Solicitation.0000031568.pdf

DEPARTMENT OF FORESTRY AND FIRE PROTECTION

P.O. Box 944246

SACRAMENTO, CA 94244‐2460

Website: www.fire.ca.gov

Request for Quote

Date: 5/29/2024

Enclosed is a Request for Quote (RFQ) Package, # 8PA3X00196 for the procurement of Seedling Extractor. Please refer the attached specification pages for the Seedling Extractor for use by CAL FIRE’s Reforestation Services facility located in Davis, CA, in Yolo County.

Please submit the following completed documents:

• Seedling Extractor Cost Quote Sheet

• Specifications for all items must be included. CAL FIRE will need to ensure proposed specifications are comparable to the specifications within the RFQ.

• Small Business (SB) and or Disabled Veteran Enterprises (DVBE) Certification, if applicable

• California STD. 204, Payee Data Record

• Copy of California Department of Tax and Fee Administration Seller’s Permit

• CAL FIRE-720, DARFUR Contracting Act Vendor Certification

• Bidder Declaration (GSPD- 05-106)

• Copy of STD Form 843, if applicable

The General Provisions Non-IT Commodities are incorporated herein by reference, (DGS PD 401 Non- IT, revised 06/21/2022).

Please refer to the attached Bidder Instructions (DGS PD-451, revised 11/09/2011), for instructions on how to provide a responsive bid.

Submission of all required RFQ documents must be received by 4:00 P.M. on June 13th, 2024 via email.

If you have any questions or should you need any clarifying information concerning this RFQ, please let me know.

Delores Westrum Procurement Analyst

CAL FIRE

Business Services Office E-Mail: delores.westrum@fire.ca.gov

“The Department of Forestry and Fire Protection serves and safeguards the people and protects the property and resources of California.”

http://www.fire.ca.gov/ https://www.documents.dgs.ca.gov/dgs/FMC/PDF/Std204.pdf https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/gspd05-106.pdf https://www.dgs.ca.gov/-/media/Divisions/PD/PTCS/OPPL/Model-Language/Non-IT/NonITGeneralProvisions062122.pdf?la=en&hash=7D58E4294765EA74730DA67AEECF7CE6247B4A3A https://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/DGSPD%20451.pdf mailto:delores.westrum@fire.ca.gov

SACRAMENTO, CA 94244‐2460

Seedling Extractor Specifications

SCOPE

This specification sets forth the requirements for the Seedling Extractor, needed to facilitate the duties of CAL FIRE Reforestation Center, LAMRC Unit. The CAL FIRE nursery located in Davis, CA is looking for a Seedling Extractor machine capable of automatically dislodging the seedlings from the stryroblock containers. The seedlings will be placed in predetermined groups on a conveyor belt for bundling and wrapping and packing. The wrapping plastic dispenser is to be attached/provide with the machine. The seedling extractor machine should be able to handle different styroblocks (growing containers) configurations.

SPECIFICATIONS

• Ability to process 100,000 (minimum) seedlings per eight-hour shift.

• Safety Feature: Automatic activation of pneumatic dump valve feature if jam up occurs.

• Complete touch screen technology for main controls.

• Easily interchangeable finger heads accommodate different Styroblock configurations.

• All conveyors have independent variable speed controls.

• Designed specifically for use with Styroblock cell containers.

• Finger push counter reset to track number of finger push cycles.

• Box counter reset to track how many blocks are processed.

• Real-time cycle timer displays production time/per block processed.

• Adjustable cycle speed and finger push speed.

• Adjustable slow start pressure valve for pin push to "ease out" more well rooted seedlings from cell.

• Full cycle pauses or individual line selectable pause feature with remote station controls for each line.

• Remote E-stop control for each line.

• Easily move with a forklift for setup and disassembly if production space is required for another use.

• Supplier will stock and provides all replacement parts as needed.

• Voltage: 120 or 208 volts available on site.

• Pneumatic Pressure: available on site 120 psi.

