STATE OF CALIFORNIA RECOVERY DIRECTORATE
OES CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
FINANCIAL PROCESSING DIVISION
FFATA FINANCIAL DISCLOSURE
OES-FPD-011 (Rev. 10-2022) Cal OES ID No.:
UEl Number:
Previous Fiscal Year End Date:
FFATA Financial Disclosure
The Federal Funding Accountability and Transparency Act (FFATA) requires information on federal awards be made available to the public and is submitted by the California Governor's Office of Emergency Services (Cal OES) to www.fsrs.gov. This is done in order that the government be held accountable for each spending decision. As a subrecipient of federal funds, you will be unable to draw down funds until this signed form is returned to Cal OES.
The Total Compensation and Names of the top five executives must be reported in the table on this form if your business or organization meets both of the following criteria:
80% or more of annual gross revenues are from Federal awards (contracts, sub- contracts, and Federal financial assistance), and $25,000,000 or more in annual gross revenues from Federal awards; and,
b) Compensation information is not already available through reporting to the Securities and Exchange Commission.
If your business or organization does NOT meet BOTH criteria, check the box below, sign, and return to Cal OES Financial Processing Unit.
Not subject to FFATA Financial Disclosure.
Annual Annual Dollar Total
Executive Name Title
Salary Value of Benefits Compensation
1 Carmen Gil , do hereby certify; as the authorized agent of Printed Name of Authorized Agent
City of Gonzales _. the information contained in this document is true Entity Name
and correct.
Citu manaaes
Title of Authorized Agent
1/7/25
Signature of Authorized Agent Date
Rev. 10-2022 OES-FPD-011
DES STATE OF CALIFORNIA RECOVERY DIRECTORATE
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES FINANCIAL PROCESSING DIVISION
LIST OF AUTHORIZED AGENTS
OES-FPD-012 (Rev. 09-2022)
List of Authorized Agents
Entity Name: City of Gonzales
Cal OES ID: 53-30392
• Enter each Authorized Agent (AA) as listed on the Designation of Applicant's Agent Resolution (Cal OES 130) for Non-State Agencies or as it appears on the Signature Authority (Cal OES 130SA) for California State Agencies. • Check box to receive electronic copies of Cal OES Notification of Obligation and/or Payment packages. (Minimum 1 AA.) • Email addresses must use an email that shares the official entity URL. Email Authorized Agent Name Authorized Agent Title Email Address Pkg? Carmen Gil City Manager [email protected]
Patrick Dobbins Public Works Director [email protected] Jason Muscio Fire Chief [email protected]
• An Approved Contact may be designated by an AA to request or receive information on grant payment status. Add them by inputting their information below. (Ex. Accounting/Admin offices) Must use an official email URL.
Email
Approved Contact Name Approved Contact Title Email Address Pkg? Please use a second page if more space is needed
Rev. 09-2022 OES-FPD-012
STATE OF CALIFORNIA RECOVERY DIRECTORATE
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES FINANCIAL PROCESSING DIVISION
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
OES-FPD-089 (Rev. 10-2022)
Disaster No: 4683
Cal OES ID No: 053-30392
UEI No: TSN7XP4SDJMS
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
SUBRECIPIENT'S NAME: City of Gonzales
(Name of Organization)
PRIMARY MAILING ADDRESS: PO Box 647
CITY:_ Gonzales _STATE: CA _ZIP CODE: 93926
TELEPHONE: 831-675-5000 FAX NUMBER:
CA ASSEMBLY DIST: _29_CA SENATE DIST: 17 _U.S. CONGRESSIONAL DIST: 18 Visit sos.ca.gov/elections/who-are-my-representatives to find your district number.
AUTHORIZED AGENT: Carmen Gil
TITLE:_ City Manager
EMAIL ADDRESS: [email protected]
ASSURANCES - CONSTRUCTION PROGRAMS
Note: Certain of these assurances may not be applicable to all your projects. If you have questions, please contact the California Governor's Office of Emergency Services. Further, certain federal assistance awarding agencies may require applicants to certify to additional assurances. If such is the case, you will be notified.
