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CITY OF SAN BERNJ..IDINO
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- REQUEST Fl )1 COUNCIL ACTION
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From: Pat Malloy, Director
Subject:
e
Authorize execu~on o~an agreement
with the State ~ Calrfornia for the
provision of refuse disposal service
to Patton State Hospital.
Dept: Public Services
Date: July 12, 1994
Synopsis of Previous Council action:
Nov. 16, 1992 - Resolution No. 92-426 was approved.
Recommended motion:
Adopt the Resolution
, -
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( ~ure
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Contact person: Kevin Barnesl Refuse Superintendent
Phone: 5053
Supporting data attached: Resoitition, Staff Report, Contract Ward:
4
"
FUNDING REQUIREMENTS:
Amount: N/A
Source: (Acct. No.)
(Acct. DescriPtion)
Finance:
Council Notes:
75-0262
Agenda Item No
/;)...
CITY OF SAN BERNA_ .DINO - REQUEST F( l COUNCIL ACTION
STAFF REPORT
Renewal of contract with the State of California, Department of Mental Health for refuse
disposal service at Patton State Hospital. Service for fiscal year 93/94 was continued from
previous fiscal year's contract.
The attached agreement provides for refuse disposal service as requested by the State. The term
,of the contract is July 1, 1994 through June 30, 1995. The total amount payable to the City
under this contract is not to exceed $30,000 per year. This amount is unchanged from last year's
contract.
0264
RESOLUTION
1 RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
2 EXECUTION OF AN AGREEMENT WITH THE STATE OF CALIFORNIA, DEPARTMENT
OF MENTAL HEALTH FOR THE PROVISION OF REFUSE DISPOSAL SERVICES TO
3 PATTON STATE HOSPITAL.
4
5
BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF
SAN BERNARDINO AS FOLLOWS:
SECTION 1.
The Mayor of the City of San Bernardino is hereby
6 authorized and
7
directed to execute on
behalf- of the City an
Agreement with the State of California, Department of Mental Health
8 for the provision of refuse disposal services to Patton State
9 Hospital, a copy of which is attached hereto marked Exhibit "A" and
10 incorporated herein by reference as fully as though set forth at
11 length.
12 SECTION 2. The authorization to execute the above referenced
13 Agreement is rescinded if the parties to the Agreement fail to
14 execute it within sixty (60) days of the passage of this Resolution.
15 SECTION 3. Resolution 92-426 and amendments thereto and any
16 other resolution in conflict herewith are hereby repealed.
17 1/1/
18
19
20
lilt
1/1/
lilt
21 1///
22 /1//
23 lilt
24 1/ 1/
25 /1/(
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26 lilt
27
28 July 27, 1994
1
RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
EXECUTION OF AN AGREEMENT WITH THE STATE OF CALIFORNIA, DEPARTMENT
1 OF MENTAL HEALTH FOR THE PROVISION OF REFUSE DISPOSAL SERVICES TO
PATTON STATE HOSPITAL.
2
3 I HEREBY CERTIFY that the foregoing resolution was duly adopted
4 by the Mayor and Common Council of the city of San Bernardino at a
5 meeting thereof, held on the day of
6 1994, by the following vote, to wit:
7 Council Members: AYES NAYS ABSTAIN ABSENT
8 NEGRETE
9 CURLIN
10 HERNANDEZ
11 OBERHELMAN
12 DEVLIN
13 POPE-LUDLAM
14 MILLER
15
16
17
18
19
20
City Clerk
The foregoing resolution is hereby approved this
day of
, 1994.
Tom Minor, Mayor
City of San Bernardino
21
22 Approved as to form
and legal content:
23
24
25
, ,
JAMES F. PENMAN,
City ttorney
26
27
28 July 27, 1994
2
S1'ATE OF CAi:IFORNIA
STANDARD AGREEMENT- Ari~~~~~:~~:AL
STD. 2 (REV.s.D1)
EXHIBIT I1A"
AGREEMENT
CONTRACT NUMBER
94-30022
TAXPAVER'S FEDERAL EMPlOYER IDEHTIFICATION NUMBER
AM. NO.