AMENDMENTS

CAL FIRE reserves the right to execute written amendments to increase or decrease for goods, time, and or money while remining within the Scope of Work of the original solicitation, and upon mutual consent with the awarded bidder.

SACRAMENTO, CA 94244‐2460

COST QUOTE SHEET

Cost Quote for RFQ # 8PA3X00196 for Seedling Extractor. Please include a detailed breakdown of costs with this bid:

Description of Product Price Per Bed Quantity Total Price

Seedling Extractor

Shipping and Handling Cost All freight/shipping charges over $50 require a supporting prepaid freight bill prior to freight payment

DELIVERY TO:

Cal Fire Reforestation Center 5800 Chilies Road Davis CA, 95618 Attn: Clarisse Goetzen (279) 559-5725

Grand Total

Submitted by: Date:

Name (Print):

Title:

Company Name:

Company Address:

Telephone Number:

E-Mail Address:

SACRAMENTO, CA 94244‐2460

Only bids quoted on CAL FIRE’s Cost Quote Sheet will be considered. Bids submitted referencing attachments which include legal terms and conditions that conflict with the State's General Provisions shall be considered non- responsive and will be rejected.

The “Cost Quote Sheet” will be used solely for computing the cost as a fair and equitable formula to determine the low bidder and is not binding on the contracting agency. However, the actual costs quoted in the cost sheet shall be binding for the term of the Agreement.

This solicitation shall be awarded on an "All or None" basis to the lowest responsive and responsible bidder meeting all administrative and technical requirements, terms, and conditions of this solicitation. In the event of a tie, a coin toss will be a permissible tiebreaker. Such event will be conducted by the procurement official and observed by a state employee as a witness.

(REVISED AND EFFECTIVE 11/09/2011)

BIDDER INSTRUCTIONS

GS PD 451

1. DEFINITIONS:

a) means an offer, made in response to a solicitation to perform a contract for work and results in award of a contract to a single or non- competitively bid contract.

b) means a supplier who submits a bid to the State in response to a solicitation.

c) means the process, by whatever name known or in whatever format used, of notifying prospective bidders that the State wishes to receive bids for furnishing goods or services.

d) means a business entity, bidder, offer or, vendor or contractor.

2. SUBMISSION OF BIDS:

a) Bids must be hand delivered or sent via U.S. Mail or common carrier unless another method

(e.g., facsimile) is specifically authorized in the solicitation.

b) must be signed and received by the closing time and date specified, and on the forms furnished by the State to be considered for award. The State reserves the right to consider provided that a signature is shown on the facsimile.

c) The bidder is solely responsible for ensuring that the full bid is received by the State in accordance with the solicitation requirements, prior to the date and time specified in the solicitation, and at the place specified. The State shall not be responsible for any delays in mail or by common carriers or by transmission errors or delays or misdelivery.

d) Bids received after the time stated will be considered non- responsive.

e) If facsimile transmission of the bid is acceptable, and the bidder chooses to transmit their bid via facsimile, the bidder understands and agrees that the State will consider only those portions of the bid received prior to the closing time specified; any pages received after that time will not be considered.

f) If no time for receipt of bids is specified in the solicitation, the bid shall be due by the close of the business day on the date indicated. Close of the business day shall be 5:00 p.m. All times are Pacific Standard Time (PST)/Pacific Daylight Time (PDT).

g) Generally, sealed bids will be opened and read on the due date unless another date and time is specified in the solicitation or any addendum thereto or the reverse auction terms and conditions are included in the solicitation. When the Department of General Services, Procurement Division, facilitates a reverse auction all bids remain confidential before and during the auction. Information is not public, including the number and names of the responders, until the Notice of Intent to Award or contract award is published, whichever occurs first.

3. SOLICITATION ADDENDUM (ADDENDA):

a) If a supplier received this solicitation through some means other than being a prequalified lity of the supplier to advise the buyer of its intention to provide a bid so that addenda or other correspondence related to the solicitation will be sent to the supplier.

b) In the event that the solicitation is revised by an addendum, supplier shall submit the original solicitation and any addenda that the buyer requires be submitted.

c) Price(s) offered shall reflect all addenda issued by the State. Failure to do so will permit the State to interpret the bid to include all addenda issued in any resulting contract.

