, benches, tables, fencing, clothing, mats, packaging, signs, posts, binders, sheet, buckets, building products, garden hose, and trays.

20 percent postconsumer, by weight, is remanufactured or has a take back program.

7A Paint: Low-VOC: < 50 grams/liter Water-based paint, graffiti abatement, interior and exterior, and maintenance. 50 percent post-consumer paint.

7B Paint: Other VOC: > 50 grams/liter

Water-based paint, graffiti abatement, interior and exterior, and maintenance. 50 percent post-consumer paint.

8 Antifreeze Recycled antifreeze, and antifreeze containing a bittering agent or made from polypropylene or other similar non-toxic substance.

70 percent post-consumer material.

9 Tires (Retreaded tires)

Truck and bus tires, and those used on fleet vehicles (and passenger cars where available).

Retreaded: Must use an existing casing that has undergone retreading or recapping process in accordance with Public Resource Code (commencing with section 42400).

10 Tire- Derived Products

Flooring, mats, wheelchair ramps, playground surfacing, sports surfacing, parking bumpers, bullet traps, hoses, bumpers, truck bedliners, pads, walkways, tree ties, wheel chocks, rollers, traffic-related products, mudflaps, accessibility ramps, paths and sidewalks, animal care products, including, but not limited to, horse arena surfacing, stall mats, cow mats, and equestrian barn and breezeway flooring, artificial turf, landscaping and rubber mulch, outdoor surfacing, pavers and tiles, and posts.

50 percent recycled used tires.

11A Metal Products Metal Products Staplers, paper clips, steel furniture, desks, pedestals, scissors, jacks, rebar, pipe, plumbing fixtures, chairs, ladders, file cabinets, shelving, containers, lockers, sheet metal, girders, building and construction products, bridges, braces, nails, and screws.

10 percent post-consumer material, by weight.

11B Metal Products Vehicles Vehicles. 10 percent post-consumer material, by weight.

12 Building Finishes

Open Office Panel Systems

Open office panel systems. Middle range of state contracts.

13 Carpet Carpet Determined by DGS and Posted in SCM.

14A Erosion Control Products

Compost Filter Socks Compost filter sock. 100 percent post-consumer material.

14B Erosion Control Products

Compost Blanket Compost blanket, layer of compost protecting bare soil surfaces. 100 percent post-consumer material.

14C Erosion Control Products

Hydraulic Mulch Hydraulic mulch or erosion control process that uses fiber slurry and tackifier. 100 percent post-consumer material.

15A Textiles Textiles 0 percent post-consumer material.

15B Textiles General Textile Wipes General purpose wipes. 100 percent post-consumer material.

16A Pavement

Surfacing Rubberized Pavement Surfaces

Rubberized asphalt concrete and chip seal. 15 percent post-consumer material.

16B Pavement Surfacing

Recycled Asphalt Pavement

Recycled Asphalt Pavement 25 percent post-consumer material.

*It is each agency’s prerogative to assign internal codes/object codes for post-consumer recycled content products based on their internal paper or computer tracking systems.

For additional information, please visit www.CalRecycle.ca.gov/BuyRecycled/StateAgency/ http://www.calrecycle.ca.gov/BuyRecycled/StateAgency/

Public Contract Code Sections 10475 -10481 applies to any company that currently or within the previous three years has had business activities or other operations outside of the United States. For such a company to bid on or submit a proposal for a State of California contract, the company must certify that it is either a) not a scrutinized company; or b) a scrutinized company that has been granted permission by the Department of General Services to submit a proposal.

If your company has not, within the previous three years, had any business activities or other operations outside of the United States, you do not need to complete this form.

OPTION #1 - CERTIFICATION

If your company, within the previous three years, has had business activities or other operations outside of the United States, in order to be eligible to submit a bid or proposal, please insert your company name and Federal ID Number and complete the certification below.

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that a) the prospective proposer/bidder named below is not a scrutinized company per Public Contract Code 10476; and b) I am duly authorized to legally bind the prospective proposer/bidder named below. This certification is made under the laws of the State of California.