TIiISAGREEMENT,rnadcandentcrcdintothis 2nd day of June ,19...2..L,
in the State of California, by and between State of California, through its duly elected or appointed, qualified and acting
95-6000772
TITlE OF OFFICER ACTING FOR STATE
Deputy D:iIector, Div. of Adninistrati
CONTRACTOR'S NAME
Ci ty of San Bernardino , hereafter called the Contractor.
WITNESSETH: That the Contractor for and in consideration of the covenants, conditions, agreements, and stipulations of the State hereinafter expressed,
does hereby agree to furnish to the State services and materials as follows: (Set forth service to be rendered by Contractor, amount to be paid Contractor,
time for performance or completion. and attach plans and speclf~ations, if any.)
AGENCY
Department of Mental Health
Patton State Hospital
, hereafter called the State, and
Contractor agrees to provide the services specified in:
Exhibit "A" - Program Narrative
Exhibit "B" - Specific Provisions; and,
Exhibit "c" - General Provisions;
attached hereto and by this reference made a part of this
agreement,
I certify that I have reviewed this agreement, and it
meets current program and departmental policy.
WILLIAM L. SUMMERS
Executive Director
Date
I CONTINUED ON
The provisions on the reverse side hereof constitute a part of this agreemenL
IN WITNESS WHEREOF, this agreement has been executed by the parties hereto, upon the date finn above writtcn.
SHEETS, EACH SEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
STATE OF CALIFORNIA CONTRACTOR
AGENCY Department of Mental Health CONTRACTOR (IIoth<<lhM."ittdividfMJ. ."".III1heIJw. 0tJtptnIi0n.~ <<c.)
Patton State Hosnital Citv of San Bernardino
BY (AUTHORIZED SIGNATURE) BY (AUTHORIZED SIGNATURE)
> [>
PRINTED NAME OF PERSON SIGNNG .. PRINTED NAME AND TITLE OF PERSON SIGNNG
. ,
LINDA A. POWELL, Deputv Director Tom Minor, Mayor
TIllE ADDRESS 300 N. "D" Street
Division of Administration San Bernardino CA 92418 1909\ 384-5145
\MOUNTENCUMBEREDBYTH~ PROGRNAlCATEGORY (CODE AND TITlE) I FUND TITlE De"."",.", of Generel Servlcee
JOCUMENT
$ 30.000.00 SUDDort General u.eOnIy
IOF'TIONAL USE) Funding subject to the approval of
:JRIOR AMOUNT ENCUMBERED FOR the Budaet Act of 1994.
rH~ CONTRACT
$ I1EM L~HAPTER ,I STATUTE I FISCAl YEAR
- endina 1994 94/95
rOTAl AMOUNT ENCUMBERED TO 4440-011-001
lATE OBJECT OF EXPENDITURE (CODE AND TITLE)
$ 348.50
I hereby csrtJfy upon my own personal knowledge lhel budgelBd funds 1 T.BA NO. r B.R.NO.
are avalleble for lire period and purpose of the expenditure sralBd above.
,GNATURE OF ACCOUNTNG OFFICER I DATE
>
I of 7
o CONlllACTOR
o STATE AllENCV
o DEF'T. OF GEN. SER.
o CONTROUER
o
"
5,.,. of C.IifOrn.. - H..lm .net W.U.r. ~ncy
Oep.rtmenlof Mental H_lth
SMALL BUSINESS IDENTIFICATION QUESTIONNAIRE
MH 1157 1101841
.. . I
INSTRUCTIONS. Pl.... compl.t. th. follOWIng, .nd .uumlt t ,.
comJ..lleted questionnaire with your bid packalJe, The, infor-
mation is required for statistical purposes and IS consulerl!o
confidential.
N.me 01 Busine"
JrOdUCII or Services t'rov.ded
I' S ' - Refuse Division Refuse pick up
Ci~ of San Bernardino - !i'1.lb 1C erv1ce ICi.v) IS'a'o' IZipl
AdCi.... TS"ooiT 92418-0001
~, h "0" St et Rm 421, S?.!l.-Be~na.rdino _ CA. .__.____.
--",-00 Nort re.. "'t I. se ch.ck this box Ilil and do no, compl.i. the r.matnder 01 tills quest,on.
If your business is a nonprofit busmess or pub"c ent. y. p a ..
naire. If your business is iI For Profit Business, see definitions on back before completing the fOllowmg.
