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					                                                                                       Procurement & Support Services

                                                                                        California State University San Marcos
                                                                                       San Marcos, California 92096-0001 USA

                                                                                        Tel: 760 750-4555: Fax: 760 750-3286
                                                                                                 www.csusm.edu/Procurement/




JULY 29, 2012


TO WHOM IT MAY CONCERN:

IMPORTANT INFORMATION REGARDING PAYMENT AND THE “PAYEE DATA
RECORD” FORM (204):

Federal law requires us to maintain information on vendors who do business with state agencies
such as Cal State University San Marcos. The State of California is required under Section 18802
of the State Revenue and Taxation Code and Section 6041 of the Internal Revenue Service (IRS)
Code to file Information Returns (1099) for certain vendors. Additionally, the state requires every
vendor entering into a contract with a state agency to provide his/her Taxpayer Identification
Number (TIN). This is in lieu of a W9.

To comply with federal requirements, the state requires a Payee Data Record form to be completed
for each vendor doing business with a state agency. If we fail to receive the completed form,
payment of your invoice cannot be made.

Enclosed is a Payee Data Record form & Vendor Questionnaire. Please fully complete and return
both forms via postal carrier or fax to: (760-750-3286). The Payee Data Record form MUST be
received PRIOR to processing your payment(s).

Should you have any questions, please call Procurement & Support Services at 760-750-4555.

Thank you for your cooperation in this matter.
STATE OF CALIFORNIA
PAYEE DATA RECORD
(Required in lieu of IRS W-9 when doing business with the State of California)
CSUSM 204
NOTE: Governmental entities, federal, state, and local (including public school districts) are not required to submit this form.
                   DEPARTMENT/OFFICE
                   CALIFORNIA STATE UNIVERSITY SAN MARCOS                                                  PURPOSE: Information contained in this form
                                                                                                           will be used by state agencies to prepare
      1            ADDRESS
                   ATTN: ACCOUNTS PAYABLE
                                                                                                           information Returns (Form 1099) and for
                                                                                                           withholding on payments to nonresident payees.
  PLEASE           333 S. TWIN OAKS VALLEY ROAD                                                            Prompt return of this fully completed form will
  RETURN           CITY, STATE, ZIP CODE                                                                   prevent delays when processing payments.
    TO:            SAN MARCOS, CA 92096-0001
                                                                                                                  (See Privacy Statement on reverse)
                   TELEPHONE/FAX
                   (760) 750-4555 or Fax to (760) 750-3286
                   PAYEE’S BUSINESS NAME


      2            SOLE PROPRIETOR – ENTER OWNER’S FULL NAME HERE (Last, First, M.I.)

  NAME             MAILING ADDRESS (Number and Street or P.O. Box Number)
   AND
 ADDRESS           (City, State, and Zip Code)