Company/Vendor Name (Printed) Federal ID Number

By (Authorized Signature)

Printed Name and Title of Person Signing

OPTION #2 – WRITTEN PERMISSION FROM DGS

Pursuant to Public Contract Code Section 10477(b), the Director of the Department of General Services may permit a scrutinized company, on a case-by-case basis, to bid on or submit a proposal for a contract with a state agency for goods or services, if it is in the best interests of the state. If you are a scrutinized company that has obtained written permission from the DGS to submit a bid or proposal, complete the information below.

We are a scrutinized company as defined in Public Contract Code section 10476, but we have received written permission from the Department of General Services to submit a bid or proposal pursuant to Public Contract Code section 10477(b). A copy of the written permission from DGS is included with our bid or proposal.

Company/Vendor Name (Printed) Federal ID Number

Printed Name and Title of Person

Bid Number: [ Insert Bid Number ]

Attachment [ Insert Attachment Number ]

CCHCS-MC-345 – Commercially Useful Function (CUF) Certification Form Rev. 11/27/2017

Commercially Useful Function (CUF) Certification Form

Complete the entire form with an original signature.

1. CONTRACTOR NAME

“DOING BUSINESS AS” (DBA) NAME OSDS REF # (CURRENTLY CERTIFIED FIRMS ONLY)

2. COMMERCIALLY USEFUL FUNCTIONS (CUF)

All certified Small Business (SB), Microbusiness, and/or Disabled Veteran Business Enterprise (DVBE) contractors, subcontractors, or suppliers must meet the commercially useful function requirements under Government Code, Section 14837(d)(4) (for SB) and Military and Veterans Code, Section 999(b)(5)(B) (for

DVBE).

Answer the following questions as they apply to the contractor when fulfilling a contract or purchase order.

Is the contractor responsible for the execution of a distinct element of the work of the contract? Yes No

Will the contractor carry out its obligation on a contract by actually performing, managing, or supervising the work involved? Yes No

Will the contractor perform work on a contract that is normal for its business services and functions? Yes No

Is the contractor responsible, with respect to products, inventories, materials, and supplies required for the contract, for negotiating price, determining quality and quantity, ordering, installing, if applicable, and making payment?

Yes No

Does the contractor perform the work themselves, rather than further subcontracting a portion of the work that is greater than would be expected by normal industry practices?

Yes No

Does the contractor add value by performing the work themselves, rather than being a subcontractor or supplier whose role is limited to that of an extra participant in a transaction, contract, or project through which funds are passed in order to obtain the appearance of SB and/or DVBE participation?

Yes No

AUTHORIZING SIGNATURE (REQUIRED)

The signatory of this document must be the certified business owner (or officer in the case of a corporation) and as such, hereby certifies under penalty of perjury under the laws of the State of California that all information provided herein is truthful and accurate.

OWNER’S/OFFICER’S SIGNATURE DATE

CALIFORNIA CORRECTIONAL HEALTH CARE SERVICES

ACQUISITIONS MANAGEMENT SECTION

GENAI DISCLOSURE & FACTSHEET

AMS 708 (REV. 03/2025)

Generative Artificial Intelligence (GenAI) Disclosure & Factsheet Bidder/Proposer/Offeror Information

Solicitation Number Bidder ID/Vendor ID (optional)

Business Name Business Telephone Number

Business Address City State Zip Code

GenAI Disclosure & Factsheet Will you be using or offering GenAI technology, model, or service (collectively, “system”)? Yes No (If No, skip to Signature section of this form.)

If yes, provide details regarding the GenAI system”). See GenAI Disclosure & Factsheet Definitions at the end of this form for more information.

Failure to disclose GenAI to the State and submit the detailed description may result in disqualification and may void any resulting contract.

