RFQ_PACKET_4824-540937_Freezer_Cooler.docx

Gavin Newsom, Governor

State of California Health and Human Services Agency Department of Rehabilitation Contracts & Procurement Section 721 Capitol Mall 6th Floor, Sacramento, CA 95814 Office (916) 558-5680 Fax (916) 558-5681

04/08/2024

REQUEST FOR QUOTE

RFQ # 4824-540937

You are invited to review and respond to this Request for Quote (RFQ) for a Cooler/Freezer Unit to be set-in-place in Redwood Valley, CA. In submitting your quote, you must comply with the Scope of Work and all instructions outlined in this RFQ and on the DR815.

Note: all agreements entered into with the State of California will include by reference General Terms and Conditions that may be viewed and downloaded at: http://www.dgs.ca.gov/pd. A hard copy can be provided by contacting the person listed below.

Questions regarding this RFQ may be submitted by email to the department contact noted below. Any questions regarding this RFQ must be received NO later than Monday, April 15th by 2:00pm. Questions received after the due date and time will not be accepted.

To be considered, ALL pages must be completely received prior to the quote due date and time specified in this solicitation.

The RFQ Due Date and Time is:

MONDAY, APRIL 22ND BY 2:00PM

Quotes received after the due date and time will not be accepted.

ALL QUESTIONS AND RFQ RESPONSES MUST BE SUBMITTED TO:

Email: Bianca.Buenaventura@dor.ca.gov ATTN: Bianca Buenaventura

ATTACHMENT 1

Request for Quote (RFQ) Requirements

Scope of Work Provide with your RFQ response (DR815) a detailed description, specifications and model number(s) of the item(s) requested in the Scope of Work.

The requirements of SAM Chapters 4800 thru 5365.3; the Purchasing Authority Manual; State Contracting Manual SCM Vol. 2 apply to this RFQ/purchase.

Freight/Shipping charges MUST be FOB Destination, Freight Prepaid or FOB Destination, Freight Prepay and Add.

Freight/Shipping/Delivery Charges, Set Up and Training Include with response a detail price breakdown of all freight, shipping, delivery charges, set-up and training. An original receipt is required for any freight or shipping cost over $50.00.

Freight/Shipping charges MUST be FOB Destination, Freight Prepaid or FOB Destination, Freight Prepay and Add.

Warranty Warranty information must be stated as a separate item in RFQ response.

Method of Award The award will be made to the lowest responsive and responsible bidder meeting all administrative and technical requirements, terms and conditions of this solicitation.

Responsive Bidder: A supplier provides a bid response that is compliant with solicitation requirements and indicates performance without material deviation from the terms and conditions of the proposed contract.

Responsible Bidder: A supplier who is responsible and submits a responsive bid is one who clearly indicates compliance without material deviation from the solicitation's terms and conditions and who possesses the experience, facilities, reputation, financial resources and other factors existing at the time of contract award.

Newly Manufactured Goods All Goods furnished under this RFQ/Contract shall be Newly Manufactured Goods unless specified otherwise in this RFQ; used or reconditioned Goods are prohibited.

Change Orders Any Purchase Order resulting from this quote may be amended, modified, or terminated at any time by mutual agreement of the parties in writing. Change orders amending, modifying or terminating the Purchase Order, including any modifications of the compensation payable, may be issued only by the Department of Rehabilitation Procurement Officer. All such change orders shall be in writing and issued only upon written concurrence of the supplier. Termination, as that term is used in this section, does not include termination for default of the supplier.

Bidder Declaration Requirements All bidders must complete the Bidder Declaration Form GSPD-05-105 (ATTACHMENT 2) and include it with the bid response. If a vendor utilizes a subcontractor(s) to provide services for this RFQ, the Vendor must identify any subcontractors on the GSPD-05-105 prior to services rendered. Bidders awarded a contract are contractually obligated to use the subcontractors for the corresponding work identified unless the State agrees to a substitution, and it is incorporated by amendment to the contract.

All bidders are required to provide CUF documentation using the State’s Master Bidder Declaration (GSPD-05-105) for purchases over $5,000. When completing the declaration, bidders must identify all SB and or DVBE subcontractors proposed for participation in the contract. Bidders awarded a contract are contractually obligated to use the SB or DVBE subcontractor for the work identified unless the State agrees to a substitution. The DOR must be notified in writing that a substitution is requested and any substitution of a SB or DVBE firm must be approved by the State.