As the duly authorized representative of the applicant, I certify that the subrecipient named above:
1. Has the legal authority to apply for federal assistance, and the institutional, managerial and financial capability (including funds sufficient to pay the non- federal share of project costs) to ensure proper planning, management, and completion of the project described in this application.
2. Will give the awarding agency, the Comptroller General of the United States, Federal Office of Inspector General 2 CFR 200.336, and if appropriate, the state, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the assistance; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives.
Rev. 10-2022 Page 1 of 5 . OES-FPD-089
STATE OF CALIFORNIA RECOVERY DIRECTORATE
OES CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES FINANCIAL PROCESSING DIVISION
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
OES-FPD-089 (Rev. 10-2022)
3. Will not dispose of, modify the use of, or change the terms of the real property title, or other interest in the site and facilities without permission and instructions from the awarding agency. Will record the federal interest in the title of real property in accordance with awarding agency directives and will include a covenant in the title of real property acquired in whole or in part with federal assistance funds to assure nondiscrimination during the useful life of the project.
4. Will comply with the requirements of the assistance-awarding agency with regard to the drafting, review and approval of construction plans and specifications.
5. Will provide and maintain competent and adequate engineering supervision at the construction site to ensure that the complete work conforms with the approved plans and specifications and will furnish progress reports and such other information as may be required by the assistance awarding agency or state.
6. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency.
7. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gains.
8. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§ 4801 et seq.), which prohibits the use of lead-based paint in construction or rehabilitation of residential structures.
9. Will comply with all federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title Vi of the Civil Rights Act of 1964 (P.L 88- 352) which prohibits discrimination on the basis of race, color, or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§ 1681-1683 and 1685-1686) which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. § 794) which prohibit discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§ 6101-6107) which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 93-255) as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616) as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) §§ 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 290 dd- 3 and 290 ee-3) as amended, relating to confidentiality of alcohol and drug abuse patient records; (h) Title VIll of the Civil Rights Act of Rev. 10-2022 Page 2 of 5 OES-FPD-089
STATE OF CALIFORNIA RECOVERY DIRECTORATE
OES CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES
FINANCIAL PROCESSING DIVISION
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
OES-FPD-089 (Rev. 10-2022)
1968 (42 U.S.C. § 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental, or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for federal assistance is being made, and (i) the requirements on any other non- discrimination statute(s) which may apply to the application.
10. Will comply, or has already complied, with the requirements of Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provides for fair and equitable treatment of persons displaced or whose property is acquired as a result of federal and federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of federal participation in purchases.
11. Will comply with the flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $5,000 or more.
12. Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.O. 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e) assurance of project consistency with the approved state management program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. §§ 1451 et seq.): (f) conformity of federal actions to State (Clean Air) Implementation Plans under Section 176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. § 7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended (P.O. 93-205).
13. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§ 1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system.
14. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. 470), EO 11593 (identification and preservation of historic properties), and the Archeological and Historic Preservation Act of 1974 (16 U.S.C. 469 a-1 et seq.).
Rev. 10-2022 Page 3 of 5 OES-FPD-089
STATE OF CALIFORNIA RECOVERY DIRECTORATE
OES CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES FINANCIAL PROCESSING DIVISION
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
OES-FPD-089 (Rev. 10-2022)
15. Will comply with Standardized Emergency Management (SEMS) requirements as stated in the California Emergency Services AcT, Government Code, Chapter 7 of Division 1 of Title 2, Section 8607.1 (e) and CCR Title 19, Sections 2445, 2446, 2447, and 2448.
16. Subrecipients expending $750,000 or more in federal grant funds annually are required to secure an audit pursuant to OMB Uniform Guidance 2 CFR Part 200, Subpart F. Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996.
17. Will disclose in writing any potential conflict of interest to the Federal awarding agency or pass-through entity in accordance with § 200.112.
