California Tax Extension Form

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					                                                                                 CHECK REQUEST FORM                                                      NOTE: FOR ALL PAYMENTS TO INDIVIDUALS OR PARTNERSHIPS FOR
                                                                                    (NON-PAYROLL)                                                        RENTS, ROYALTIES, INTEREST, FELLOWSHIPS, PERSONAL SERVICES, ETC.,
                                                                                                                                                         THAT ARE SUBJECT TO INCOME TAX REPORTING, COMPLETE THE SECTION
                                                                                        U 5 (R-7/99)
                                                                                                                                                         BELOW.
NAME
STREET
CITY
STATE
ZIP
COUNTRY
DATE PREPARED                                                                                                                                            RESIDENT OF CALIFORNIA
VENDOR NUMBER                                                                                                                                            YES                NO
TAX CODE                                                                                                                                                 IF NON-U. S. CITIZEN, COUNTRY OF RESIDENCE                     VISA TYPE
INVOICE NUMBER
DATE NEEDED                     PICK-UP            CAMPUS MAIL           U.S. MAIL           DEPARTMENT                                   EXTENSION      SOCIAL SECURITY NUMBER                         FEDERAL TAX ID NUMBER
01/00/00                                                                 U.S. MAIL           Library - Acquisitions Accounts Unit         4381
                                                                                             E-MAIL ADDRESS                              IS PAYEE A UC EMPLOYEE                                         EMPLOYEE WITHOUT SALARY
                                                                                                                                         YES             NO                                             YES          NO
AUTHORIZING SIGNATURE                                                    DATE                SIGNATURE FOR AUTHORIZATION OF EXPENDITURES AS AN EXCEPTION                                                                DATE


TYPE NAME AND TITLE                                                                          TYPE NAME AND TITLE - DEAN, V/C, EVC, ASSISTANT CHANCELLOR, OR CHANCELLOR                                                  UCR ACCOUNTING AUDIT




DIRECT CHARGES                                                           LEASE                            BLANKET PURCHASE ORDER                                   PURCHASE ORDER                       SUB-PURCHASE ORDER
                                                                         PURCHASE
      REIMBURSEMENT TO EMPLOYEE                                          NUMBER                           NUMBER                                                   NUMBER                               NUMBER
      PETTY CASH                                                         EXPLANATION                                                                                                                                                AMOUNT
      CASUAL LABOR                                                                                         Prepayment for:
      MEMBERSHIP FEE                                                     Cost
      HONORARIUM                                                         Shipping
      PERFORMANCE AGREEMENT                                              Tax
      AGREEMENT ALLOWANCE (UNEX ONLY)                                    Total
      SUB CONTRACT
      FREIGHT                                                            PO.
      TELEPHONE BILLS
  X   OTHER
GENERAL CATA


FULL ACCOUNTING UNIT - TO BE CHARGED
                                                                                    LINE                                                                                                                                          LINE REFERENCE
                                                                                 DISTRIBUT
                                                                                    ION                                                                                           COST
Line#  VENDOR NUMBER           DATE                INVOICE NUMBER GROSS AMOUNT AMOUNT DESCRIPTION (OPTIONAL)                                ACCOUNT       FUND ACTIVITY FUNCTION CENTER                      PROJECT #2
                                                                                                                                                                                                        PROJECT #1 OPEN ITEM
                                                                                                                                                                                                                         (VOUCHER NUMBER)
    1                         01/00/00             0000F5                   0.00    0.00                                                     803250       19900 A01169     60     ALSE
    2
    3
    4
    5
    6
FULL ACCOUNTING UNIT - TO BE CHARGED
                                                                                  LINE                                                                                                        COST                                LINE REFERENCE
                                                                               DISTRIBUT
                                                                                  ION
Line#      VENDOR NUMBER DATE                      INVOICE NUMBER GROSS AMOUNT AMOUNT DESCRIPTION (OPTIONAL) ACCOUNT                                       FUND ACTIVITY FUNCTION CENTER PROJECT #1 OPEN ITEM  PROJECT #2       (VOUCHER NUMBER)
    7
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RETENTION: ACCOUNTING: 5 YEARS SUBJECT TO CONTRACT AND GRANT REQUIREMENTS/OTHER COPIES: 0-5 YEARS                                                                                                                       ACCOUNTING OFFICE
PRIVACY NOTIFICATION: STATE - The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following information to individuals who are asked to supply personal information about
requesting this information on this form is to report payments for income tax purposes to Federal and State governments, as applicable. University policy and State and Federal statutes authorize the maintenance of this information; 2) Furnishing all
provide such information will delay or may even prevent the payment for which this form is being filled out. Information furnished on this form is used by University departments for nonpayroll payments, and may be transmitted to the State and
the right of access to this record as it pertains to themselves; 4) Campus Accounting Officers are responsible for maintaining the information contained on this form.
FEDERAL - Pursuant to the Federal Privacy Act of 1974, you are hereby notified that disclosure of your social security number is mandatory. Disclosure of the social security number is required pursuant to Section 6011 and 6015 of Subtitle F of
Regulation 4, Section 404.1256, Code of Federal Regulations under Section 218, Title II of the Social Security Act, as amended. The social security number is used to verify your identity. The principal uses of the number shall be to report
governments.

				
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