Sex 01 Owner ElhnK: Classification of Owners
D Male D Black 0 POlvnesian
D Female DAlian American D American Indianl
AI.skian Native
D Hispanic American D Filipino
--
Sill of Business
D I 8m a prequ.lified sm.1I business with OSMB.
o I am . tmall business, but haw nOI been prequalilied with OSMB.
3rlv bu..,..u would not t:. considered. sm.1l business.
o Caucasianl
White
o All other
STATE USE ONLY
Document Number Fisc.l Ve.r Reponing Qu.rter
Amount
S .
OEFINITIONS
SIZ~ OF BUSINESS Chf!Ck rhe Iltst box ..nit " VOur h.."n"" has been "re"Ud"'''''' 'r., th" ,,,,.11 l"lslne.. pr.'.r."ce hy rho O/l.ce 0'
Small an" Minori.y Busin"" IOSMBI Chock tho ,econl/ box i' vo" ,.., yr.ur husme" 1\ J "ndlll",'""',,, wr have no. b<'.II P""lua"''',d
h'( OSMB. o.'!Ck (hI' tflird hox If You '~l"1 ,/Ollr buSjOl~SS is 1101 a small businp.ss
SEX OF OWNERS. The Female hlor.k w,1I he checked 10 Ih" Item if a bustne" is alleast 50 p.rcent woman,owne,j '''. in the case of
Publicly "wn.d husin.s...s, .t least 51 ,..rr.en. 01 ,he ""<ok " woman.owned.lo' all olh.r instanc.s. the Mal. hlock will be checked.
ETHNIC CLASSIFICATION OF OWNERS' Th. coele ch.ck.d should ,.flect the ethnic 0"910 of the p.rson who OWII at least 51 per.
cen. of Ih. busin.", or in rh. case ala publicly r.w"ed busin.", atl.ast 51 percent of th. stock. In the cas. of an,equal parrn.rshin
betw..n a Cauc.si.n .od minorilv group member, the cod. of the mtnority group m.mber w,II be marked. Mark on/v om' block in
this item.
DEPARTMENT INSTRUCTIONS
~EADaUARTERS: Offices .warding contracts will complet. the S,a", U. On/v section on the front of rhis form for each bidd.r
Iw.rded · contract .nd SUbm~tth. qu.stionnaire with the contract to Support Servic.s Sectioo. Admin"tr.tion Division.
;TATE HOSPITALS: Complet. the Sure UIl! On/V section on th. front of this form for .ach bidd.r .w.rded a conrract, s.rvice ord.r
.r subpurch... ord.r. For Conrr.crs .nach th. compl.t.d qu.stionnaire with the copy a' th. contract submin.d to Support S.rvices
ectian. For S.rvice Orders MId Su/1t>urch_ Orders use the inform.tion collected to compl.t. the Small Business Monitoring Report
no 8101 .ach qu.rt.r. Submit the r.port by th. 10th of th. month following th. r.porting quart.r 10: D.p.rtment of D.v.'opmental
...ic.., Support Services Section, Administration Division, 1600 9th Street, Sacram.nto, CA 95814.
STAlE OF CALIFORNIA
DRUG-FREE WORKPLACE CERT.. .CATION
STD. 21 (NEW 11."0)
COMPANYIORG4NIZAOON NAME
The contractor or grant recIpIent named above hereby certifies compliance with Government Code
Section 8355 in matters relating to providing a drug-free workplace. The above named contractor or
grant recipient will:
1. Publish a statement notifying employees that unlawful manufacture, di3tribution, dispensation,
possession, or use of a controlled substance is prohibited and specifying actions to be taken against
employees for violations, as required by Government Code Section 8355(a).
2. Establish a Drug-Free Awareness Program as required by Government Code Section 8355(b), to
inform employees about all of the following:
(a) The dangers of drug abuse in the workplace,
(b) The person's or organization's policy of maintaining a drug-free workplace,
(c) Any available counseling, rehabilitation and employee assistance programs, and
(d) Penalties that may be imposed upon employees for drug abuse violations.
3. Provide as required by Government Code Section 8355(c), that every employee who works on the
\,
proposed contract or grant: ,
(a) Will receive a copy of the company's drug-free policy statement, and
(b) Will agree to abide by the terms of the company's statement as a condition of employment on
the contract or granL
CERTIFICATION
I, the official named beloW, hereby swear that I am duly authorized legally to bind the. contractor or
grant recipient to the above described certification. I am fully aware that this certification, executed on
the date and in the county below, is made under penalty of petjury under the laws of the State of
California.