4. PRICES:

a) All prices and notations must be printed in ink or typewritten.

b) All prices must be bid in U.S. currency.

c) Unit prices may not be more than four (4) places to the right of the decimal point. For example, a unit price of $.56726 each, would exceed this limitation. Unit prices which exceed this limitation will automatically be truncated to the fourth decimal place for both evaluation and award purposes. Using the example just cited, the "6" at the end of the unit price would be truncated (i.e., dropped off) leaving a unit price of $.5672 each.

d) An error in the bid may cause the rejection of that bid; however, the State may at its sole option retain the bid and make certain arithmetic corrections. In determining if a correction will be made, the State will consider the conformance of the bid to the format and content required by the solicitation, and any unusual complexity of the format and content required by the solicitation.

i) the State may at its sole option correct an error based on that established intent.

ii) The State may at its sole option correct obvious clerical errors.

iii) The total price of unit-price items will be the product of the unit price and the quantity of the item. If the unit price is ambiguous, unintelligible or uncertain for any cause, or is omitted, it shall be the amount obtained price by the quantity of the item.

5. CASH DISCOUNTS:

The State encourages bidders to offer cash discounts for prompt payment, however, unless provided elsewhere in the solicitation, cash discounts offered by bidders for the prompt payment of invoices will not be considered in evaluating offers to determine the successful bidder for award of any resulting contract.

6. INSPECTION OF SOLICITATION DOCUMENTS:

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 bid. Failure to examine any document, risk.

7. BRAND NAMES:

Any reference to brand names and model numbers in the solicitation is intended to be descriptive, but not restrictive, unless otherwise specified Bids offering equivalent items meeting the standards of quality specified may be considered, unless otherwise specified, providing the bid clearly describes the article offered and how it differs from the referenced brand. Unless bidder specifies otherwise, it is understood that the bidder is offering a referenced brand item as specified in the solicitation. The State reserves the right to determine whether a substitute offer is equivalent to and meets the standards of quality indicated by the brand name references, and the State may require the supply of additional descriptive material and a sample.

8. EVALUATION OF BIDS:

a) Where more than one-line item is specified in the solicitation, the State reserves the right to determine the lowest responsible bidder, either on the basis of individual items, combination of items as specified in the solicitation, or on the basis of all items included in the solicitation, unless otherwise expressly provided.

b) Unless otherwise specified in the solicitation, the State may accept any item or combination of items as specified in the solicitation, of any bid unless the bidder expressly objects and conditions its response on receiving all items for which it provided a bid. In the event that the bidder so objects, the whether the award on such basis will result in the lowest price to the State or may determine in its sole discretion that such an objection is non-responsive and renders the bidder ineligible for award.

c) This solicitation is subject to all requirements set forth in the Electronic Waste Recycling Act of 2003 (Chapter 8.5, Part 3 of Division 30, commencing with Section 42460 of the Public Resources Code, relating to hazardous and solid waste, hereafter calle products and/or services being acquired pursuant to this solicitation are not subject to the Act, then bidder must demonstrate that the Act is inapplicable to all lines of business engaged by the supplier (or related agents, subsidiaries, partners, joint ventures, and sub-contractors).

Contracts awarded, wherein a violation of the Act is found, are subject to sanctions defined in Public Resources Code, Chapter 8.5, Article 7.

d) This solicitation is subject to all requirements set forth in Sections 6452, 6487, 7101 and 18510 of the Revenue and Taxation Code, and Section 10295.1 of the Public Contract Code, registration, and, if applicable, the permit or certification of all participating affiliates issued by solicitation, a nd, if applicable, the permit or certification of all participating affiliates, must be submitted within five (5) State business documentation will cause the bid to be considered non- responsive and the bid rejected.

