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<br />STATE QF CALIFORNIA-DEPARTMENT OF FINANCE <br />PAYEE DATA RECORD <br />(Required when receiving payment from the State of California in lieu of IRS W-9) <br />STD, 204 (Rev, 6-2003) <br /> <br />¿] INSTRUCTIONS: Complete all information on this form. Sign, date, and return to the State agency (departmenUoffice) address shown at <br />the bottom of this page. Prompt return of this fully completed form will prevent delays when processing payments. Information provided in <br />this form will be used by State agencies to prepare Information Returns (1099). See reverse side for more information and Privacy <br />Statement. <br /> NOTE: Governmental entities, federal, State, and local (including school districts), are not required to submit this form. <br /> PAYEE'S LEGAL BUSINESS NAME (Type or Print) <br />QJ <br />SOLE PROPRIETOR - ENTER NAME AS SHOWN ON SSN (Last, First, M.I.) I E-MAIL ADDRESS <br /> MAILING ADDRESS BUSINESS ADDRESS <br /> CITY, STATE, ZIP CODE CITY, STATE, ZIP CODE <br />ŒJ ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): IQ141-1610101/111l161 NOTE: <br />D Payment will not <br />PARTNERSHIP CORPORATION: be processed <br />PAYEE I:J MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.) without an <br />ENTITY D ESTATE OR TRUST I:J LEGAL (e.g.. attomey services) accompanying <br />TYPE I:J EXEMPT (nonprofit) taxpayer I.D. <br /> I:J ALL OTHERS number. <br />CHECK I I I I-I I I-I I I I I <br />ONE BOX D INDIVIDUAL OR SOLE PROPRIETOR <br />ONLY ENTER SOCIAL SECURITY NUMBER: <br /> (SSN reQuired bv authoritY of California Revenue and Tax Code Section 18646\ <br />~ ø California resident - Qualified to do business in California or maintains a permanent place of business in California. <br />D California nonresident (see reverse side) - Payments to nonresidents for services may be subject to State income tax <br />PAYEE withholding. <br />RESIDENCY I:J No services performed in Califomia. <br />STATUS I:J Copy of Franchise Tax Board waiver of State withholding attached. <br />ŒJ I hereby certify under penalty of perjury that the information provided on this document is true and correct <br /> Should my residency status change, I will promptly notify the State agency below. <br /> AUTHORIZED PAYEE REPRESENTATIVE'S NAME (Type or Print) I TITLE <br /> SIGNATURE DATE TELEPHONE <br /> ( ) <br /> Please return completed form to: <br />~ D rtm tlOffi State Council on Developmental Disabilities <br /> epa en Ice: <br /> Contracts Unit - Szandra Keszthelyi <br /> Unit/Section: <br /> Mailing Address: 1507 21st Street Suite 210 <br /> City/State/Zip: Sacramento, CA 95814 <br /> Telephone: <2.!i> 322-8481 Fax: (iJi) 443-4957 <br /> E '\ Add szandra.keszthelyi@scdd.ca.gov <br /> -mal ress: <br /> <br />