1. GenAI Model Name, Version (including number of parameters)

2. Model Owner

3. Overview

4. Purpose

5. Intended Domain

6. Model Training Data

7. Model Information

ACQUISITIONS MANAGEMENT SECTION

GENAI DISCLOSURE & FACTSHEET

AMS 708 (REV. 03/2025)

8. Input and Outputs

9. Performance Metrics

10. Optimal Conditions

11. Poor Conditions

12. Bias

13. Test Data

14. Risk Categorization for Vendor Solutions (High, Medium, Low)

15. Ownership of AI system-generated data and/or content (Vendor or Agency)

Explain below how you are ensuring the GenAI system is not adversely affecting “decisions that materially impact access to, or approval for, housing or accommodations, education, employment, credit, health care, and criminal justice.” (AB 302, Department of Technology: High-Risk automated decision systems: inventory).

Signature

By signing this document, I certify that I have identified and disclosed, if any, all GenAI components in the proposed solution or service.

Signature Date

ACQUISITIONS MANAGEMENT SECTION

GenAI Disclosure & Factsheet Definitions Please use the following definitions to complete the GenAI Disclosure and Factsheet:

1. Model Name, Version & Number of Parameters:

Definition: The unique identifier or name assigned to the specific GenAI model or service.

Purpose: Allows users to refer to and distinguish between different GenAI models.

2. Model Owner Definition: The name of the organization or entity responsible for creating or deploying the GenAI model or service.

Importance: Helps identify the source and accountability for the GenAI system.

3. Overview:

Definition: A concise summary of the GenAI model’s purpose, functionality, and key characteristics.

Role: Provides a high-level understanding for users and stakeholders.

4. Purpose:

Definition: The intended use or goal of the GenAI model (e.g., image recognition, natural language processing, text summarization).

Significance: Helps users assess whether the GenAI model aligns with their needs.

5. Intended Domain:

Definition: The context, subject matter or domain for which the GenAI model is designed to operate effectively.

Importance: Helps users determine if the GenAI model is suitable for their specific use case.

6. Training Data:

Definition: Information used to train the GenAI model (e.g., labeled images, text corpora).

Role: Influences the GenAI model’s behavior and performance.

7. Model Information:

Definition: Details about the architecture, parameters, and configuration of the GenAI model.

Relevance: Provides insights into how the GenAI model functions.

8. Inputs and Outputs:

Definition:

o Inputs: The data or features provided to the model for prediction (e.g., images, text).

o Outputs: The GenAI model’s predictions or results (e.g., class labels, probabilities).

Understanding: Crucial for integrating the GenAI model into applications.

9. Performance Metrics:

Definition: Quantitative measures (e.g., accuracy, F1-score) used to evaluate the GenAI model’s performance.

Assessment: Determines how well the GenAI model meets its intended purpose.

Continuous Monitoring Plan: Establishes a plan for continuous monitoring and evaluation of the GenAI model’s performance.

ACQUISITIONS MANAGEMENT SECTION

10. Optimal Conditions:

Definition: The ideal environment or context for the GenAI model to perform optimally.

Contextual Guidance: Helps users achieve the best results.

11. Poor Conditions:

Definition: Scenarios or conditions where the GenAI model’s performance may degrade.

Risk Awareness: Alerts users to potential limitations.

12. Bias:

Definition: Any systematic error or unfairness in the GenAI model’s predictions due to biased training data or design.

Mitigation: Addressing bias is crucial for ethical and unbiased GenAI.

13. Test Data:

Definition: Independent data used to evaluate the GenAI model’s performance after training.

Validation: Ensures the GenAI model generalizes well to unseen examples.

CERTIFICATION

Submit the completed DGS PD 802 (VSDS) Form via email to:

CCHCSAcquisitionsManagement@cdcr.ca.gov

STD. 830 (REV. 05/2022) (FRONT)

TARGET AREA CONTRACT PREFERENCE ACT

STATE OF CALIFORNIA- DEPARTMENT OF GENERAL SERVICES

DISPUTE RESOLUTION UNIT AND PREFERENCE PROGRAMS

PREFERENCE REQUEST FOR GOODS AND SERVICES SOLICITATIONS

Complete this form to request TACPA preferences for this bid.

