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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:

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 or P.O. Box #) 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:

Section 4

Vendor Entity Type

Taxpayer Identification Number

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

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

Section 5

Vendor Activity

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

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 (From the CA Franchise Tax Board,

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

Are you a California resident or nonresident?

Each corporation, individual/sole proprietor, partnership, estate, or trust doing business with the State of California must indicate residency status along with their taxpayer identification number.

A corporation is defined as a "resident" if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California.

For individuals and sole proprietors, the term "resident" includes every individual who is in California for other than a temporary or transitory purpose and any individual domiciled in California who is absent for a temporary or transitory purpose. Generally, an individual who comes to California for a purpose, which will extend over a long or indefinite period, will be considered a resident. However, an individual who comes to perform a particular contract of short duration will be considered a nonresident.

A partnership is considered a resident partnership if it has a permanent place of business in California. An estate is a resident if the decedent was a California resident at time of death. A trust is a resident if at least one trustee is a California resident.
For information on residency status, contact the Franchise Tax Board at the numbers listed below:

NOTE: An estate is a resident if decedent was a California resident at the time of death. A trustis a resident if one or more trustees are California residents.

From within the United States, call 1-800-852-5711
From outside the United States, call 1-916-845-6500
For hearing impaired with TDD, call 1-800-822-6268
Website -

Are you subject to California nonresident withholding?

Payments made to California nonresident vendors, including corporations, individuals, partnerships, estates and trusts, are subject to California income tax withholding. California nonresident vendors performing services in California or receiving rent, lease or royalty payments from property (real or personal) located in California will have 7% of their total payments withheld for state income taxes. However, no withholding is required if total payments to the payee are $1,500 or less for the calendar year.

A California nonresident vendor may request that income tax withholding be waived by sending a completed form FTB 588 to the address below. A waiver will generally be granted when a payee has a history of filing California returns and making timely estimated payments. If the vendor activity is carried on outside of California or partially outside of California, a waiver may be granted.

A California nonresident vendor may request a reduction in the standard 7% income tax withholding amount by sending a completed form FTB 589 to the address below, or by completing the form online at If a reduced rate of withholding or waiver has been authorized by the Franchise Tax Board, attach a copy to this form.

For more information, contact the Franchise Tax Board:
Withholding Services and Compliance Section

P.O. Box 942867
Sacramento, CA 94267-0651
Telephone from within the U.S.: 1-888-792-4900
Telephone from outside the U.S.: 1-916-845-4900
Fax: (916) 845-9512 Email:

Foreign Individuals and Foreign Businesses

Federal tax withholding regulations differ significantly from California’s tax withholding requirements. A tax analysis is required and all foreign individuals must complete the "Foreign National Data Collection Form" to determine U.S. residency status. Failure to complete the form may require up to 30% federal tax withholdings from payment. For more information, refer to the IRS website for nonresident withholding at

Privacy Statement

Section 7(b) of the Privacy Act of 1974 (Public Law 93-5791) requires that any federal, state, or local governmental agency which requests an individual to disclose his social security account number shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it.

The State of California requires that all parties entering into business transactions that may lead to payment(s) from the State must provide their Taxpayer Identification Number (TIN) as required by Revenue and Taxation Code Section 18646, to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by Internal Revenue Code Section 6109(a). The TIN for individuals and sole proprietorships is their Social Security Number (SSN).

It is mandatory to furnish the information requested. Federal law requires that payments for which the requested information is not provided is subject to withholding and state law imposes noncompliance penalties up to $20,000.

You have the right to access records containing your personal information, such as your SSN. To exercise that right, please contact CSUS Account Payable at 916-278-6476.

Please call the Department of Finance, Fiscal Systems and Consulting Unit at (916) 324-0385 if you have any questions regarding this Privacy Statement. All other questions should be referred to the requesting department listed in section 1.