18. Will comply with all applicable requirements of all other federal laws, Executive Orders, regulations and policies governing this program.
19. Has requested through the State of California, federal financial assistance to be used to perform eligible work approved in the subrecipient application for federal assistance. Will, after the receipt of federal financial assistance, through the State of California, agree to the following:
a. The state warrant covering federal financial assistance will be deposited in a special and separate account and will be used to pay only eligible costs for projects described above.
b. To return to the State of California such part of the funds so reimbursed pursuant to the above numbered application, which are excess to the approved actual expenditures as accepted by final audit of the federal or state government.
c. In the event the approved amount of the above numbered project application is reduced, the reimbursement applicable to the amount of the reduction will be promptly refunded to the State of California.
20. The non-Federal entity for a Federal award must disclose, in a timely manner, in writing to the Federal awarding agency or pass-through entity all violations of Federal criminal law involving fraud, bribery, or gratuity violations potentially affecting the Federal award §200.113. Failure to make required disclosures can result in any of the remedies described in § 200.338 Remedies for noncompliance, including suspension or debarment.
Rev. 10-2022 Page 4 of 5 OES-FPD-089
STATE OF CALIFORNIA RECOVERY DIRECTORATE
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES FINANCIAL PROCESSING DIVISION
PROJECT ASSURANCES FOR FEDERAL ASSISTANCE
OES-FPD-089 (Rev. 10-2022)
21. Will not make any award or permit any award (subaward or contract) to any party which is debarred or suspended or is otherwise excluded from or ineligible for participation in Federal assistance programs under Executive Order 12549 and 12689, "Debarment and Suspension."
"I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized by the City Council of the City of Gonzales
(Name of Organization)
to enter into this agreement for and on behalf of said subrecipient, and by my signature do bind the subrecipient to the terms thereof." Carmen Gil
PRINTED NAME
SIGNATURE OF AUTHORIZED AGENT
City Manager 1/14/2025
TITLE DATE
Rev. 10-2022 Page 5 of 5 OES-FPD-089
OES , STATE OF CALIFORNIA RECOVERY DIRECTORATE
CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES FINANCIAL PROCESSING DIVISION
DESIGNATION OF APPLICANT'S AGENT RESOLUTION
NON-STATE AGENCIES Cal OES ID No: _
OES-FPD-130 (Rev. 10-2022)
DESIGNATION OF APPLICANT'S AGENT RESOLUTION FOR NON-STATE AGENCIES BE IT RESOLVED BY THE City Council OFTHE City of Gonzales (Governing Body) (Name of Applicant)
THAT City Manager _ OR
(Title of Authorized Agent)
Public Works Director _. OR
(Title of Authorized Agent)
Fire Chief
(Title of Authorized Agent)
is hereby authorized to execute for and on behalf of the City of Gonzales (Name of Applicant)
a public entity established under the laws of the State of California, this application and to file it with the California Governor's Office of Emergency Services for the purpose of obtaining federal financial assistance for any existing or future grant program, including, but not limited to any of the following:
- Federally declared Disaster (DR), Fire Mitigation Assistance Grant (FMAG), California State Only Disaster (CDAA), Immediate Services Program (ISP), Hazard Mitigation Grant Program (HMGP), Building Resilient Infrastructure and Communities (BRIC), Legislative Pre-Disaster Mitigation Program (LPDM), under - Public Law 93-288 as amended by the Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988, and/or state financial assistance under the California Disaster Assistance Act.
- Flood Mitigation Assistance Program (FMA), under Section 1366 of the National Flood Insurance Act of 1968.
