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Accounts Payable


Vendor Data Record (204 Form)

Required in lieu of IRS W-9 when doing business with the State of California (CSUS Rev. 11-2017)



  • Vendor Data Record Page 1
  • Vendor Data Record Page 2

Section 1

Contact Information

  • Modoc Hall 3005 – Mail Stop 6004 
    6000 J Street, Sacramento, CA 95819
    Phone: (916) 278-6476 - Email: vendordatarecordform@csus.edu

Section 2

Name and Address


  • Is this a US Address?
    Yes No

    Vendor's Legal Business Name
    Doing Business As (if applicable) Phone
  • Mailing Address (Street and Number) Fax
    City State Zip Code
  • Foreign Residence Address
    City Province/Region
    Country Postal Code
  • Email - Required: This is how we will communicate with you.
    Make checks payable to
Section 3
  • No Yes If yes, please enter Employee ID:


  • No Yes
    If yes, please enter Student ID:

Section 4

Vendor Entity Type







Taxpayer Identification Number

  • Single member LLC
    C Corporation
    Partnership
    Estate/Trust
  • Individual/Sole Proprietor
    S Corporation
    Exempt (Non-Profit)
    Government Entity
    Foreign


  • Limited Liability Company (check IRS tax classification below):
    Partnership
    C Corporation
    S Corporation
  • (For Foreign status enter nine zeros in either box)

Section 5

Vendor Activity

  • Services: (Non-Medical)
    Equipment & Supplies
    Rent
  • Services: (Medical/Health Care)
    Attorney/Legal Fees
    Non-employee travel reimbursement

Section 6

 Federal ID requirements

  • I am a U.S. Citizen
    I am a Permanent Resident Alien and I have a Green Card
    I am not a U.S. Citizen and I do not have a Permanent Resident Green Card
  • (Note: All Foreign Nationals must complete the W-8BEN for individuals or the W-8BEN-E for an entity. The IRS link to these forms can be found on Page 2 of this form.)

Section 7

CA income requirements

  • California Resident - Maintains a permanent place of business in CA at the address shown above or is qualified through the California Secretary of State (SOS) to do business in CA
    California Non-resident (see page 2) - Payments to CA non-residents may be subject to state income tax withholding
    A Waiver from CA state tax withholding was emailed to vendordatarecordform@csus.edu (From the CA Franchise Tax Board, www.ftb.ca.gov)

Section 8

Certifying Signature

  • I hereby certify under penalty of perjury under the laws of the State of California that the information provided on this document is true and correct. If my residency status should change, I will promptly inform you.
  • Authorized Vendor Representative or Individual Name Date
    Email Phone