e) Public Resources Code Section 42290 et seq. prohibits the State from contracting with any supplier, manufacturer, or wholesaler, and any of its divisions, subsidiaries, or successors that have been determined to be noncompliant to the recycled content plastic trash bag certification requirements. This includes award of a State contract or subcontract or renewal, extension, or modification of an existing contract or subcontract. Prior to award the State shall ascertain if the intended awardee or proposed subcontractor is a business identified on the current California Integrated Waste Management Board noncompliant list(s). In the event of any doubt of the status or identity of the business in violation, the State will notify the Board of the proposed award and afford the Board the opportunity to advise the State. No award will be made when either the bidder or a subcontractor has been identified either by published list or by advice from the Board, to be in violation of certification requirements.

f) All other criteria to be used in evaluating bids will be identified elsewhere in the solicitation.

9. CONFLICT OFINTEREST:

a) Current State Employees (PCC Section 10410):

i) No officer or employee shall engage in any employment, activity or enterprise from which the officer or employee receives compensation or has a financial interest and which is sponsored or funded by any State agency, unless the employment, activity or enterprise is required as a condition of regular State employment.

ii) No officer or employee shall contract on his or her own behalf as an independent contractor with any State agency to provide goods or services.

b) Former State Employees (PCC Section 10411):

For the two-year period from the date he or she left State employment, no former State officer or employee may enter into a contract in which he or she engaged in any of the negotiations, transactions, planning, arrangements or any part of the decision-making process relevant to the contract while employed in any capacity by any State agency.

c) For the twelve-month period from the date he or she left State employment, no former State officer or employee may enter into a contract with any State agency if he or she was employed by that State agency in a policy-making position in the same general subject area as the proposed contract within the twelve-month period prior to his or her leaving State service.

10.JOINT BIDS:

A joint bid submitted by two or more bidders participating jointly in one bid may be submitted and each participating bidder must sign the joint bid. If a contract is awarded to bidders who furnished a joint bid, it shall be deemed one indivisible contract. Each such joint contractor will be jointly and severally liable for the performance of the entire contract, and the joint contractors must designate, in writing, one individual having authority to represent them in all matters relating to the contract.

The State assumes no responsibility or obligation for the division of orders or purchases among joint contractors.

11.SAMPLES TO DETERMINE RESPONSIVENESS TO TECHNICAL REQUIREMENTS FOR

PURPOSES OF AWARD:

a) Samples of items, when required by the State, must be furnished free of expense to the State, unless otherwise provided.

b) Unless expressly set forth in the solicitation, the sample or samples furnished must be identical in all respects to the product or products being offered to the State.

c) Bidders offering products of a different manufacturer and model number than those specified in the solicitation may be required to submit samples for inspection and specification compliance testing in order for the State to determine if the item offered is equivalent to and meets the minimum standards of quality acceptable to the State as indicated by the manufacturer and model number specified in the solicitation.

d) Samples, if not destroyed by tests, may, upon request made at the time the sample is expense.

e) Samples may be required prior to award. If requested, such samples must be delivered to the address specified and within the timeframe identified in the notification. Failure to submit samples as specified may be grounds for rejection.

12.SPECIFICATION CONCERNS:

a) In the event a supplier believes that the State's solicitation is unfairly restrictive, ambiguous, contract would be commercially impractical to perform, the matter should be promptly brought to the attention of the buyer identified in the solicitation, either by telephone, letter or visit, immediately upon receipt of the solicitation, in order that the matter may be fully considered and appropriate action taken by the State prior to the closing time set to receive bids.

b) Unless otherwise specified, failure by any supplier to raise any concern relating to the solicitation requirements within at least two (2) working days prior to the bid close date, will be deemed a waiver of the for contract award relating to requirements.

13.VALIDITY OF BID:

-five (45) days following the date the response is due.

14.MISTAKE IN BID:

If prior to contract award, a bidder discovers a mistake in their bid which renders the bidder unwilling to perform under any resulting contract, the bidder must immediately notify the buyer and request will be permitted. If the solicitation contemplated evaluation and award items, then any withdrawal must be for the entire bid. If the solicitation provided for evaluation and award on a line item or combination of items basis, the State may consider permitting withdrawal of specific line item(s) or combination of items.