• National Earthquake Hazards Reduction Program (NEHRP) 42 U.S. Code 7704 (b) ((2) (A) (ix) and 42 U.S. Code 7704 (b) (2) (B) National Earthquake Hazards Reduction Program, and also The Consolidated Appropriations Act. 2018, Div. F, Department of Homeland Security Appropriations Act, 2018, Pub. L. No. 115-141 - California Early Earthquake Warning (CEEW) under CA Gov Code - Gov, Title 2, Div. 1, Chapter 7, Article 5, Sections 8587.8, 8587.11, 8587.12 That the _ City of Gonzales — a public entity established under the (Name of Applicant)
laws of the State of California, hereby authorizes its agents) to provide to the Governor's Office of Emergency Services for all matters pertaining to such state disaster assistance the assurances and agreements required.
Rev. 10-2022 Page 1 of 4 OES-FPD-130
STATE OF CALIFORNIA RECOVERY DIRECTORATE
OES CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES FINANCIAL PROCESSING DIVISION
DESIGNATION OF APPLICANT'S AGENT RESOLUTION
NON-STATE AGENCIES
OES-FPD-130 (Rev. 10-2022)
Please check the appropriate box below
This is a universal resolution and is effective for all open and future disasters/grants declared up to three (3) years following the date of approval. • This is a disaster/grant specific resolution and is effective for only disaster/grant numbers):_
Passed and approved this 13 day of January _. 2025
Jose L. Rios, Mayor
(Name and Title of Governing Body Representative)
Scott Funk, Mayor Pro Tem
(Name and Title of Governing Body Representative)
Liz Silva, Council member
(Name and Title of Governing Body Representative)
CERTIFICATION
, May Villegas _duly appointed and Deputy City Clerk of (Name)
City of Gonzales _ do hereby certify that the above is a true and (Name of Applicant)
City Council
correct copy of a resolution passed and approved by the (Governing Body)
City of Gonzales _on the 13th _ day of January _. 2025. of the
(Name of Applicant)
Deputy City Clerk
(Signature) (Title)
Rev. 10-2022 Page 2 of 4 OES-FPD-130
AGAL STATE OF CALIFORNIA RECOVERY DIRECTORATE
OES CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES FINANCIAL PROCESSING DIVISION
DESIGNATION OF APPLICANT'S AGENT RESOLUTION
NON-STATE AGENCIES
OES-FPD-130 (Rev. 10-2022)
CaLOES Form 130 Instructions
A Designation of Applicant's Agent Resolution for Non-State Agencies is required of all Applicants to be eligible to receive funding. A new resolution must be submitted if a previously submitted resolution is older than three (3) years from the last date of approval, is invalid, or has not been submitted.
When completing the Cal OES Form 130, Applicants should fill in the blanks on pages 1 and 2. The blanks are to be filled in as follows:
Resolution Section:
Governing Body: This is the group responsible for appointing and approving the Authorized Agents.
Examples include: Board of Directors, City Council, Board of Supervisors, Board of Education, etc.
Name of Applicant: The public entity established under the laws of the State of California.
Examples include: School District, Office of Education, City, County or Non-profit agency that has applied for the grant, such as: City of San Diego, Sacramento County, Burbank Unified School District, Napa County Office of Education, University Southern California.
Authorized Agent: These are the individuals that are authorized by the Governing Body to engage with the Federal Emergency Management Agency and the California Governor's Office of Emergency Services regarding grants for which they have applied.
There are two ways of completing this section:
1. Titles Only: The titles of the Authorized Agents should be entered here, not their names. This allows the document to remain valid if an Authorized Agent leaves the position and is replaced by another individual. If "Titles Only" is the chosen method, this document must be accompanied by either a cover letter naming the Authorized Agents by name and title, or the Cal OES AA Names document. The supporting document can be completed by any authorized person within the Agency (e.g., administrative assistant, the Authorized Agent, secretary to the Director). It does not require the Governing Body's signature.
2. Names and Titles: If the Governing Body so chooses, the names and titles of the Authorized Agents would be listed. A new Cal OES Form 130 will be required if any of the Authorized Agents are replaced, leave the position listed on the document, or their title changes.
