RFQ__25IR063_Bulk_Prune_Juice___HF_Apple_Juice.pdf

STATE OF CALIFORNIA — DEPARTMENT OF STATE HOSPITALS Gavin Newsom, Governor

DEPARTMENT OF STATE HOSPITALS

Solicitation Number:

DSH 2010 - Revised 08/22/23

Except as outlined in PCC 12156 (b), it is unlawful to prohibit a printer or duplication cartridge that is sold to the State from being remanufactured or recycled.

5/31/2026 to file a full and complete written statement specifying in detail the ground of the protest and the facts in support thereof

5% 4% to 4.99% inclusive 4% 3% to 3.99% inclusive 3%

5% or Over

Small-Business Pref.: DGS.ca.gov - Small Business Preference

5/14/2026 to submit a written request to have notice of proposed award publicly posted

Post-Award Protests In accordance with PCC 10306, the following are the key action dates related to Post-Award Protests. All dates are Close of Business (COB).

5/21/2026 to submit a protest to the awarding department/buyer concerning the proposed contract award

DVBE Waiver Notification:

The DVBE Program requirement is either not applicable or is waived for this solicitation and resulting contract.

Tie Breaking Ties between bidders will be resolved in accordance with GC 14838 and CCR, Title 2,

1896.6. If a tie remains, a witnessed coin toss will determine the winner.

DVBE Incentive An incentive will be given to bidders who provide DVBE participation either as DVBEs or through subcontracting. The following percentages will apply:

DVBE Participation Incentive

GENAI Disclosure & Factsheet

The State of California seeks to realize the potential benefits of GenAI, through the development and deployment of GenAI tools, while balancing the risks of these new technologies. Bidder / Offeror must notify the State in writing if it: (1) intends to provide GenAI as a deliverable to the State; or (2), intends to utilize GenAI, including GenAI from third parties, to complete all or a portion of any deliverable that materially impacts: (i) functionality of a State system, (ii) risk to the State, or (iii) Contract performance. For avoidance of doubt, the term “materially impacts” shall have the meaning set forth in State Administrative Manual (SAM) § 4986.2 Definitions for GenAI. Failure to report GenAI to the State may result in disqualification. The State reserves the right to seek any and all relief to which it may be entitled to as a result of such non-disclosure. Upon notification by a Bidder / Offeror of GenAI as required, the State reserves the right to incorporate GenAI Special Provisions into the final contract or reject bids/offers that present an unacceptable level of risk to the State. Government Code 11549.64 defines “Generative Artificial Intelligence (GenAI)” as an artificial intelligence system that can generate derived synthetic content, including text, images, video, and audio that emulates the structure and characteristics of the

Bidder Declaration Form Requirements: DGS.ca.gov - Bidder Declaration Use and Evaluation Procedure

Bidder Instructions: DGS.ca.gov - Bidder Instructions

10333 El Camino Real Atascadero, CA 93422

805-468-2591 isaiah.rodriguez@dsh.ca.gov

#25IR063

The Department of State Hospitals (DSH) would like to request a quote from your company, which will be awarded to the lowest cost vendor. If your company/firm is interested in bidding, please note that the following provisions and instructions are in force for this solicitation. Bidders are advised to read each document.

Classification: Non-Information Technology (Non-IT)

Recycled Products Requirement

Recycled products shall be offered and/or used to the maximum extent economically feasible.

Solicitation Method: Competitive (Advertised)