POST CONSUMER-RECYCLED CONTENT CERTIFICATION: The Bidder shall certify in writing under penalty of perjury, the minimum, if not exact, percentage of post -consumer material as defined in the Public Contract Code Section 12200, in products, materials, goods, or supplies offered or sold to the State regardless of whether the product meets the requirements of Section 12209. The Bidder shall include in the bid, the signed certification form included with this packet (ATTACHMENT 3).

Payee Data Record The successful bidder will be required to submit a Payee Data Record, STD. Form 204 (ATTACHMENT 4) listing their Taxpayer Identification Number. An electronic version of this form can be found at http://www.documents.dgs.ca.gov/dgs/fmc/pdf/std204.pdf.

Seller’s Permit Bidder must provide the following document prior to award.

You must provide your company’s California retailer seller’s permit or certification of registration and, if applicable, the permit or certification of all participating affiliates, issued by the California Department of Tax and Fee Administration (CDTFA), pursuant to all requirements as set forth in Sections 6487, 7101 and sections 6452.1, 6487.3, 18510 of the Revenue and Taxation Code, and Section 10295.1 of the Public Contract code. In order to expedite the process of verifying the validity of the permit, provide the CDTFA permit number in the space provided below (or attach a copy of the permit with your quote.)

Retailer Seller’s Permit Number: _______________________

Void Contract for Tax Delinquency (AB1424) Any agreement that a state agency enters into after July 1, 2012, is void if the contract is between a state agency and a contractor whose name appears on either list of the 500 largest tax delinquencies pursuant to Section 7063 or 19195 of the Revenue and Taxation Code. (Public Contract Code sec. 10295.4). In accordance with Public Contract Code Section 10295.4, agencies are required to cancel agreements with entities that appear on either list. (Franchise Tax Board) https://www.ftb.ca.gov/about-ftb/newsroom/top-500-past-due-balances/index.html (California Department of Tax and Fee Administration) https://www.cdtfa.ca.gov/taxes-and-fees/top500.htm

Federal Debarment, Suspension, Ineligibility And Voluntary Exclusion By accepting and fulfilling this agreement for goods and/or services, the contractor/vendor certifies that neither it nor its principals is presently debarred, suspended, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. (System for Award Management) https://sam.gov/SAM/

DARFUR CONTRACTING ACT CERTIFICATION: Effective January 1, 2009, all solicitations for goods or services must address the requirements of the Darfur Contracting Act of 2008 (Act). (Public Contract Code sections 10475, et seq.; Stats. 2008, Ch. 272). The Act was passed by the California Legislature and signed into law by the Governor to preclude State agencies generally from contracting with “scrutinized” companies that do business in the African nation of Sudan (of which the Darfur region is a part), for the reasons described in Public Contract Code section 10475.

A scrutinized company is a company doing business in Sudan as defined in Public Contract Code section 10476. Scrutinized companies are ineligible to, and cannot, quote on or submit a proposal for a contract with a State agency for goods or services. (Public Contract Code section 10477(a)).

Therefore, Public Contract Code section 10478 (a) requires a company that currently has (or within the previous three years has had) business activities or other operations outside of the United States to certify that it is not a “scrutinized” company when it submits a quote or proposal to a State agency (ATTACHMENT 5).

A scrutinized company may still, however, submit a quote or proposal for a contract with a State agency for goods or services if the company first obtains permission from the Department of General Services (DGS) according to the criteria set forth in Public Contract Code section 10477(b).

EXECUTIVE ORDER N-6-22 – RUSSIAN SANCTIONS: On March 4, 2022, Governor Gavin Newsom issued Executive Order N-6-22 (the EO) regarding Economic Sanctions against Russia and Russian entities and individuals. “Economic Sanctions” refers to sanctions imposed by the U.S. government in response to Russia’s actions in Ukraine, as well as any sanctions imposed under state law. By submitting a bid or proposal, Contractor represents that it is not a target of Economic Sanctions. Should the State determine Contractor is a target of Economic Sanctions or is conducting prohibited transactions with sanctioned individuals or entities, that shall be grounds for rejection of the Contractor’s bid/proposal any time prior to contract execution, or, if determined after contract execution, shall be grounds for termination by the State.

