STD204_-_Payee_Data_Record.pdf

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. 4/2017)

INSTRUCTIONS: Type or print the information. Complete all information on this form. Sign, date, and return to the state agency (department/office) address shown in Box 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 to prepare Information Returns (Form1099). See next page for more information and Privacy Statement.

NOTE: Governmental entities, i.e. federal, state, and local (including school districts), are not required to submit this form.

(SSN required by authority of California Revenue and Tax Code sections 18646 and 18661)

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.

Please return completed form to:

ZIP CODESTATECITYZIP CODESTATECITY

BUSINESS ADDRESSMAILING ADDRESS

E-MAIL ADDRESSSOLE PROPRIETOR OR INDIVIDUAL– ENTER NAME AS SHOWN ON SSN (Last, First, M.I.)

PAYEE’S LEGAL BUSINESS NAME (As shown on your income tax return)

ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN):

PARTNERSHIP

ESTATE OR TRUST MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.)

CORPORATION:

LEGAL (e.g., attorney services)

EXEMPT (nonprofit)

ALL OTHERS

SOLE PROPRIETOR OR INDIVIDUAL

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

CALIFORNIA NON RESIDENT (see next page for more information) - 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 attached.

AUTHORIZED PAYEE REPRESENTATIVE’S NAME (Type or Print) TITLE

SIGNATURE DATE

TELEPHONE (include area code)

UNIT/SECTIONDEPARTMENT/OFFICE

ZIP CODESTATECITY

MAILING ADDRESS TELEPHONE (include area code)

E-MAIL ADDRESS

FAX

PAYEE

ENTITY

TYPE

CHECK

ONE BOX

ONLY

PAYEE

RESIDENCY

STATUS

NOTE:

Payment will not be processed without an accompanying taxpayer identification number.

E-MAIL ADDRESS

Enter social security number (SSN) or Individual taxpayer identification number (ITIN)

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. 4/2017)

Requirement to Complete the Payee Data Record, STD 204

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).

Enter the payee's legal business name. The name must match the name on the payee's tax return as filed with the federal Internal Revenue Service. Sole proprietorships must also include the owner's full name. An individual must list his/her full name as shown on the SSN or as entered on the W-7 form for ITIN.

The mailing address should be the address at which the payee chooses to receive correspondence (i.e. 1099 form) and payments. The business address is the address of the business' physical location; do not enter the payment address or lock box information here.

Check only one box that corresponds to the payee business type. Corporations must check the box that identifies the type of corporation.

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 the R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and the preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Payees must provide one of the following TINs on this form: social security number (SSN), individual taxpayer identification number (ITIN), or federal employer identification number (FEIN). The TIN for sole proprietorships and individuals is the SSN or ITIN. Only partnerships, estates, trusts, and corporations will enter their FEIN.

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.

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.

Payments to all nonresidents may be subject to withholding. Nonresident payees performing services in California or receiving rent, lease, or royalty payments from property (real or personal) located in California will have 7% of their total payments withheld for state income taxes. However, no withholding is required if total payments to the payee are $1,500 or less for the calendar year.

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

Provide the name, title, email address, signature, and telephone number of the individual completing this form. Provide the date the form was completed.

This section must be completed by the state agency 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.

http://www.ftb.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. 4/2017)

PAYEE DATA RECORD

FICDIAZ

6.1.0.20150517.1.919161 Section 4

Section 3 INSTRUCTIONS: Type or print the information. Complete all information on this form. Sign, date, and return to the state agency (department/office) address shown in Box 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 to prepare Information Returns (Form1099). See next page for more information and Privacy Statement.

NOTE: Governmental entities, i.e. federal, state, and local (including school districts), are not required to submit this form.

INSTRUCTIONS: Complete all information on this form. Sign, date, and return to the State agency (department/office) address shown at the bottom of this page. Prompt return of this fully completed form will prevent delays when processing payments. Information provided in this form will be used by State agencies to prepare Information Returns (1099). See reverse side for more information and Privacy Statement. NOTE: Governmental entities, federal, State, and local (including school districts), are not required to submit this form.

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.

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.

Please return completed form to:

Please return completed form to:

Section One Section 2 Section 5

Section 6

CORPORATION:

CORPORATION

PAYEE ENTITY TYPE

PAYEE ENTITY TYPE

CHECK ONE BOX ONLY

CHECK ONE BOX ONLY

PAYEE RESIDENCY STATUS

PAYEE RESIDENCY STATUS

NOTE:

Payment will not be processed without an accompanying taxpayer identification number.

NOTE:

Payment will not be processed without an accompanying taxpayer I.D. number.

Enter social security number (SSN) or Individual taxpayer identification number (ITIN) Enter social security number (SSN) or Individual taxpayer identification number (ITIN) Section 4 details

Section 3 details Section 1 details Section 2 details Section 5 details Section 6 details Requirement to Complete the Payee Data Record, STD 204 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).

Enter the payee's legal business name. The name must match the name on the payee's tax return as filed with the federal Internal Revenue Service. Sole proprietorships must also include the owner's full name. An individual must list his/her full name as shown on the SSN or as entered on the W-7 form for ITIN. The mailing address should be the address at which the payee chooses to receive correspondence (i.e. 1099 form) and payments. The business address is the address of the business' physical location; do not enter the payment address or lock box information here.

Check only one box that corresponds to the payee business type. Corporations must check the box that identifies the type of corporation.

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 the R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and the preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Payees must provide one of the following TINs on this form: social security number (SSN), individual taxpayer identification number (ITIN), or federal employer identification number (FEIN). The TIN for sole proprietorships and individuals is the SSN or ITIN. Only partnerships, estates, trusts, and corporations will enter their FEIN.

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.

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.

Payments to all nonresidents may be subject to withholding. Nonresident payees performing services in California or receiving rent, lease, or royalty payments from property (real or personal) located in California will have 7% of their total payments withheld for state income taxes. However, no withholding is required if total payments to the payee are $1,500 or less for the calendar year.

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 Provide the name, title, email address, signature, and telephone number of the individual completing this form. Provide the date the form was completed.

This section must be completed by the state agency 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.

Section 4 Section 3 INSTRUCTIONS: Complete all information on this form. Sign, date, and return to the State agency (department/office) address shown at the bottom of this page. Prompt return of this fully completed form will prevent delays when processing payments. Information provided in this form will be used by State agencies to prepare Information Returns (1099). See reverse side for more information and Privacy Statement. NOTE: Governmental entities, federal, State, and local (including school districts), are not required to submit this form.

9 digit social security number. Required by authority of California Revenue and Tax Code Section 18646) 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.

Please return completed form to:

Section One Section 2 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 Section 5 Section 6 9 digit Federal Employer Identification Number 0,0,0 0,0,0 0,0,0

CORPORATION

0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0

PAYEE ENTITY TYPE

CHECK ONE BOX ONLY

PAYEE RESIDENCY STATUS

NOTE:

Payment will not be processed without an accompanying taxpayer I.D. number.

0,0,0 0,0,0 0,0,0 Enter social security number (SSN) or Individual taxpayer identification number (ITIN) Section 4 details Section 3 details Section 1 details Section 2 details Section 5 details Section 6 details