IFFtc/AL'S NAME
T Mi
ATE EXECUTED
Mao
ONTRACTOR or GRANT RECIPIENT SIGNA.TlIE:
EXECUTED tI_ CCUN1Y OF
San Bernardino
m.e
;:DERAl LD. NUMBER
95-6000772
STATE.OF CALFORNIA
NONDISCRIMINATION COMPLIANCE STATEMENT
STD. 18 (REV. 3-81)
COMP~Y NAME
City of San Bernardino - Public Services - Refuse Division
The company named above (hereinafter referred to as "prospective contractor") hereby certifies,
unless specifically exempted, compliance with Government Code Section 12990 and California
Code of Regulations, Title 2, Division 4, Chapter 5 in matters relating to the development,
implementation and maintenance of a nondiscrimination program. Prospective contractor agrees
not to unlawfully discriminate against any employee or applicant for employment because of race,
religion, color, national origin, ancestry, physical handicap, medical condition (cancer related),
marital status, sex or age (over forty).
CERTIFICATION
!, the official named below, hereby swear that! am duly authorized to legally bind the prospective
contractor to the above described certification. ! am fully aware that this certification, executed on
the date and in the county below, is made under penalty of perjury under the laws of the State of
California.
OFFICW.'S NAME
Tom Minor, Ma or
DATE EXECUTED
EXECUTED "THE COUNTY OF
San Bernardino
PROSPECTIVE CONl'RACTOA'S SIGNA1URE
PROSPECTIVE CONTRACTOR'S Tm.E
"
PROSPECTIVE CONTRACTOR'S FEDERAL EMPLOYER IDENTFICATION NUMBER
Q5-600077'
CONTRACTOR:
CONTRACT it:
CITY OF SAN BERNARDINO
94-30022
EXHIBIT "A"
Program Narrative
,
" .
Contractor agrees to
(1; -lO-yard and four
State Hospital.
provide refuse disposal
(4) IS-yard container
ser\"ice for one
bins at Patton
"
I;isi)Osal service shall be pro\"ided by the Contractor, \\~hen
service is requested by the Project Coordinator.
3. Contractor shall possess all applicable licenses, permits, and
insurance; and, must comply ~ith any requirements set forth by
an authorized agency.
4. Contractor shall leave a receipt for pick-up of refuse Kith
the Project Coordinator.
5. Contractor shall abide by all applicable safet~- and code
regulations.
"
2 of 7
CONTRACTOR:
CONTRACT #:
CITY OF SAN BERNARDINO
94-30022
EXHIBIT "B"
Specific Provisions
1. The term of this contract shall be July 1, 1994 through June
30, 1995.
2. The State has designated Robert ."\barca, Landscap:e Superyisor
II, to be its Project Coordinator.
3. l'pon completion of the serv::..ces in E:-~HIBIT "A", Progr-anl
:\arratiye, performed in a manner acceptable to the State, aJ,d
upon the submission of an invoice in triplic~te as specified
in EXHIBIT "C", paragraphs 3 and 4, ,ehE' State agrees to pay
Contractor, monthly in arrears.
4. The total amount payable under this contract shall not exceed
S30,OOO.00.
5. This contrR(.'L shall not be effecti\-e until it has been
approved by the Department of General Services.
"
3 of 7
CO/>;TRACTOR:
CONTRACT #:
CITY OF SAN BERNARDINO
94-30022
EXHIBIT "n-1"
Budget - Price Breakdown
Refuse Disposal
Tlj ~';"I-..<)saJ SE'r'~'l cEfol' fO'l~r -; 15-~-s.:::'(~ bin:=-. Oh'!l~'C b~- Pattofl ~:tate
H.:)~:l~.i ~ u 1 :
rj ::kdl' {t:p to fcuI'
" ,
, ~ I
tODe, ;
s
0--} 1 en
';;'_..L . '.Iv
O\--<:r-\-;eight {o\'e::" four {-ll tons}
s
JG.G5
Djsp()s~l ser,-ice for one! 1) ~O-yard bin owned b~- Patton State
Hos~~i:'Ed :
Pickup {up to eight 18: ~onsl
~,
J68.20
O,'er-;.-eight (over elght : 8) tons}
s
'"6 6-
o . ~::.-.
