Laserfiche WebLink
STATE OF CALIFORNIAAEPARTMENT OF FINANCE <br />PAYEE DATA RECORD <br />(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) <br />STD 204 (Rev. 512018) <br />INSTRUCTIONS: Type or print the information. Complete all information on this form. Sign, date, and return to the state <br />1 <br />agency (departmentloffiice) address shown in Box 6. Prompt return of this fully completed form will prevent delays when <br />processing payments. <br />Information provided in this form will be used by California state agencies to prepare Information Returns (Form1099). See next <br />a for more information and Privacy Statement. <br />NOTE: Governmental entities, i.e. federal, state, and lo_c �nciuding school districts), are not required to submit this form. <br />BUSINESS NAME (AssMwn on yourhimme toe/alum) <br />2 <br />SOLE PROPRIETOR, SINGLE MEMBER LLC, INDIVIDUAL (Name as shown on 85NmInM Last First, Ml <br />E-MAIL ADDRESS <br />MAILING ADDRESS <br />BUSINESS ADDRESS <br />CITY <br />STATE <br />ZIP CODE <br />CITY <br />STATE <br />ZIP CODE <br />3 <br />ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): <br />NOTE: <br />PAYEE <br />PARTNERSHIP CORPORATION• <br />Payment will not <br />be processed <br />ENTITY <br />ESTATE OR TRUST Q MEDI L (e.g., dentistry, psychotherapy, chiropractic, etc.) <br />without an <br />TYPE <br />\ X Q AL (e.g., attorneyservices) <br />accompanying <br />YY <br />EXEMPT (nonprofit) <br />taxpayer <br />identification <br />CHECK <br />O ALLOTHERS <br />number. <br />ONE BOX <br />ONLY <br />ER SSN OR ITIN: <br />Z,OR <br />SOLE PROPRIETOR, INDIVIDSocial Security Number (SSN)orindividua( Taxpayerldenbficatlon <br />SINGLE MEMBER LLC (Dis ity) Number are required by authority of California Revenue and <br />Tax Code sections 18646 and 18661) <br />4 <br />T- Qualified to do business in California or maintains a permanent place of business in California. <br />CALI/RNIAN7 <br />�CALISIDENT( seenextpage for moreInformation)- Payments to nonresidents for services may be subject <br />PAYEE <br />to stathholdingRESIDENC <br />Oormed In CalforniaSTATUS <br />Oe Tax Board waiver of state withholding attached. <br />1 here certify under penalty of perjury that the information provided on this document is true and correct. <br />5 <br />Sho d my residency status change, I will promptly notify the state agency below. <br />T—RIZED PAYEE REPRESENTATIVE'S NAME (Type or Print) <br />TITLE <br />TELEPHONE (include area code) <br />SIGNATURE <br />DATE <br />E-MAILADDRESS <br />Please return completed form to: <br />6 <br />DEPARTMENT/OFFICE <br />UNIT/SECTION <br />MAILING ADDRESS <br />TELEPHONE (include area code) <br />FAX <br />CITY <br />STATE <br />ZIPCODE <br />E-MAILADDRESS <br />