ATTACHMENT 2

BIDDER DECLARATION - GSPD–05–105

1. Prime bidder information (Review attached Bidder Declaration Instructions prior to completion of this form):

a. Identify current California certification(s) (MB, SB, SB/NVSA, DVBE): ____________ or None ____ (If “None”, go to Item #2)

b. Will subcontractors be used for this contract? Yes ___ No ___ (If yes, indicate the distinct element of work your firm will perform in this contract e.g., list the proposed products produced by your firm, state if your firm owns the transportation vehicles that will deliver the products to the State, identify which solicited services your firm will perform, etc.). Use additional sheets, as necessary.

c. If you are a California certified DVBE:

(1) Are you a broker or agent? Yes ___ No ___

(2) If the contract includes equipment rental, does your company own at least 51% of the equipment provided in this contract (quantity and value)? Yes ___ No ___ N/A ___

2. If no subcontractors will be used, skip to certification below. Otherwise, list all subcontractors for this contract. (Attach additional pages if necessary):

Subcontractor Name Contact Person Phone Number & Fax Number

(MB, SB, DVBE or None)

3. CERTIFICATION: By signing this form, I certify under penalty of perjury that the information provided is true and correct.

Printed Name: ____________________________ Signature: _____________________________

Date Signed: __________________

State of California—Department of General Services, Procurement Division GSPD–05–105 (EST 8/05) Written Version Page ___of ____ BIDDER DECLARATION Instructions

All prime bidders (the firm submitting the bid) must complete the Bidder Declaration.

1.a. Identify all current certifications issued by the State of California. If the prime bidder has no California certification(s), check the line labeled “None” and proceed to Item #2. If the prime bidder possesses one or more of the following certifications, enter the applicable certification(s) on the line:

• Microbusiness (MB)

• Small Business (SB)

• Small Business Nonprofit Veteran Service Agency (SB/NVSA)

• Disabled Veteran Business Enterprise (DVBE) 1.b. Mark either “Yes” or “No” to identify whether subcontractors will be used for the contract. If the response is “No”, proceed to Item #1.c. If “Yes”, enter on the line the distinct element of work contained in the contract to be performed or the goods to be provided by the prime bidder. Do not include goods or services to be provided by subcontractors.

Bidders certified as MB, SB, SB/NVSA, and/or DVBE must provide a commercially useful function as defined in Military and Veterans Code Section 999(e)(2)(A) for DVBEs and Government Code Section 14837(d)(4)(A) for small/microbusinesses. For questions regarding commercially useful function determinations made in conjunction with certification approval, contact the Department of General Services, Procurement Division, Office of Small Business and DVBE Certification (OSDC), OSDC Certification and Compliance Unit via email at: osdchelp@dgs.ca.gov.

Bids must propose that certified bidders provide a commercially useful function for the resulting contract or the bid will be deemed non-responsive and rejected by the State. For questions regarding the solicitation, contact the procurement official identified in the solicitation.

Note: A subcontractor is any person, firm, corporation, or organization contracting to perform part of the prime’s contract.

1.c. This Item is only to be completed by businesses certified by California as a DVBE.

(1) Declare whether the prime bidder is a broker or agent by marking either “Yes” or “No”. The Military and Veterans Code Section 999.2 (b) defines “broker” or “agent” as a certified DVBE contractor or subcontractor that does not have title, possession, control, and risk of loss of materials, supplies, services, or equipment provided to an awarding department, unless one or more of the disabled veteran owners has at least 51-percent ownership of the quantity and value of the materials, supplies, services, and of each piece of equipment provided under the contract.

(2) If bidding rental equipment, mark either “Yes” or “No” to identify if the prime bidder owns at least 51% of the equipment provided (quantity and value). If not bidding rental equipment, mark “N/A” for “not applicable.”

2. If no subcontractors are proposed, do not complete the table. Read the certification at the bottom of the form and complete “Page ___ of ___” on the form.

If subcontractors will be used, complete the table listing all subcontractors. If necessary, attach additional pages and complete the “Page ___ of ___” accordingly.

Subcontractor Name, Contact Person, Phone Number & Fax Number—List each element for all subcontractors.

Subcontractor Address & Email Address—Enter the address and if available, an Email address.

CA Certification (MB, SB, DVBE or None)—If the subcontractor possesses a current State of California certification(s), verify on the OSDC website (www.pd.dgs.ca.gov/smbus) that it is still valid and list all current certifications here. Otherwise, enter “None”. [Note: A SB/NVSA should not be participating as a subcontractor] Work performed or goods provided for this contract—Identify the distinct element of work contained in the contract to be performed or the goods to be provided by each subcontractor. Certified subcontractors must provide a commercially useful function for the contract. (See paragraph 1.b above for code citations regarding the definition of commercially useful function.)

