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STATE OF CALIFORNIA-DEPARTMENT OF FINANCE <br />PAYEE DATA RECORD <br />(Required when receiving payment from the State of California in Ileu of IRS W-9 or W-7) <br />STD 204 (ReV. 512018) <br />1 <br />INSTRUCTIONS: Type or print the Information. Complete all Information on this form. Sign, date, and retu n to the state <br />agency (department/office) address shown in Box 6. Prompt return of this fully completed form will pre 6 t delays when <br />processing payments. <br />Information provided In this form will be used by California state agencies to prepare Information Rat r s (FOrm1099). See next <br />page for more information and Privacy Statement. <br />NOTE: Governmental entities, i.e. federal, state, and local (Including school districts), are not re fired to submit this form. <br />BUSINESS NAME(Asshmnonyourincomel mmm) <br />2 <br />SOLE PROPRIETOR, SINGLEMEMBER LLC,INDIVIDUAL pamaosshmnon SSNorITIN)last Flat, Ml <br />AILADDRESS <br />MAILING ADDRESS <br />BUSINESS AD ESS <br />CITY <br />STATE <br />ZIP CODE <br />CITY <br />STATE <br />ZIPCODE <br />3 <br />ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): / <br />NOTE: <br />PAYEE <br />ā‘ PARTNERSHIP CORPORATION: <br />Payment will not <br />be processed <br />ENTITY <br />ESTATE OR TRUST O MEDICAL (,gā€ž dentistry, psychotherapy, cMropmollc, etc.) <br />withoutan <br />TYPE <br />LEGAL <br />0 (g.., attorney services) <br />accompanying <br />taxpayer <br />CHECK <br />Q EXEMP (nonprofit) <br />Q ALL, THEIRS <br />Identification <br />number. <br />ONE BOX <br />ONLY <br />ENTER SSN ]TIN: <br />SOLE PROPRIETOR, INDIVIDUAL, OR Sodal Security Number(SSIV) orindividuet Texpeyerldenfi6cation <br />SINGLE MEMBER LLC (Disregarded Entity) Number (MIN) ere Mqulmd by eutfrodty of Calltomla Revenue and <br />Tax Code sections 1S646 and 16661) <br />ā‘ CALIFORNIA RESIDENT- Quali/Iobusiness in California or maintains a permanent place of business In California. <br />CALIFORNIA NON RESIDENT (ge for morn lnhxnaaffon) -Payments to nonresidents for services maybe subject <br />PAYEE <br />to state Income tax wilhh0ldlrg. <br />IRESIDENCN <br />C7 No services performed in California <br />STATUS <br />0 Copy of Franchise Tax Board waiver of slate withholding attached. <br />1 hereby certify under peya Ity of perjury that the information provided on this document is true and correct. <br />6 <br />Should my residency st tus change, I will promptly notify the state agency below. <br />AUTHORIZED PAYEE REPRESENTATIVE'S NAME (Type or Print) <br />TITLE <br />TELEPHONE (Include area code) <br />SIGNATURE /,/ <br />DATE <br />E-MAIL ADDRESS <br />Please re O rn Completed form to: <br />6 <br />DEPARTMENTIOFFICE <br />UNITISECTION <br />MAILING ADDRESS <br />TELEPHONE (include area code) <br />FAX <br />CITY <br />STATE <br />ZIP CODE <br />EMAIL ADDRESS <br />