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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 lieu of IRS W-9 or W-7) <br />STD 204 (Rev. 5/2018) <br />INSTRUCTIONS: Type or print the information. Complete all information on this form. Sign, date, and return to the state <br />agency (department/office) 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 />page for more information and Priva Statement. <br />NOTE: g9wrimental entities, i.e. federal, state, and local I cluding school districts), are not required to submit this form. <br />BUSINESS NAME (As shown on yaurinmma fae relum) <br />2 <br />SOLE PROPRIETOR, SINGLE MEMBER LLC, INDIVIDUAL (Nam asshomon SSNarImN)Last, First, M/ <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 />PARTNERSHIP CORPORATION: <br />Payment will not <br />PAYEE <br />be processed <br />ENTITY <br />ESTATE OR TRUST 0 MEDICAL (e.g., dentistry, psycho ropy, chimpmclic, etc.) <br />without an <br />TYPE <br />Q LEGAL (e.g., attorney service <br />accompanying <br />O EXEMPT (nonpmht) <br />taxpayer <br />CHECK <br />ONE BOX <br />O ALL OTHERS <br />identification <br />number. <br />ONLY <br />ENTER SSN OR ITIN: <br />SOLE PROPRIETOR, INDIVIDUAL, OR S to/SeoudryNumber(SSN)orindividuel Taxpayer/dentilrcation <br />SINGLE MEMBER <br />LLC(Disregarded Entity) umber(ITlN)are required by authority OfCaliiom/a Revenue antl <br />Tax Code sections 18646 antl 18661) <br />4 <br />CALIFORNIA RESIDENT - Qualified to do business t California or maintains a permanent place of business in California. <br />CALIFORNIA NON RESIDENT (see next page for re information) - Payments to nonresidents for services may be subject <br />PAYEE <br />to state Income tax withholding. <br />RESIDENCY <br />O No services performed in California. <br />STATUS <br />O Copy of Franchise Tax Board wain of state withholding attached. <br />I hereby certify under penalty of pef ury that the information provided on this document is true and correct. <br />5 <br />Should my residency status charge, I will promptly notify the state agency below. <br />AUTHORIZED PAYEE REPRESEN7VE'S NAME (Type or Print) <br />TITLE <br />TELEPHONE (include area code) <br />SIGNATURE <br />DATE <br />E-MAIL ADDRESS <br />Please return completed farm to: <br />6 <br />DEPARTMENTIOF7 <br />// <br />UNIT)SECTION <br />MAILING ADDREs9 <br />// <br />TELEPHONE (include aura code) <br />FAX <br />CITY <br />STATE <br />ZIP CODE <br />E-MAIL ADDRESS <br />