State of California
Financial Information System for California (FI$Cal)
GOVERNMENT AGENCY TAXPAYER ID FORM
2000 Evergreen Street, Suite 215
Sacramento, CA 95815
www.fiscal.ca.gov
1-855-347-2250
The principal purpose of the information provided is to establish the unique identification of the government entity.
Instructions: You may submit one form for the principal government agency and all subsidiaries sharing the same TIN. Subsidiaries with a different TIN must submit a separate form. Fields marked with an asterisk (*) are required. Hover over fields to view help information. Please print the form to sign prior to submittal. You may email the form to: [email protected], or fax it to (916) 576-5200, or mail it to the address above.
Principal
Government
Agency Name*
Remit-To
Address (Street
or PO Box)*
City* State * Zip Code*+4
Government Type: City County
Special District Federal
Other (Specify)
Federal
Employer
Identification
Number
(FEIN)*
List other subsidiary Departments, Divisions or Units under your principal agency's jurisdiction who share the same FEIN and receives payment from the State of California.
Dept/Division/Unit Complete
Name Address
Dept/Division/Unit
Name
Complete
Address
Dept/Division/Unit
Name
Complete
Address
Dept/Division/Unit
Name
Complete
Address
Title
E-mail address
Contact Person*
Phone number*
Signature* Date