Rates are established by resolution of the City of San Bernardino
Mayor and Common Council.
"
4 of 7
CONTRACTOR:
CONTRACT #:
City of San Bernardino
94-30022
EXHIBIT "c"
General Provisions
1. Contractor shall submit any SUbCo~1t.':'ac.ts to the State for
appro\-al prior to iI;:plemen::..C\tioli, Lpon termination of an;:
subcontrac1, '!..hE.' St.ate 5L&11 be notified immediately.
"
By s i 'gLiI1g thi 2. contract, contractor S1.~+ears upon penalty of
per,jury that no ma:re than one final unappealabL'e finding of
COlltempt of court by a Federal COllrt tlas been isslled against
this contractor ~-ithin the immediatel;: preceding tKo-~-ear
period becallse of the contractor's failllre to comply with an
order of a Federal court which orders the contractor to comply
with an order of the ~ational Labor Relations Board (Public
Contract Code, Section 10296).
3.
All reports, in\"oices,
delivered to the Project
3102 E. Highland Avenue,
or other communications are to be
Coordinator, Patton State Hospital,
Patton, CA 92369.
~. All invoices are to be submitted in triplicate, stating the
agreement number and the time period covered, to the Project
Coordinator as specified in EXHIBIT "B". It is further
understood that in no event shall the maximum price specified
in EXHIBIT "B" be exceeded.
o. This agreement may be canceled at any time by either party, by
giving 30 days written notice to the other party, and may be
amended upon mutual consent.
6. Contractor understands that no Federal or State income tax
\"ill be withheld from the payments under this contract.
However, the State is required to report all payments to the
Internal Revenue Service for tax purposes. No distinction of
fee, travel, or per diem will be made. :\0 wage and tax
statement (W-2) will be issued for the sen"ices performed
under this agreement.
7. Contract~r understands that the product(s) and the contractor
staff services provided in fulfillment of the requiremehts of
this contract will be evaluated by the State (Public Contract
Code Section 10370).
8. During the performance of this contract, contractor and its
subcontractors shall not unlawfully discriminate against any
employee or applicant for employment because of race,
reltgion, color, national origin, ancestry, physical handicap,
medfcal condition, marital status, age (over 40), or sex.
Contractors and subcontractors shall comply with the
5 of 7
..
EXHIBIT "c"
General Provisions
(continued)
CONTRACTOR:
CONTRACT #:
City of San Bernardino
94-30022
provisions of the Fair Employment and Housing Act IGovernment
Code, Section 12900 et seg.) and the applicable regulations
promulgated thereunder ICalifornia Administrative Code, Title
2, Section ,285 et seg.). The applicable reguLctions of the
Fair Employment and Housing Commission implementiLg' Government
Code Section 12990, set forth in Chapter 5 of Di vision.. of
Ti tIe 2 of the Cali fornia Adm.inistrati\.e Code. are
inr'orpGrated into this contract b~ reference and made & part
hereof as if set fOlth in full. Contractor and its
subcorltractol's shall gi,'e Kritten notice of their obligations
under this clause to labor organizations with which they have
a colJecti\"e bargaining or o~her agreement. Contractor shall
include the non-discrimination and compliance provisions of
this clause in all subcontracts to perform v.;ark under the
contraC1. (SAN 120...5).
9. Should a dispute arise under this contract, contractor may in
addition to any other remedies which may be available, provide
written notice of the particulars of such dispute to the
Deputy Director, Division of Administration, Department of
Mental Health, 1600 Ninth Street, Sacramento, CA 9581... Such
written notIce must contain the contract number. Within ten
days of receipt of such notice, the Deputy Director, Division
of Administration, shall advise contractor of his findings and
a recommended means of resolving the dispute (Fublic Contract
Code Section 10381).
10. Contractor agrees to place in each of its subcontracts, which
are in excess of $10,000.00 and utilize State funds, a
provision that: "The contracting parties shall be subject to
the examination and audit of the Auditor General for a period
of three years after final payment under contract (GOVERNMENT
CODE SECTION 10532)". The Contractor shall also be subject to
the examination and audit of the Auditor General for a period
of three years after final payment under contract (GOVERNMENT
CODE SECTION 10532).