                   PAYEE PHONE NUMBER                                                                      PAYEE FAX NUMBER


                        INDIVIDUAL/SOLE                        PARTNERSHIP                ESTATE OR TRUST                       NOTE:
                   PROPRIETOR (Must provide                                                                                     Government entities
                   Social Security #)                                                                                           are not required to
      3               LIMITED                                  EXEMPT                                                           submit this form.
 VENDOR            LIABILITY COMPANY                       ORGANIZATION
 ENTITY &                                                  (Nonprofit)
 PAYMENT                MEDICAL CORPORATION                     LEGAL (e.g.,            ALL OTHER
   TYPE             (e.g., dentistry, podiatry,            attorney services)        CORPORATIONS
                   chiropractic,        optometry, etc.)   CORPORATION
                        GOODS                                                             SERVICES ONLY
                                                           GOODS/SERVICES
                        RENT                                   OTHER
                   SOCIAL SECURITY NUMBER REQUIRED FOR INDIVIDUAL/SOLE PROPRIETOR BY AUTHORITY OF THE                           NOTE: Payment will
                   REVENUE AND TAXATION CODE SECTION 18646 (See reverse)                                                        not be processed
                                                                                                                                without
      4            FEDERAL EMPLOYERS IDENTIFICATION NUMBER (FEIN)                 SOCIAL SECURITY NUMBER/ITIN                   accompanying
  PAYEE’S                               -                                                             -    -                    taxpayer I.D. number.
 TAXPAYER          IF PAYEE ENTITY TYPE IS A CORPORATION, PARTNER-SHIP,           IF PAYEE ENTITY TYPE IS INDIVIDUAL OR
                   ESTATE OR TRUST, ENTER FEIN.                                   SOLEPROPRIETOR, ENTER SSN.
    I.D.                                                                          ITIN / SSN IF RESIDENT OF FOREIGN COUNTRY.
  NUMBER
                   Check All Boxes that Apply                                                                                   NOTE:
      5            Federal Income Tax Withholding Status (Applies to Individuals Only):                                         Prior to making payments to
                                                                                                                                foreign citizens, United
   PAYEE                I am a U.S. Citizen         I am a Permanent Resident Alien and I have a Green Card                     States tax laws require all
 RESIDENCY                                                                                                                      employers to perform a tax
                       I am not a U.S. Citizen and I do not have a Permanent Resident Green Card
DECLARATION                                                                                                                     analysis with respect to
                   Note: All Foreign Citizens/Entities must complete a tax analysis before payments can be made.
  FOR TAX                                                                                                                       country of citizenship to
 PURPOSES              Tax Exempt by Tax Treat. Country of Residency:                                                           determine residency for
                        TIN RCS                                                                                                 Federal tax purposes.
                                                                                                                                (Please see Reverse)
 All payments
 made by the       California State Tax Withholding Status (Applies to all Payees):                                             NOTE:
                                                                                                                                An estate is a resident if
University are         California Resident Qualified to do business in CA or have a permanent place of business in CA.
                                                                                                                                decedent was a California
  subject to            California Nonresident (See Reverse). Payments to CA nonresidents may be subject to state taxes.        resident at time of death. A
 Federal and                     A Waiver from CA state tax withholding is attached (From the California Franchise Tax          trust is resident if one or more
California State             Board).
                                                                                                                                trustees are CA residents.
   tax laws                                                                                                                     Rules for assessing State
                                 All services related to this payment were performed OUTSIDE of the state of California.        taxes differ significantly
                                                                                                                                from Federal tax rules.
                                                                                                                                (Please see Reverse)
                   I hereby certify under penalty of perjury under the laws of the State of California that the information provided on
      6            this document is true and correct. If my residency status should change, I will promptly inform you .
CERTIFYING         AUTHORIZED PAYEE REPRESENTATIVE’S NAME (Print)                    TITLE
SIGNATURE
                   SIGNATURE                                                         DATE                              TELEPHONE NUMBER
           
REV10/07
PAYEE DATA RECORD
CSUSM. 204 (REV.10/07) (REVERSE)

ARE YOU A RESIDENT OR A NONRESIDENT?                                     ARE YOU SUBJECT TO NONRESIDENT WITHHOLDING?

Each corporation, individual/sole proprietor, partnership,               Payments made to nonresident payees, including corporations,
estate or trust doing business with the State of California must         individuals, partnerships, estates and trusts, are subject to
indicate their residency status along with their taxpayer                withholding. Nonresident payees performing services in
identification number.                                                   California or receiving rent, lease or royalty payments from
                                                                         property (real or personal) located in California will have 7% of
A corporation will be considered a "resident" if it has a                their total payments withheld for state income taxes. However,
permanent place of business in California. The corporation has           no withholding is required if total payments to the payee are
a permanent place of business in California if it is organized           $1500 or less for the calendar year.
and existing under the laws of this state or, if a foreign
corporation has qualified to transact intrastate business. A             A nonresident payee may request that income taxes be
corporation that has not qualified to transact intrastate business       withheld at a lower rate or waived by sending a completed
(e.g., a corporation engaged exclusively in interstate commerce)         form FTB 588 to the address below. A waiver will generally be
will be considered as having a permanent place of business in            granted when a payee has a history of filing California returns
this state only if it maintains a permanent office in this state         and making timely estimated payments. If the payee activity is
that is permanently staffed by its employees.                            carried on outside of California or partially outside of
                                                                         California, a waiver or reduced withholding rate may be
For individuals/sole proprietors, the term "resident" includes           granted. For more information, contact:
every individual who is in California for other than a
temporary or transitory purpose and any individual domiciled             Franchise Tax Board
in California who is absent for a temporary or transitory                Nonresident Withholding Section
purpose. Generally, an individual who comes to California for            Attention: State Agency Withholding Coordinator
a purpose which will extend over a long or indefinite period             P.O. Box 651 Sacramento, CA 95812-0651
will be considered a resident. However, an individual who                Telephone: (916) 845-4900
comes to perform a particular contract of short duration will be         FAX: (916)-845-9512
considered a nonresident.
                                                                         If a reduced rate of withholding or waiver has been authorized
For withholding purposes, a partnership is considered a                  by the Franchise Tax Board, attach a copy to this form.
resident partnership if it has a permanent place of business in
California. An estate is considered a California estate if the           FOREIGN CITIZENS and FOREIGN BUSINESSES
decedent was a California resident at the time of death and a            Federal tax withholding regulations differ significantly from
trust is considered a California trust if at least one trustee is a      California tax withholding requirements. Certain information
California resident.                                                     is required in order to obtain a proper tax analysis. Please note
                                                                         that the University cannot process any payments without this
More information on residency status can be obtained by                  information. Please contact Cal State San Marcos at 760-750-
calling the Franchise Tax Board at the numbers listed below:             4424 for the required information.