15.S RIGHTS:

a) The State reserves the right to modify or cancel in whole or in part its solicitation at any time prior to contract award.

b) was non-responsive to the solicitation requirements and to waive informalities and minor irregularities in bids received.

c) The State reserves the right to reject any or all bids if the State determines that a bidder is not a responsible supplier.

16.UNFAIR PRACTICES ACT AND OTHER LAWS:

Supplier warrants that its bid complies with the Unfair Practices Act (Business and Professions Code Section 17000 et seq.) and all applicable State and Federal laws and regulations.

17.VIOLATION OF AIR OR WATER POLLUTION LAWS:

a) Unless the contract is less than $25,000 or with a non- competitively bid contract supplier, Government Code Section 4477 prohibits the State from contracting with a person, including a corporation or other business association, who has been determined to be in violation of any state or federal air or water pollution control law.

b) Prior to an award, the State shall ascertain if the intended awardee is a person included in notices from the Boards. In the event of any doubt of the intended awardee's identity or status as a person who is in violation of any state or federal air or water pollution law, the State will notify the appropriate Board of the proposed award and afford the Board the opportunity to advise the State that the intended awardee is such a person.

c) No award will be made to a person who is identified either by the published notices or by advice, as a person in violation of state or federal air or water pollution control laws.

18.NON-DISCRIMINATION TOWARD WTO GPA SIGNATORIES:

Any contract resulting from this solicitation in excess of $554,000 is subject to the requirements of the World Trade Organization (WTO) Government Procurement Agreement (GPA). All bidders offering products or services of countries that are signatories to the WTO GPA and that have agreed to cover reciprocal sub central coverage under the WTO GPA will be accorded non-discriminatory treatment in the award of contracts under this solicitation. These countries currently include the member states of the European Union (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden, and the United Kingdom), Aruba, Hong Kong, Singapore, Israel, Japan, Korea, Liechtenstein, Norway, and Switzerland.

19.INDEPENDENCE OF BID:

Unless supplier is furnishing a joint bid, by submitting this bid, bidder swears under penalty of perjury that it did not conspire with any other supplier to set prices in violation of anti-trust laws.

20.BID EVALUATION PREFERENCES:

In evaluating bids, the State will give preferences in accordance with the law for suppliers who are a California certified Small Business. If the bidder claims preferences under the Enterprise Zone Act (EZA), Target Area Contract Preference Act (TACPA) and Local Agency Military Base Recovery Area (LAMBRA) Act, the bidder must complete and return the appropriate forms incorporated in the solicitation. Preferences may also be given for bidders using recycled products in accordance with Public Resources Code Section 42890 et seq. Where multiple preferences are claimed, the State will verify eligibility for the preference(s) and evaluate and apply preference(s) in accordance with law and established procedures.

21.PROTESTS:

The Department of General Services, Procurement Division, has appointed a Protest Coordinator to serve as the primary point of contact for handling: (1) initial protests of solicitation requirements as allowed for in Public Contract Code (PCC) Section 12102(h); (2) protests of proposed awards for commodities (PCC Section 10306) and information technology goods and services (PCC Section 12102[h]); and (3) the Alternative Protest Process (PCC Section 12125 et seq.). A Supplier Advocate has been established in accordance with PCC Section 10300 as a resource to protesting bidders seeking assistance and information. Contact the buyer or contact the Procurement Division at (916) 375-4400 for assistance.

22.INDEPENDENT CONTRACTOR REPORTING REQUIREMENTS:

Any independent contractor, prior to being awarded a purchase order which contains services, must provide certain information pertaining to its business to the State. The State, in accordance with Unemployment Insurance Code Section 1088.8, will report such information to the Employment Development Department. By submitting a bid, bidder acknowledges this information is required and that it is being reported to the Employment Development Department.