Rev. 10-2022 Page 3 of 4 OES-FPD-130
STATE OF CALIFORNIA RECOVERY DIRECTORATE
OES CALIFORNIA GOVERNOR'S OFFICE OF EMERGENCY SERVICES FINANCIAL PROCESSING DIVISION
DESIGNATION OF APPLICANT'S AGENT RESOLUTION
NON-STATE AGENCIES
OES-FPD-130 (Rev. 10-2022)
Checking Universal or Disaster-Specific Box: A Universal resolution is effective for all past disasters and for those declared up to three (3) years following the date of approval. Upon expiration it is no longer effective for new disasters, but it remains in effect for disasters declared prior to expiration. It remains effective until the disaster goes through closeout unless it is superseded by a newer resolution.
Governing Body Representative: These are the names and titles of the approving Board Members.
Examples include: Chairman of the Board, Director, Superintendent, etc. The names and titles cannot be one of the designated Authorized Agents. A minimum of three (3) approving board members must be listed. If less than three are present, meeting minutes must be attached in order to verify a quorum was met.
Certification Section:
Name and Title: This is the individual in attendance who recorded the creation and approval of this resolution.
Examples include: City Clerk, Secretary to the Board of Directors, County Clerk, etc. This person cannot be one of the designated Authorized Agents or Approving Board Member. If a person holds two positions (such as City Manager and Secretary to the Board) and the City Manager is to be listed as an Authorized Agent, then that person could sign the document as Secretary to the Board (not City Manager) to eliminate "Self-Certification." Rev. 10-2022 Page 4 of 4 OES-FPD-130
Print Form Reset Form
STATE OF CALIFORNIA - DEPARTMENT OF FINANCE
PAYEE DATA RECORD
(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)
Section 1 - Payee Information
NAME (This is required. Do not leave this line blank. Must match the payee's federal tax return) City of Gonzales
BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above) MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2) PO Box 647
CITY, STATE, ZIP CODE E-MAIL ADDRESS
Gonzales, CA 93926 [email protected]
Section 2 - Entity Type
Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2) • SOLE PROPRIETOR / INDIVIDUAL CORPORATION (see instructions on page 2) • SINGLE MEMBER LLC Disregarded Entity owned by an individual • MEDICAL (e.g., dentistry, chiropractic, etc.) • PARTNERSHIP • LEGAL (e.g., attomey services)
• ESTATE OR TRUST * EXEMPT (e.g., nonprofit)
• ALL OTHERS
Section 3 - Tax Identification Number
Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN. Social Security Number (SSN) or The TIN is a 9-digit number. Note: Payment will not be processed without a TIN.
Individual Tax Identification Number (ITIN)
• For Individuals, enter SSN.
• If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.
• Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may OR not have a separate FEIN. Those trusts must enter the individual grantor's SSN. • For Sole Proprietor or Single Member LLC (disregarded entity), in which the Federal Employer Identification Number sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB (FEIN) prefers SSN).
94 - 6 0 _ O 4 .1
• For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity's FEIN. Do not use the disregarded entity's FEIN.
• For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity's FEIN.
Section 4 - Payee Residency Status (See instructions)
• CALIFORNIA RESIDENT - Qualified to do business in California or maintains a permanent place of business in California. • CALIFORNIA NONRESIDENT - Payments to nonresidents for services may be subject to state income tax withholding. •No services performed in Califomia
•Copy of Franchise Tax Board waiver of state withholding is attached.
Section 5 - Certification
1 holy my i deny penal or go, with on thy nat the road on this document is true and correct.
NAME OF AUTHORIZED PAYEE REPRESENTATIVE E-MAIL ADDRESS
Patrick Dobbins Public Works Director [email protected] SIGNATURE DATE TELEPHONE (include area code
1/14/2025 831-675-5000
Section 6 - Paying State Agency
Please return completed form to:
STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION
CA Governor's Office of Emergency Services
MAILING ADDRESS FAX TELEPHONE (include area code)
3650 Schriever Avenue 916-845-8510
CITY STATE ZIP CODE E-MAIL ADDRESS
Mather CA 95655
STATE OF CALIFORNIA - DEPARTMENT OF FINANCE
PAYEE DATA RECORD
(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)
GENERAL INSTRUCTIONS
Type or print the information on the Payee Data Record, STD 204 form. Sign, date, and return to the state agency/department office address shown in Section 6.