    From within the United States, cal1 …1-800-852-5711                  IRS website for tax analysis and forms: http://www.irs.gov
    From outside the United States, call …1-916-845-6500
    For hearing impaired with TDD, call…1-800-822-6268

                                                           PRIVACY STATEMENT
Section 7(b) of the Privacy Act of 1974 (Public Law 93                                         r local governmental agency which
requests an individual to disclose his 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.

The State of California requires that all parties entering into business transactions that may lead to payment(s) from the State must
provide their Taxpayer Identification Number (TIN) as required by the State Revenue and Taxation Code, Section 18646 to facilitate tax
compliance enforcement activities and to facilitate the preparation of Form 1099 and other information returns as required by the
Internal Revenue Code, Section 6109(a). The TIN for individual and sole proprietorships is the Social Security Number (SSN).

It is mandatory to furnish the information requested. Federal law requires that payments for which the requested information is not
provided be subject to a 31% 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.

Please call the Department of Finance, Fiscal Systems and Consulting Unit at (916) 324                                       ng this
Privacy Statement. Questions related to residency or withholding should be referred to the telephone numbers listed above. All other
questions should be referred to the requesting agency listed in Section 1.
                                                                  PROCUREMENT & SUPPORT SERVICES
                                                                VENDOR/CONTRACTOR QUESTIONNAIRE
UNIVERSITY CONTACT INFORMATION
CALIFORNIA STATE UNIVERSITY SAN MARCOS
PROCUREMENT & SUPPORT SERVICES
SAN MARCOS, CALIFORNIA 92096-0001
P: (760) 750-4555   F: (760) 750-3286

VENDOR/CONTRACTOR INFORMATION:

COMPANY NAME:

MAILING ADDRESS                                                                                MAIL STOP

CITY                                                                                     STATE                       ZIP

TELEPHONE NO.                   (       )                                                FAX        (    )

FEDERAL ID NO.                                                    EMAIL

TO COMPLY WITH STATE REPORTING REQUIREMENTS, PLEASE COMPLETE THE FOLLOWING:
1)     Of the following, please check ALL that apply:
      Large Business

      Small Business                                      OSBCR Certificate No

      Micro Business                                      OSBCR Certificate No

      Disabled Veteran Owned Business                     OSBCR Certificate No

      Non-Profit Corporation

      Non-Profit Government Agency

      Woman Owned Business
2a)    Do you sell products which utilize recycled materials?                                     Yes.                           No.
2b)    Do you package products with recycled materials?                                           Yes.                           No.
3)     Race
         American Indian or Alaska Native                                   Native Hawaiian or Pacific Islander
         Asian                                                              White
         Black or African American                                          Other:
4)     Ethnicity
         Asian-Indian: Origins from India, Pakistan or Bangladesh
         Black or African American: Origins from any of the black racial groups of Africa
         Hispanic: Origins from Mexico, Puerto Rico, Cuba, Central or South America or other Spanish or Protuguese culture of origin,
         regardless of race
         Native American: Origins are American Indian, Eskimo, Aleut or Native Hawaiian
         Pacific-Asian: Origins are from Japan, China, Taiwan, Korea, Vietnam, Laos, Cambodia, the Philippines, Samoa, Guam or the United
         States Trust Territories of the Pacific including the Northern Marianas.
         Other: Any other group of natural persons identified as minorities:
Company Official: (Print Name)                                                                      Title:

Company Official Signature:                 ✍                                                       Date

				
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