PAYEE DATA RECORD (in lieu of IRS W-9) Required in lieu of IRS W-9 form when receiving payments from the Judicial Council of California (JCC) on behalf of the Superior Courts of California 1 Instructions See page two for additional instructional infor mation and Privacy Statement. Complete all information on this form, sign, date, and return the form. Prompt return of this fully completed form will prevent delays when processing payments. Information provided in this form will be used to prepare Information Returns (1099). Submit the completed form to the following address: Superior Court of California County of Santa Clara 191 North First Street San Jose, CA 95113 Attn: Finance Division SECTION S 2 THRU 5 TO BE COMPLETED BY VENDOR 2 Legal Name PAYEE'S LEGAL NAME - AS SHOWN ON FEDERAL INCOME TAX RETURN BUSINESS NAME - IF DIFFERENT FROM ABOVE E - MAIL ADDRESS REMITTANCE MAILING ADDRESS BUSINESS ADDRESS (if different from remittance mailing address) CITY, STATE, ZIP CODE , CITY, STATE, ZIP CODE , PHONE NUMBER FACSIMILE NUMBER 3 Payee Entity Type Complete One Box Only NOTE A taxpayer identification number is required ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) - PARTNERSHIP CORPORATION EXEMPT (NON-PROFIT) LIMITED LIABILITY COMPANY CORPORATION 226 LEGAL GOVERNMENT CORPORATION 226 MEDICAL OTHER 226 ESTATE OR TRUST INDIVIDUAL/SOLE PROPRIETOR ENTER SOCIAL SECURITY NUMBER (SSN) - - If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN; however, the IRS prefers that you use your SSN. An employee vendor is not required to provide a SSN. 4 Resident Status check the appropriate box California Resident - Qualified to do business in California or maintains place of business California Nonresident (see reverse side) - Payments to non-resident for services may be subject to State Income Tax withholding. No services performed in California Copy of Franchise Tax Board waiver of State Withholding attached 5 Certification NOTE See instructions on page 2 Vendor Contact Information and signature Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person, as defined by the IRS. I hereby certify under the penalty of perjury that the information provided on this document is true and correct. Should my information change, I will promptly notify the JCC at the address listed in Section 1. VENDOR REPRESENTATIVE'S NAME (Type or Print) TITLE E - MAIL AUTHORIZED VENDOR SIGNATURE DATE TELEPHONE SECTION 6 TO BE COMPLETED BY COURT 6 Vendor Category Court Contact Please choose from the JC C Vendor c ategory below to help us expedite payment ARBITRATOR VOLUNTEER OTHER (description required) CONTRACTOR GRAND JURY RENT COURT APPT. COUNSEL INTEREST PAYMENTS ONLY DECEASED FINAL PAYMENT COURT REPORTER COURT INTERPRETER: (indicate language) EMPLOYEE MEDIATOR GARNISHMENT TRUSTEE PAYMENT TERMS COURT CONTACT NAME PHONE NUMBE R EMAIL FOR JC C USE ON LY (Form updated 02/01/2013 ) Assigned Vendor Number Assigned By: FN-030 REV 01/29/15 American LegalNet, Inc. www.FormsWorkFlow.com Requirement to Complete Payee Data Record A completed Payee Data Record (in lieu of the IRS W - 9) i s required for payments and will be kept on file at the Judicial Council of California - Administrative Office of the Courts, Trial Court Administrative Services Division. Since each state agency with which you do business must have a separate Payee Data R ecord on file, it is possible for a payee to receive a similar form from various state agencies. SECTIONS 2 THRU 5 TO BE FILLED OUT BY VENDOR 2 Enter the payee222s legal name. Sole proprietorships must also include the owner222s full name. An individual must list his/her legal name as it appears on his/her Federal Income tax return. If a different name is used, that name should also be entered, beneath the legal name. The mailing address should be the address at which the payee chooses to receive correspondence. The business address is the physical location of business, if different than mailing address. The phone number, e-mail address, and facsimile number should also be provided. 3 Check the box that corresponds to the payee business type. Check o nly one box. Corporations must check the box that identifies the type of corporation. The State of California requires that all parties entering into business transactions that may lead to payment(s) from the State provide their Taxpayer Identification Number (TIN). The TIN is required by the California Revenue and Taxation Code Section 18646 to facilitate tax compliance enforcement activities and the preparation of Form 1099 and other information returns as required by the Internal Revenue Code Section 6109(a). The TIN for individuals is their Social Security Number (SSN). A sole proprietor may have both a Federal Employer Identification Number (FEIN) and a SSN, the IRS prefers that sole proprietors user their SSN. Only partnerships, estates, trusts, and corporations will enter their FEIN. 4 Are you a California resident or non - resident? A corporation will be defined as a 223resident224 if it has a permanent place of business in California or is qualified through the Secretary of State to do business in California. 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 the time of death. A trust is a resident if at least one trustee is a California resident. For individuals and sole proprietors, the term 223resident224 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 that 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 non-resident. Payments to all non-residents may be subject to withholding. Non-resident payees 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. For information on Non-resident Withholding, contact the Franchise Tax Board at the numbers listed below: Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov 5 This form must be signed . Provide the name, title, e - mail, and telephone number of the individual completing this form. Also, provide the date the form was completed. Certification Instructions: You must cross out item 2 if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. If you are not a U.S. Citizen or U.S. person, as defined by the Internal Revenue Service, a different form may be required and tax withholdings may apply. See IRS website http://www.irs.gov/businesses/international/index.html for additional information. SECTION 6 TO BE FILLED OUT BY COURT 6 Please check the box that best describes the type of business/work the vendor provides. This will assist us in processing payment and tax withholdings. If the court is sending the request, please include contact information to assist with processing your request. Not including court contact information may delay processing the request. Privacy Stateme