Independent Contractor (Ic) Checklist Page 7
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STATE OF CALIFORNIA - CALIFORNIA STATE UNIVERSITY SAN MARCOS
PAYEE DATA RECORD
(Assigned by CSUSM)
(Required when receiving payment from the State of California in lieu of IRS W-9)
(CSUSM 204 Rev. 02/11)
INSTRUCTIONS:
Complete all information on this form. Sign, date, and return to the State agency (department/office) address shown at
the bottom of this page. Prompt return of this fully completed form will prevent delays when processing payments. Information provided in
this form will be used by state agencies to prepare Information Returns (Form 1099) and for withholding on payments to nonresident payees.
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See page 1 for more information and Privacy Statement.
NOTE:
Governmental entities, federal, state, and local (including school districts) are not required to submit this form.
PAYEE’S LEGAL BUSINESS NAME
(Type or Print
)
SOLE PROPRIETOR – ENTER NAME AS SHOWN ON SSN
E-MAIL ADDRESS
(Last, First, M.I.)
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MAILING ADDRESS
WEB ADDRESS
FAX NUMBER
CITY, STATE, ZIP CODE
PHONE NUMBER
INDIVIDUAL OR SOLE PROPRIETOR
CORPORATION:
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MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.)
ESTATE OR TRUST
PAYEE
LEGAL (e.g., attorney services)
NOTE:
LIMITED LIABILITY COMPANY (LLC)
ENTITY
Payment
TYPE
EXEMPT (nonprofit)
will not be
PARTNERSHIP
processed
ALL OTHERS
CHECK
without an
ONE BOX
-
accompanying
ONLY
ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN):
taxpayer I.D.
number
OR
-
-
ENTER SOCIAL SECURITY NUMBER/
(SSN required by authority of California Revenue and Tax Code Section 18646)
EQUIPMENT/SUPPLIES/GOODS
SERVICES - NON MEDICAL
SERVICES - MEDICAL
ROYALTIES
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ATTORNEY FEES
LEGAL SETTLEMENT
OTHER - PLEASE SPECIFY:
RENT
CA Certified Small Bus - OSBCR Cert No.
CA Certified Disabled Vet - OSBCR Cert No.
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CA Certified Micro Bus - OSBCR Cert No.
California State Tax Withholding Status (Applies to all Payees):
California resident - Qualified to do business in California or maintains a permanent place
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of business in California.
NOTE:
California nonresident (see page 1) - Payments to nonresidents for services may be
If the individual is not a US
subject to State income tax withholding.
PAYEE
Citizen or Permanent
No services performed in California.
RESIDENCY
Resident Alien (Green Card
STATUS
Holder), the individual may
Copy of Franchise Tax Board waiver of State withholding attached.
have to fill out additional
For Federal Income Tax Withholding Status (Applies to Individuals Only) (
):
Please Check One
paperwork. (see page 1)
US Citizen
Permanent Resident Alien (Green Card Holder)
Neither a US Citizen nor a Permanent Resident Alien - see note)
Visa type:
Country of Residency:
I hereby certify under penalty of perjury that the information provided on this document is true and correct.
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Should my residency status change, I will promptly notify the State agency below
.
TITLE
AUTHORIZED PAYEE REPRESENTATIVE’S NAME (Type or Print)
DATE
PHONE NUMBER
SIGNATURE
Please return completed form to:
California State University San Marcos
Accounts Payable Department
Attn: Mercedes Wilson
8
333 S. Twin Oaks Valley Road
San Marcos, CA 92096-0001
Phone: (760) 750-4480
Fax: (760) 750-3286
Email: mwilson@csusm.edu
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