Prompt return of this fully completed form will prevent delays when processing payments.
Information provided in this form will be used by California state agencies/departments to prepare Information Returns (Form1099).
NOTE: Completion of this form is optional for Government entities, i.e. federal, state, local, and special districts.
A completed Payee Data Record, STD 204 form, is required for all payees (non-governmental entities or individuals) entering into a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.
Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup withholding. Amounts reported on information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and the California Revenue and Taxation Code (R&TC).
Section 1 - Payee information
Name - Enter the name that appears on the payee's federal tax return. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).
• Sole Proprietor/Individual/Revocable Trusts - enter the name shown on your federal tax return. • Single Member Limited Liability Companies (LLCs) that is disregarded as an entity separate from its owner for federal tax purposes - enter the name of the individual or business entity that is tax liable for the business in section 1. Enter the DBA, LLC name, trade, or fictitious name under Business Name. • Note: for the State of California tax purposes, a Single Member LLC is not disregarded from its owner, even if they may be disregarded at the Federal level. • Partnerships, Estates/Trusts, or Corporations - enter the entity name as shown on the entity's federal tax return. The name provided in Section 1 must match to the TIN provided in section 3. Enter any DBA, trade, or fictitious business names under Business Name.
Business Name - Enter the business name, DBA name, trade or fictitious name, or disregarded LLC name.
Mailing Address - The mailing address is the address where the payee will receive information returns. Use form STD 205, Payee Data Record Supplement to provide a remittance address if different from the mailing address for information returns, or make subsequent changes to the remittance address.
Section 2 - Entity Type
If the Payee in Section 1 is a(n)... THEN Select the Box for...
Individual • Sole Proprietorship • Grantor (Revocable Living) Trust disregarded for federal tax purposes Sole Proprietor/Individual Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes Single Member LLC-owned by an individual Partnerships • Limited Liability Partnerships (LLP) • and, LLC treated as a Partnership Partnerships Estate • Trust (other than disregarded Grantor Trust) Estate or Trust Corporation that is medical in nature (e.g., medical and healthcare services, physician care, nursery Corporation-Medical care, dentistry, etc. • LLC that is to be taxed like a Corporation and is medical in nature Corporation that is legal in nature (e.g., services of attorneys, arbitrators, notary publics involving legal Corporation-Legal or law related matters, etc.) • LLC that is to be taxed like a Corporation and is legal in nature Corporation that qualifies for an Exempt status, including 501(c) 3 and domestic non-profit corporations. Corporation-Exempt corporation that does not meet the qualifications of any of the other corporation types listed above • LLO Corporation-All Other that is to be taxed as a Corporation and does not meet any of the other corporation types listed above Section 3 - Tax Identification Number
The State of California requires that all parties entering into business transactions that may lead to payments) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by R&T sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&T section 18662 and its regulations.
Section 4 - Payee Residency Status
Are you a California resident or nonresident?
• A corporation will be 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.
• 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 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 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 nonresident.
For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:
Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: [email protected] For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov Section 5 - Certification
Provide the name, title, email address, signature, and telephone number of individual completing this form and date completed. In the event that a SSN or ITIN is provided, the individual identified as the tax liable party must certify the form. Note: the signee may differ from the tax liable party in this situation if the signee can provide a power of attorney documented for the individual.
Section 6 - Paying State Agency
This section must be completed by the state agency/department requesting the STD 204.
Privacy Statement
Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency, which requests an individual to disclose their 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. It is mandatory to furnish the information requested. Federal law requires that payment for which the requested information is not provided is subject to federal backup 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 that business.
All questions should be referred to the requesting state agency listed on the bottom front of this form.