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STATE OF CALIFORNIA VENDOR DATA RECORD (Required in lieu of IRS W-9 when doing business with the State of California) STD.204(REV.12-94) NOTE: Governmental entitles, federal, state, and local(Including school districts)are not required to submit this form. SECTION 1 must be completed by the requesting state agency before forwarding to the vendor DEPARTMENT/OFFICE PURPOSE: Information contained in this form STREET ADDRESS will be used by state agencies to prepare Infor- PLEASE mation Returns(Form 1099)and for withholding RETURN CITY,STATE,ZIP CODE on payments to nonresident vendors. Prompt TO: return of this fully completed form will prevent TELEPHONE NUMBER delays when processing payments. (See Privacy Statement on reverse.) © VENDOR'S BUSINESS NAME SOLE PROPRIETOR—ENTER OWNERS FULL NAME HERE(Last Fist.M.1.) MAILING ADDRESS(Nunber and Street or P.O.Box Number) (City,State.and Zip Code) © CHECK ONE BOX ONLY MEDICAL CORPORATION(Includnp dentistry, NOTE:State and ❑VENDOR podiatry,psydafMrapy,optometry,chkcpractic eta) ❑ PARTNERSHIP local governmental ENTITY TYPE entities,including ❑ EXEMPT CORPORATION(Non-profit) ESTATE OR TRUST school districts are not required to • ❑ ALL OTHER CORPORATIONS ❑ INDIVIDUAL/SOLE PROPRIETOR submit this form. SOCIAL SECURITY NUMBER REQUIRED FOR INDIVIDUAL/SOLE PROPRIETOR BY AUTHORITY OF THE REVENUE AND TAXATION CODE SECTION 18646(See reverse) NOTE: Payment will VENDOR'S not be processed TAXPAYER FEDERAL EMPLOYER'S IDENTIFICATION NUMBER(FEIN) SOCIAL SECURITY NUMBER without an accom- 1.D.NUMBER I f i ( — 1 I I I I ! I I ( [ 1 I— I I I —I ! III panying taxpayer I.D. number. IF VENDOR ENTITY TYPE IS A CORPORATION.PARTNER- IF VENDOR ENTITY TYPE IS INDIVIDUAL/SOLE PROPRIETOR, If SHIP.ESTATE OR TRUST.ENTER FEIN. ENTER SSN. © CHECK APPROPRIATE BOX(ES) NOTE: California Resident-Qualified to do business in CA or a permanent place of a. An estate is a VENDOR 1-1 business in CA resident if RESIDENCY decedent was a STATUS ❑ Nonresident(See Reverse)Payments for services by nonresidents California resident may be subject to state withholding at time of death. b. A trust is a 0 WAIVER OF STATE WITHHOLDING FROM FRANCHISE TAX BOARD ATTACHED resident if at least one trustee is a ❑ SERVICES PERFORMED OUTSIDE OF CALIFORNIA California resi- dent. (See reverse.) 6 I hereby certify under penalty of perjury that the information provided on this document is true and correct. If my residency status should change, I will promptly inform you. CERTIFYING SIGNATURE AUTHORIZED VENDOR REPRESENTATIVE'S NAME(Type or Print) TITLE SIGNATURE DATE TELEPHONE NUMBER 91