I SOLICITATION NUMBER I AGENCY/DEPT

Target Area Contract Preference Act (TACPA) preferences are available only if the lowest responsible bid and resulting contract exceeds $100,000. Your firm must be California based. You must certify, under penalty of perjury, to perform either 50% of the labor hours required to complete a contract for GOODS, or 90% of the labor hours required to complete a contract for SERVICES in the Target Area Contract Preference Act zone(s) you identify in Section I. The TACPA provides bid selection preferences of 5% for eligible worksites (Section I), and 1 % to 4% for hiring eligible workforce employees (Section II). To identify Census Tract and Block Group numbers contact the city or county Planning and Development Commission for the intended worksite or visit the U.S. Census Bureau website (www.census.gov).

Section I. 5% WORKSITE(S) PREFERENCE ELIGIBILITY AND LABOR HOURS

To the Bidder: Preference may be denied for failure to provide the following required information:

(1) Identify each firm in the supply chain, including yours, that will perform any of the contract labor hours required to complete this contract. Identify your role in the distribution process. Transportation hours performed by each carrier must be reported separately.

(2) List complete addresses for each firm named below.

(3) Report projected number of labor hours required to perform the contract for each firm.

(4) Enter the CENSUS TRACT number.

(5) Enter the BLOCK GROUP number.

(6) Identify the California designated TACPA worksite(s) by entering the proper Criteria letter A, B, C, D, E, F (see reverse for instructions) in the Criteria column.

(1) FIRM NAME and CONTRACT FUNCTION:

(Manufacturing, transportation, shipping, warehousing, admin., etc.)

Use additional pages, as needed, to fully report worksite information.

Section II. 1% TO 4% WORKFORCE PREFERENCE

(2) (3)

WORKSITE ADDRESS PROJECTED

Street Address, City, County, State, Zip Code, Phone Number LABOR HOURS

TOTAL PROJECTED LABOR HOURS:

Bidders must qualify their firm's work site eligibility to request an additional 1 % to 4% workforce preference in Section II.

D I request a 1 % preference for hiring eligible persons to perform 5 to 9% of the total contract labor hours.

□ I request a 2% preference for hiring eligible persons to perform 10 to 14% of the total contract labor hours.

□ I request a 3% preference for hiring eligible persons to perform 15 to 19% of the total contract labor hours.

□ I request a 4% preference for hiring eligible persons to perform 20% or more of the total contract labor hours.

Section Ill. CERTIFICATION FOR WORKSITE AND WORKFORCE PREFERENCES

To receive TACPA preferences, the following certification must be completed and signed by the Bidder.

COMPLETE FOR ALL SITES LOCATED WITHIN A TACPA

PREFERENCE AREA(S)

(4) (5) (6)

TRACT NUMBER BLOCK NUMBER CRITERIA (A - F)

I hereby certify under penalty of perjury that the bidder (1) is a California based company as defined in the TACPA regulations; (2) shall ensure that at least 50% of the labor hours required to complete a contract for Goods, or 90% of the labor hours to complete a Services contract shall be performed at the designated TACPA worksite(s) claimed in Section I; (3) shall hire persons who are TACPA eligible employees to perform the specified percent of total contract labor hours as claimed in Section II; (4) has provided accurate information on this request. I understand that any person furnishing false certification, willfully providing false information or omitting information, or failing to comply with the TACPA requirements is subject to sanctions as set forth in the statutes.

BIDDER'S NAME & TITLE BIDDER'S SIGNATURE PHONE NUMBER EMAIL ADDRESS

FAX NUMBER DATE

STATE OF CALIFORNIA DEPARTMENT OF GENERAL SERVICES

CALIFORNIA CIVIL RIGHTS LAWS ATTACHMENT OFFICE OF LEGAL SERVICES

DGS OLS 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.

By (Authorized Signature)

Printed Name and Title of Person Signing

Executed in the County of Executed in the State of

Date Executed

Proposer/Bidder Firm Name (Printed) Federal ID Number

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)

CITY

STATE ZIP

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 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

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.

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)

CITY

STATE

ZIP

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.