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   <br />  <br />State of California <br />Financial Information System for California (FI$Cal) <br />GOVERNMENT AGENCY TAXPAYER ID FORM <br />2000 Evergreen Street, Suite 215 <br />Sacramento, CA 95815 <br />www.fiscal.ca.gov <br />1-855-347-2250 <br />The principal purpose of the information provided is to establish the unique identification of the government entity. <br />Instructions: You may submit one form for the principal government agency and all subsidiaries sharing the same TIN. Subsidiaries with a <br />different TIN must submit a separate form. Fields bordered in red are required. Hover over fields to view help information. Please print the <br />form to sign prior to submittal. You may email the form to: vendors@fiscal.ca.gov, or fax it to (916) 576-5200, or mail it to the address above. <br />Principal <br />Government <br />Agency Name <br />Remit-To <br />Address (Street <br />or PO Box) <br />City <br />Government Type: <br />State Zip Code+4 <br />County Federal <br />Employer <br />City <br />Special District Federal Identification <br />Other (Specify) Number <br />(FEIN) <br />List other subsidiary Departments, Divisions or Units under your principal agency's jurisdiction who share the same <br />FEIN and receives payment from the State of California. <br />Dept/Division/Unit Complete <br />Name Address <br />Dept/Division/Unit Complete <br />Name Address <br />Dept/Division/Unit Complete <br />Name Address <br />Dept/Division/Unit Complete <br />Name Address <br />Contact Person Title <br />Phone number E-mail address <br />Signature Date <br />DocuSign Envelope ID: 559950F4-C2A7-4C48-AD17-D6B4EF4D5FB6 <br /> <br /> <br />Santa Ana <br />92701-4010 <br />X <br />20 Civic Center Plaza <br /> <br />Santa Ana <br />Santa Ana Public Library 26 Civic Center Plaza, Santa Ana, CA 92701 <br />956000-785 <br />1/3/2024 <br /> <br />CA