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STATE OF CALIFORNIA-ONPARTWNT OF FINANCE <br />PAYEE DATA RECORD <br />(Required when reoelving payment from the State of California In Iiau of IRS R-g or w-7) <br />STD 204 (RaV. 03021) <br />NAME (This Is required, `Do not leave this line blank. Must match the payee's federal tax return) <br />BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (if different from above) <br />MAILING ADDRIUS (number, street, apt. or suite no.) (See Instructions on Page a) <br />CITY, STATE, ZIP CODE <br />❑ SINGLE MEMBER LLC Disregarded Enf/ly owned by an IndMdual <br />❑ PARTNERSHIP <br />El ESTATE OR TRUST <br />E-MAIL ADDRESS <br />❑ MEDICAL (e.g„ dentistry, uhlropractlo, eta) <br />0 LEGAL (e.g., atfomoysenBces) <br />0 EXEMPT (e.g„ nanpmng <br />M ALL OTHERS <br />match the name given In Section 1 of this form. Do not provide more then ohs (1) TIP <br />The TIN is a 9-digit number. NOW: Payment will not be processed without a TIN. <br />• For Individuals, enter SSN. <br />• If you are a Resident Allen, and you do not lava and are not eligible to got an <br />SSN, enter your ITIN. <br />• Grantor Trusts (such as a Revocable Living Trust while the grantors are Ove) me <br />not have a separate FEIN. Those trusts must enter the Individual grantor's SSN. <br />• For Sole proprietor or Single Member LLC (disregarded entity), In which the <br />Social Security Number ISSN) or <br />Individual Tax Identification Number (ITIN) <br />OR <br />Federal Employer Identification Number <br />prefers BEN). <br />• For Single Member MG (dieregarded entity), In which the sole member is a — -----,--- <br />business entity, enter the owner entitys FEIN. Do not use the disregarded <br />entity's FEIN. <br />• For all other entities Including LLC that is taxed as a corporation or partnership, <br />estateslfrusts (with F6iNs), enter the entity's FEIN. <br />fU CALIFORNIA RESIDENT.. Qualified to do business In Colifornla or maintains a permanent place of business In California. <br />11 CALIFORNIA NONRESIDENT - Payments to nonresidents for services may be subject to state Income tax withholding. <br />©No services performed In California <br />ElCopy of Franchise Tax Board waiver of state withholding Is attached. <br />,Xy„ : :, �;.. iy ,• z, 1, >agwe�'ta'�rt w <br />" � ' `,A'➢`S�'$§'tCitY �4 f r r41dYl' � r;fa 1u'awk -a (' Y <br />t hereby certify underponatty of perjury that the Information provided on this document Is trite and correct <br />Should Loy rostdoney status change, I w111 Promptly notifIr the stats agency below. <br />NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS <br />SIGNATURE I DATE I TELEPHONE (Inclado area code) <br />-"f rr. <br />Please return completed form to: <br />STATE AGENCYIDEPARTMGNTOFFIC15 UNITISECTION <br />MAILING ADDRESS FAX TELEPHONE (hwlade area code) <br />CITY STATE ZIP CODE E-MAIL ADDRESS <br />