11. It is mutually understood between the parties that this
contract ~ay have been written and executed prior to July 1,
for the mutual benefit of both parties, in order to' avoid
program and fiscal delays which could Occur if the contract
were executed after July 1, of the State fiscal year.
12. This contract is valid and enforceable, onl~- if sufficient
funds are made available by the Budget Act for this fiscal
year for the purposes of this program. In addition, this
contract is subject to any additional restrictions,
limitations, or conditions enacted by the Legislature which
may effect the provision, terms or funding of this contract in
any manner.
6 of 7
,
EXHIBIT "c"
General Provisions
(continued)
CONTRACTOR:
CONTRACT it:
City of San Bernardino
94-30022
13. It is mutually agreed that if the Budget .-\.ct dDes not
appropriate Sllff'icient funds for the program, tnis con~ract
shall be inval id and of no further force aile! e:'fect. In thi~.
event, tlle St.ate shall ha\"e no furttler l~ability to ~a~- aflY
funds \o..'hatsoe\'er t.o the cont.ractor or ~._o fur:lish any Dther
considerations Ufldel' ttlis co~tr'act, and the contractor shall
not 11e obl:gat,~d to perfo!"m any pro\'isions of this contract.
"
7 of 7
STA~OFCALFORNIA
VENDOR DATA RECORD
(Required In lieu of IRS W-9 when doing business with the StBte of CsllfornlB) CONTRACT #94-30022
STD..204 (REV. 1-12)
DEPARTMENTJOFFICE PURPOSE: Information contained inthis form
Patton State Hospital will be used by State agencies to prepare Infor-
PLEASE STREET ADDRESS mation Returns (Form 1 099) and for withholding
RETURN
TO: 3102 E. Highland Avenue on payments to nonresident vendors.
CITY, STATE, ZIP CODE (See Privacy Statement on reverse.)
,.~ Q"~Q
VENOOA'S BUSINESS NAME OWNERS FUU. NAME ru-t. Fat ilL)
City of San Bernardino Public Services - Refuse
STREET ADDRESS ARE YOU SUBJECT TO FEDERAL BACKUP
300 North "0" Street, Room 421 WITHHOUltlG?
,........... _IRS Fomr W4}
CITY, STATE, AND ZIP CODE o YES ~NO
San Bernardino CA 92418-0001
INSTRUCTIONS:
(1). Check box indicating type of business entity and provide taxpayer identnication number.
(2). Check box Indicating resident or nonresident. (See reverse for additional information).
(3). Check one or more VENDOR ACTIVITY boxes specnylng vendor activity type.
1';:i!iI11';\ill!t~tlll_;!)I,'JI.II'II.llttltlt"rll~~;:;=lJ:"i1;':;'i:~=;I;.;~ii~=:~~~:;':~!!%7~!!;~i!;i~jMjNNinA;
IV! CORPORATION
~ (EnIw F.,.. EmpIoyw JdenC" r" 1 NumI>>t)
I 9 I 5 I-=.J 6 I 0 I 0 I 0 I 7 I 7 I 2 I
I'VI Resident - Qualnled to do business in CA I
IAJ Permanent place at business in CA
O MEDICAl SERVICESfh:*,dingdilrtle.*r,
podiaty, paJl'l'holl'-Wflf, C1pll:lmHy,
d~..,..-Ai..,eIt:.)
~ SERVICES (NON MEDICAL)
O EQUIPMENT JSUPPLES
----
Non Resident See Raverse
o RENT
O OlHER
-
o INDMDUALISOLE PROPRIETOR
(E.--___......NOTFE1N}
l=J
l=J
O NON EMPLOYEE COMPENSATION {IrtcIudittg 0 EQUIPMEHTJSUPPlES
-...."'-'....--.................-1 ____
O IlEDICALSERVICES__.
pttItdi&y, _,.;.\.Ah-~,. ClPbne*r.
dI.ii..,..-4iI.,.eIt:.}
o NTEREST_--_J
o RENT
o Resident
o Non Resident (See Reverse)
O PARTNERSHIP
(Enfw F.,.. E~.... f- ".,..,.."