General Provisions: DGS.ca.gov - General Provisions

DEPT. OF STATE HOSPITALS - ATASCADERO

10333 El Camino Real Atascadero, CA 93422

Isaiah RodriguezMay 14, 2026 https://www.dgs.ca.gov/PD/Resources/Page-Content/Procurement-Division-Resources-List-Folder/Required-Language-for-Solicitations-and-Contracts https://www.dgs.ca.gov/PD/Resources/Page-Content/Procurement-Division-Resources-List-Folder/Required-Language-for-Solicitations-and-Contracts https://www.dgs.ca.gov/PD/Resources/Page-Content/Procurement-Division-Resources-List-Folder/Required-Language-for-Solicitations-and-Contracts https://www.dgs.ca.gov/PD/Resources/Page-Content/Procurement-Division-Resources-List-Folder/Required-Language-for-Solicitations-and-Contracts https://www.dgs.ca.gov/PD/Resources/Page-Content/Procurement-Division-Resources-List-Folder/Required-Language-for-Solicitations-and-Contracts https://www.dgs.ca.gov/PD/Resources/Page-Content/Procurement-Division-Resources-List-Folder/Required-Language-for-Solicitations-and-Contracts https://www.dgs.ca.gov/PD/Resources/Page-Content/Procurement-Division-Resources-List-Folder/Required-Language-for-Solicitations-and-Contracts https://www.dgs.ca.gov/PD/Resources/Page-Content/Procurement-Division-Resources-List-Folder/Required-Language-for-Solicitations-and-Contracts https://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/DGSPD%20451.pdf https://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/DGSPD%20451.pdf https://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/DGSPD%20451.pdf https://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/DGSPD%20451.pdf https://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/DGSPD%20451.pdf https://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/DGSPD%20451.pdf https://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/DGSPD%20451.pdf https://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/DGSPD%20451.pdf 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https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiN0_6s5_CAAxXGJ0QIHWnwBUAQFnoECBIQAQ&url=https%3A%2F%2Fwww.dgs.ca.gov%2F-%2Fmedia%2F79E7700ECE0F47EB95525FDEA2ABBEB8.ashx&usg=AOvVaw3pfibKAopkeq11D3vTa1Gg&opi=89978449 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiN0_6s5_CAAxXGJ0QIHWnwBUAQFnoECBIQAQ&url=https%3A%2F%2Fwww.dgs.ca.gov%2F-%2Fmedia%2F79E7700ECE0F47EB95525FDEA2ABBEB8.ashx&usg=AOvVaw3pfibKAopkeq11D3vTa1Gg&opi=89978449 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiN0_6s5_CAAxXGJ0QIHWnwBUAQFnoECBIQAQ&url=https%3A%2F%2Fwww.dgs.ca.gov%2F-%2Fmedia%2F79E7700ECE0F47EB95525FDEA2ABBEB8.ashx&usg=AOvVaw3pfibKAopkeq11D3vTa1Gg&opi=89978449 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiN0_6s5_CAAxXGJ0QIHWnwBUAQFnoECBIQAQ&url=https%3A%2F%2Fwww.dgs.ca.gov%2F-%2Fmedia%2F79E7700ECE0F47EB95525FDEA2ABBEB8.ashx&usg=AOvVaw3pfibKAopkeq11D3vTa1Gg&opi=89978449 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https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiN0_6s5_CAAxXGJ0QIHWnwBUAQFnoECBIQAQ&url=https%3A%2F%2Fwww.dgs.ca.gov%2F-%2Fmedia%2F79E7700ECE0F47EB95525FDEA2ABBEB8.ashx&usg=AOvVaw3pfibKAopkeq11D3vTa1Gg&opi=89978449 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.dgs.ca.gov/PD/Resources/SCM/TOC/12/12-04 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiN0_6s5_CAAxXGJ0QIHWnwBUAQFnoECBIQAQ&url=https%3A%2F%2Fwww.dgs.ca.gov%2F-%2Fmedia%2F79E7700ECE0F47EB95525FDEA2ABBEB8.ashx&usg=AOvVaw3pfibKAopkeq11D3vTa1Gg&opi=89978449 https://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/DGSPD%20451.pdf https://www.dgs.ca.gov/PD/Resources/Page-Content/Procurement-Division-Resources-List-Folder/Required-Language-for-Solicitations-and-Contracts

DEPT. OF STATE HOSPITALS - ATASCADERO

Cert. #:

1.

2.

3.

4.

X

REQUEST FOR QUOTATION

ATTACHMENT A - BIDDER'S INFORMATION AND CERTIFICATIONS

SOLICITATION SPECIFICS:

Solicitation Number: Solicitation Due Date: Solicitation Eval Date: Evaluation Method:

#25IR063 5/28/2026 3:00 PM PST 05/29/26 Low-Cost Determination Delivery Location:

Receiving Dock: 10333 El camino Real, Atascadero, CA 93422 Specific Instructions/Requirements (if any):

Receiving Dock Hours: Monday through Friday, 0700am-0300pm, excluding holidays

BIDDER'S INFORMATION

Firm's Legal Name: Seller's Permit / Cert. of Registration #:

Firm's Address: City, State, and Zip:

Bidder's FEIN Number: Claiming SB/MB or Non-SB Pref.? Certified DVBE? Cert. #:

Approximate Lead Time: Product Warranty Period: Date Quote Expires DVBE Participation %:

That I am duly authorized to legally bind the prospective Contractor to the specifications, clauses, and requirements of this solicitation and its attachments;

BIDDER'S REPRESENTATIVE

Designated Contact Person: Phone Number: E-Mail:

BIDDER'S CERTIFICATIONS

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY, and under the laws of the State of California, the following:

That the information provided is accurate to the best of my knowledge;

That the products I have identified in Attachment B meet the specifications as they are written in this solicitation and its attachments; AND

That I have understood and shall comply with the terms, conditions, and requirements as outlined in this solicitation and its attachments, including but not limited to, the General Provisions and Bidder's Instructions as referenced herein.