23.LOSS LEADER:

It is unlawful for any person engaged in business within this state to sell or use any article or ssions Code.

(PCC 10302(b) and 12104.5(b).).

23.AMERICANS WITH DISABILITY ACT (ADA):

To comply with the non-discrimination requirements of the ADA, it is the policy of the State to make every effort to ensure that its programs, activities and services are available to all persons, including persons with disabilities. For persons with a disability needing a reasonable modification to participate in the procurement process, or for persons having questions regarding reasonable modifications for the procurement process, you may contact the buyer listed elsewhere in this solicitation.

a) If the contracting agency issuing this solicitation is an agency other than the Department of

General Services, Procurement Division, the telephone numbers for TTY/TDD (telephone device for the deaf) or California Relay Service Numbers will be provided elsewhere in this solicitation.

b) If the agency issuing this solicitation is the Department of General Services, Procurement Division, you may also contact the Procurement Division at (916) 375-4400 (main office), or contact the Procurement Division TTY/TDD (telephone device for the deaf) or California Relay Service Numbers, as follows:

Procurement Division TTY:

Sacramento Office: (916) 376-1891 California Relay Service:

Voice: 1-800-735-2922 or 1-888-877-5379 TTY: 1-800-735-2929 or 1-888-877-5378 Speech to Speech: 1-800-854-7784

Note: To ensure that we can meet your need, it is best that we receive your request for reasonable modification at least 10 working days before the scheduled event or the due date for procurement documents.

STATE OF CALIFORNIA, NATURAL RESOURCES AGENCY Page 1 of 2

DARFUR CONTRACTING ACT VENDOR CERTIFICATION

CAL FIRE-720 (REV. 08/21)

DARFUR CONTRACTING ACT VENDOR CERTIFICATION

Pursuant to Public Contract Code Section 10475-10481, 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 (see attached definition).

Therefore, to be eligible to submit a bid or proposal, please complete the company/vendor information and one of the three following clauses (NOTE: Clause #1 requires initials only; Clause #2 requires initials only;

Clause #3 requires initials and a certification signature):

DATE

FEDERAL ID NUMBER

PRINTED COMPANY / VENDOR NAME

PRINTED NAME AND TITLE OF AUTHORIZED PERSON INITIALING AN OPTION BELOW

Complete ONLY ONE of the following:

1.

We do not currently have, and have not had within the previous three (3) years, business activities or other operations outside of the United States.

Initials only

OR

2. 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 (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.

Initials only

OR

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

Initials only certification below

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 AUTHORIZED PERSON SIGNING

DATE EXECUTED

EXECUTED IN THE COUNTY AND STATE OF

STATE OF CALIFORNIA, NATURAL RESOURCES AGENCY Page 2 of 2

DARFUR CONTRACTING ACT VENDOR CERTIFICATION

CAL FIRE-720 (REV. 08/21)

DEFINITION of SCRUTINIZED COMPANY

PUBLIC CONTRACT CODE SECTION 10476

10476. As used in this article, the following definition applies:

"Scrutinized company" means a company in Sudan that is involved in power production activities, mineral extraction activities, oil-related activities, or the production of military equipment, but excludes a company that can demonstrate any of the following:

(a) Its business operations are conducted under contract directly and exclusively with the regional government of southern Sudan.

(b) Its business operations are conducted under a license from the Office of Foreign Assets Control or are expressly exempted under federal law from the requirement to be conducted under such a license.

(c) Its business operations consist of providing goods or services to marginalized populations of

Sudan.

(d) Its business operations exclusively consist of providing goods or services to an internationally recognized peacekeeping force or humanitarian organization.

(e) Its business operations consist of providing goods or services that are used only to promote health or education.

(f) Its business operations with the Government of Sudan will be voluntarily suspended for the entire duration of the contract for goods or services for which they have bid on, or submitted a proposal for, a contract with a state agency.

(g) It has adopted, publicized, and is implementing a formal plan to cease business operations within one year and to refrain from conducting any new business operations.

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.