L:J
o ROYALTIES
o Resident
o
Non Resident (See Ravarsa)
o PRIZESANDAWARDS
o
I
ESTATE OR TRUST
(E.-__.... .. . ._
o OlHER_
I.::J
O Resident (Estate) - Decedent was a CA resident at
the lime of death
O Reside'!t (Trust) - At least one trustee Is a CA
reSIdent
o Non Resident (See Ravarse)
f he,.by certify under pIIIIII/ty of pIIrjury "'at the Infonnatfon provldild on III,. documflllt I. trua and COmH:t.
H m ,..Idilnc mtu. .hould chen , I will If Inform DU.
AUTHORIZED VENDOR REPRESENTAnyE'S NAME (Tn>> fK PM) T1TLE
'lOO MINOR MAYOR
"
SlGNAlURE
DATE
o RENT 0 OlHER
",ITIAI.S
DATE INITIAlED
NONRESOENT Wl1llHOLDtlG
o STANDARD RATE
o WAIVED
o REDUCED RATE
%
O NONEMPlOVEE 0 MEDICAl
COMPENSATION SERVICES
REPORTABLE INCOME CODE PER STATE AOUINISTRATrvE MANUAL SECTION M22." fC'** Ortt}
01 02 03 04 05 06 07
STATE OF CALFOANIA
VENDOR DATA RECORD
STD. 204 (REV. &<12) (REVERSO)
ARE YOU A RESIDENT OR A NONRESIDENT?
Each corporation, individual/sole proprietor, pannership, es-
tate or trust doing business with the State of California must
indicate their residency status along with their vendor identi-
fication number.
A corporation will be considered a "resident" if it has a
permanent place of business in California. A permanent place
of business has been established if the corporation is organized
and existing under the laws of this state or, if a foreign
corporation, it has qualified to transact intrastate business. A
corporation which has not qualified to transact business (e.g.,
a corporation engaged exclusively in interstate commerce)
will be considered as having a permanent place of business in
this state only if it maintains a permanent office in this state
which is permanently staffed by its employees.
For individuals/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 fora 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 consid-
ered a nonresident
For withholding purposes, a partnership is considered a resi-
dent partnership if it has a permanent place of business in
California. An estate is considered a California estate if the
decedent was a California resident at the time of death and a
trust is considered a California trust if at least one trustee is a
California resident.
More information on residency status can be obtained by
caUing the numbers listed below:
From within the United States, cali .......1-800-852-5711
From outside the United States, cali ......1-800-854-6500
For hearing impared with TOO, cali...... 1-800-822-6268
ARE YOU SUBJECT TO NONRESIDENT
WITHHOLDING?
Payments made to nonresident vendors, including corpora-
tions, individuals, partnerships, estates and trusts, are subject
to withholding. 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 totaJ payments withheld for state income taxes. How-
ever, no withholding is required if total payments to the vendor
for the calendar year are $1500 or less.
A nonresident vendor can req~tthat income taxes be with-
held at a lower rate or waived; A waiver will generally be
granted when a vendor has a history ofming Califomiareturns .
and making timely estimated payments. If the vendor activity
is carried on outside of California or partially outside of
California, a waiver or reduced withholding rate may be
granted. For more information, contact:
Franchise Tax Board
Withhold at Source Unit
Attention: State Agency Withholding Coordinator
P.O. Box 651
Sacramento, CA 95812-0651
(916) 369-4900 FAX (916) 369-4831
If a reduced rate of witbboldiDg or waiver bas beeD
autborized by tbe FraDcbise Tax Board, attacb a copy
to tbis form.
.-
PRIVACY STATEMENT
"
Section 7(b) of the Privacy Act of 1974 (Public Law 93-5791) requires thatany federal, state, or local governmental agency which requests
an individual to disclose his social security account numbershall inform that individual whether that disclosure is mandatory orvoluntary,
by which statutory or other authority such number is solicited, and what uses will be made of it
The State of California requires thatall parties entering into business transactions that may lead to payment(s) from the State must provide
their Taxpayer Identification Number (TIN) in order to facilitate the preparation of Form 1099 and other information returns as required
by the Internal Revenue Code, Section 6109 and the State Revenue and Taxation Code, Section 18934, The TIN for individual and sole
proprietorships is the 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 be subject to a 20% withholding and State law imposes noncompliance penalties of 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 the
business services unit or the accounts payable unit of the State agency(ies) with which you transact business.
If you have any questions regarding this notice, plea<le call the Department ofFmance, FISCal Systems and Consulting Unit, at (916) 324-0385.