Printed Name and Title of Signatory:

Signature: Date Executed:

YES NO YES NO

DEPT. OF STATE HOSPITALS - ATASCADERO

Solicitation #: #25IR063 Vendor Name:

Quotation Award

# DESCRIPTION OF GOODS / SERVICES QTY UOM UNIT PRICE EXTENSION

Bulk Prune Juice - No Orchard Splash brand.

Fruit juice must be 100% Fruit Juice without added sugar or other sweeteners. All containers must be 46 oz. with 12 containers per case. No plastic or metal cans/containers.

Product must be shelf-stable and require no refrigeration.

Pallets packed to a maximum of 6 tiers/layer. Products must have minimum of six months post-delivery shelf life.

400 CS $ -

High Fiber Apple Juice (Reference Brand: Lyons Ready Care Fiber Apple Juice) Must contain 100% Juice, no added sugar/sweeteners/corn syrup 12 - 46 oz Container. No plastic or metal cans/containers. One 4-oz serving must contain at least 5 grams of fiber Product must be shelf-stable and require no refrigeration. Pallets packed to a maximum of 6 tiers/layer. All products must have minimum of six (6) months post-delivery shelf life

500 CS $ -

IMPORTANT:

Contract period 7/1/26-12/31/26.

Must provide nutritional info/ingredients for each product submitted. Total quantities may be increased or decreased by up to 15% during the contract duration. Delivery schedule will be provided once the bid is awarded, distributed once per quarter.

Deliveries monthly.

SHIPPING OPTIONS Initial Date

1 No shipping Fee is associated with this quote

2 ADD Shipping (Non Taxable)

3 ADD Shipping and Handling (Taxable)

SUBTOTAL:

OTHER, NON-SHIPPING * CHARGES:

TOTAL:

*: Do NOT include tax in your pricing. Tax will be added later.

REQUEST FOR QUOTATION

ATTACHMENT B - GOODS AND SERVICES PRICING PAGE

Response Disclaimer:

Solicitations sent to any other email will not be considered. To be considered, all pages of the emailed solicitation that are received prior to the bid solicitation deadline specified in the solicitation will be considered "the complete solicitation". Supplier shall carefully review all documents referenced and made a part of this solicitation to ensure that all information required to properly respond to the solicitation has been received or made available and all requirements are priced in the solicitation. Failure to examine any document, drawing, specification, or instruction will be at the supplier's sole risk.

Soliciting Office: Return E-Mail Address:

DSH-A Procurement Isaiah.Rodriguez@dsh.ca.gov

Amount mailto:Isaiah.Rodriguez@dsh.ca.gov mailto:Isaiah.Rodriguez@dsh.ca.gov mailto:Isaiah.Rodriguez@dsh.ca.gov

DEPT. OF STATE HOSPITALS - ATASCADERO

Solicitation #: #25IR063 Vendor Name:

Form Name Form Form Description Darfur Contracting Act Certification Darfur Public Contract Code section 10475, et. seq. prohibits state agencies from doing business with vendors which have certain business dealings with the Sudan. This form documents that the bidder has no such relationships and is therefore eligible to bid.

Payee Data Record STD204 This form provides the awarding department the bidder's legal name and address, corporate status, and tax identification number.

Bidders Declaration Form GSPD-05-106 This form is used to capture subcontractor information and is used to determine whether a bidder is performing a commercially useful function, as required by statute.

DVBE Declarations Form STD843 This form documents the ownership and broker-status of a disabled veteran business enterprise.

Recycled Content Certification Form CalRecycle074 Effective 1/1/23 PCC 12201.c.2. During bid evaluation, DSH reserves the right to award to the vendor who meets recycled products content in lieu of lowest bid. Not in excess of 10% greater total cost than nonrecycled products.

Voluntary Statistical Data Sheet VSDS Utilized to track reporting data.

The Department of State Hospitals shall make available to each bidder the forms checked below by double clicking the form name under the "Form" header. However, failure on the part of the DSH to provide each form does not excuse the bidder from their responsibility to submit the required forms with their bids. Bidders are hereby advised that they may locate copies of each of the forms below at the Department of General Services' website, at www.pd.dgs.ca.gov. Bidders may also contact the Buyer for this solicitation and request a copy of some or all of these forms prior to the due date for the solicitation, and if the forms were not provided with the solicitation itself.

Required Forms Disclaimer:

If a box is checked below, the corresponding form must be submitted with a bidder's bid before the solicitation due date. Other forms not check may be required after the close of the solicitation and prior to award. Failure on the part of the bidder to submit those forms may be grounds for disqualification. Seller's Permit copy or number required.

REQUEST FOR QUOTATION

ATTACHMENT C - REQUIRED FORMS

Provision of Required Forms Disclaimer:

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

Atascadero State Hospital Accounting / Procurement

PO BOX 7002 (805) 468-3261 (805) 468-2000

Atascadero CA 93422 isaiah.rodriguez@dsh.ca.gov

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.