If a certified subcontractor is further subcontracting a greater portion of the work or goods provided for the resulting contract than would be expected by normal industry practices, attach a separate sheet of paper explaining the situation.

Corresponding % of bid price—Enter the corresponding percentage of the total bid price for the goods and/or services to be provided by each subcontractor. Do not enter a dollar amount.

Good Standing?—Provide a response for each subcontractor listed. Enter either “Yes” or “No” to indicate that the prime bidder has verified that the subcontractor(s) is in good standing for all of the following:

• Possesses valid license(s) for any license(s) or permits required by the solicitation or by law

• If a corporation, the company is qualified to do business in California and designated by the State of California Secretary of State to be in good standing

• Possesses valid State of California certification(s) if claiming MB, SB, and/or DVBE status

• Is not listed on the OSDC website as ineligible to transact business with the State 51% Rental?—This pertains to the applicability of rental equipment. Based on the following parameters, enter either “N/A” (not applicable), “Yes” or “No” for each subcontractor listed.

Enter “N/A” if the:

• Subcontractor is NOT a DVBE (regardless of whether or not rental equipment is provided by the subcontractor) or

• Subcontractor is NOT providing rental equipment (regardless of whether or not subcontractor is a DVBE) Enter “Yes” if the subcontractor is a California certified DVBE providing rental equipment and the subcontractor owns at least 51% of the rental equipment (quantity and value) it will be providing for the contract.

Enter “No” if the subcontractor is a California certified DVBE providing rental equipment but the subcontractor does NOT own at least 51% of the rental equipment (quantity and value) it will be providing.

3. Read the certification at the bottom of the page. An individual that is authorized to bind the firm contractually is to print their name, sign and date the form. Also, complete the “Page ___of ____” accordingly.

ATTACHMENT 3

ATTACHMENT 4

ATTACHMENT 5

DARFUR CONTRACTING ACT CERTIFICATION

Pursuant to Public Contract Code section 10478, if a bidder or proposer currently or within the previous three years has had business activities or other operations outside of the United States, it must certify that it is not a “scrutinized” company as defined in Public Contract Code section 10476.

Therefore, to be eligible to submit a bid or proposal, please insert your company name and Federal ID Number and complete only one of the following three paragraphs (via initials for Paragraph # 1 or Paragraph # 2, or via initials and certification for Paragraph # 3):

Company/Vendor Name (Printed)

Federal ID Number

Printed Name and Title of Person Initialing (for Options 1 or 2)

1. _____ We do not currently have, and have not had within the previous Initials three years, business activities or other operations outside of the United States.

OR

2. _____ We are a scrutinized company as defined in Public Contract Code section 10476, Initials but we have received written permission from the Department of General Services (DGS) 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.

OR

3. _____ We currently have, or we have had within the previous three years, Initials business activities or other operations outside of the United States, + certification but we certify below that we are not a scrutinized company below as defined in Public Contract Code section 10476.

CERTIFICATION For # 3.

I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the prospective proposer/bidder to the clause listed above in # 3. This certification is made under the laws of the State of California.

By (Authorized Signature)

Printed Name and Title of Person Signing

Please See DR 815: Request for Quote and additional Attachments image3.png image4.png image5.emf

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

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… Individual ● Sole Proprietorship ● 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.

www.ftb.ca.gov mailto:wscs.gen@ftb.ca.gov

CITY STATE ZIP CODE:

EMAIL ADDRESS:

NAME OF AUTHORIZED PAYEE REPRESENTATIVE:

TITLE:

EMAIL ADDRESS_2:

DATE:

TELEPHONE include area code:

STATE AGENCYDEPARTMENT OFFICE:

UNITSECTION:

MAILING ADDRESS:

FAX:

TELEPHONE include area code_2:

CITY:

STATE:

ZIP CODE:

EMAIL ADDRESS_3:

MAILING ADDRESS (number, street, apt:

or suite no:

) (See instructions on Page 2):

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

NAME (This is required:

Do not leave this line blank:

Must match the payee’s federal tax return):

Social Security Number (SSN) or:

Federal Employer Identification Number (FEIN):

sole: Off single: Off partnership: Off estate: Off corpMedical: Off corpLegal: Off corpExempt: Off corpOthers: Off calRes: Off calNonRes: Off calNonResNo: Off calNonResCopy: Off

ResetForm:

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