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Staff Report - Local Agency Technical Assistance (LATA) Grant Program

Sacramento City Council
November 1, 2022

Document
Staff Report - Local Agency Technical Assistance (LATA) Grant Program
Meeting
November 1, 2022
Body
Sacramento City Council
Pages
2
Original file
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Text extracted from the city's file for reading and search. Open the original on sacramento.granicus.com. That file is the official record.

City of Sacramento
City Council - 5PM Report
915 I Street Sacramento, CA 95814
www.cityofsacramento.org
File ID: 2022-01871 11/1/2022 Consent Item 14.

Local Agency Technical Assistance (LATA) Grant Program
File ID: 2022-01871
Location: Citywide
Recommendation: Adopt a Resolution authorizing the City Manager or the City Manager’s designee to: 1) accept the LATA grant for an amount of $210,300 from the State of California Public Utilities Commission (CPUC) to provide technical services to facilitate the expansion of high-speed broadband services; 2) establish an operating grant G07000100 (Digital Expansion Project) ; and 3) establish the revenue and expenditure budgets in the amount of $210,300.

Contact: Maria MacGunigal, Chief Information Officer, (916) 808-7988, [email protected]; Darin Arcolino, Assistant IT Director, (916) 808-0403, [email protected], Information Technology Department Presenter: None
Attachments:
1-Description/Analysis
2-Resolution
3-Award Letter
Additional Description/Analysis
Issue Detail: The LATA grants support tribes and local agencies in their efforts to expand broadband service to unserved and underserved Californians. Established by the CPUC according to Senate Bill 156, the program has a $50 million budget for grants. Technical assistance funding is for planning work that will facilitate high-speed broadband infrastructure projects.

On August 17, 2022, the City of Sacramento Information Technology Department submitted the application to the CPUC to receive funding for planning work for a Digital Expansion Project. On October 6, 2022, the CPUC authorized an award amount of $210,300 to fund the project within a 24- month timeframe. This report recommends that Council authorize the City Manager, or his designee, to accept the awarded funds.

Page 1 of 2 ends

File ID: 2022-01871 11/1/2022 Consent Item 14.

The Digital Expansion Project will help the city gain a clear picture of the current broadband environment and find innovative ways to play a role in improving competition, reliability, and resiliency for our communities.

Policy Considerations: Acceptance of the CPUC funding is consistent with City Council action relative to state and federal grant awards.

Economic Impacts: None.

Environmental Considerations: The report does not constitute a “project” as the activity will have no significant effect on the environment and is a continuing administrative activity. It is therefore exempt from the California Environmental Quality Act (CEQA) (CEQA Guidelines Sections 15061(b) (3);15378(b)(2)).

Sustainability: Not applicable.

Commission/Committee Action: Not applicable.

Rationale for Recommendation: The report does not constitute a “project” as the activity will have no significant effect on the environment and is a continuing administrative activity. It is therefore exempt from the California Environmental Quality Act (CEQA) (CEQA Guidelines Sections 15061(b) (3);15378(b)(2)).

Financial Considerations: The CPUC has approved a LATA grant in the amount of $210,300. Grant project G07000100 (Digital Expansion Project) will be established to support this project.

Local Business Enterprise (LBE): Not applicable.

Page 2 of 2 ends

RESOLUTION NO. 2022-
Adopted by the Sacramento City Council
November _________, 2022
Local Agency Technical Assistance (LATA) Grant Program

BACKGROUND
A. The State of California Public Utilities Commission (CPUC) established the LATA grant program to support tribes and local agencies in their efforts to expand broadband service to unserved and underserved Californians.

B. According to Senate Bill 156, the LATA grant program has a $50 million budget for grants to provide technical assistance funding for planning work that will facilitate high-speed broadband infrastructure projects.

C. On August 17, 2022, the City of Sacramento’s Information Technology Department applied to the CPUC to receive funding for planning work to support the City of Sacramento’s digital expansion efforts.

D. On October 6, 2022, the CPUC authorized a grant award amount of $210,300 to fund the digital expansion efforts within a 24-month timeframe.

BASED ON THE FACTS SET FORTH IN THE BACKGROUND AND STAFF REPORT, THE CITY COUNCIL RESOLVES AS FOLLOWS:

Section 1. The City Manager or the City Manager’s designee is authorized to accept the LATA grant for an amount of $210,300 from the State of California Public Utilities Commission to provide technical services to facilitate the expansion of high-speed broadband services.

Section 2. The City Manager or the City Manager’s designee is authorized to establish an operating grant G07000100 (Digital Expansion Project).

Section 3. The City Manager or the City Manager’s designee is authorized to establish the revenue and expenditure budgets in the amount of $210,300.

Oct. 6, 2022
Darin Arcolino
[email protected]
City of Sacramento Digital Expansion Project

Dear Darin Arcolino,

Congratulations! The California Public Utilities Commission is pleased to inform you that the City of Sacramento’s application for Local Agency Technical Assistance grant funding for the City of Sacramento Digital Expansion Project in the amount of up to $210,300.00 has been approved.

Pursuant to Decision (D.) 22-02-026, Staff is authorized to approve applications that meet all the criteria for Ministerial Review. Your application was received on August 17, 2022 and was posted on the CPUC’s Local Agency Technical Assistance webpage. Staff reviewed your application and determined that your application is eligible for a grant and meets eligibility criteria for Ministerial Review.

The award is predicated on the City of Sacramento’s agreement to provide technical assistance as detailed in its application. In its application, the City of Sacramento agreed to comply with the specified Ministerial Review criteria as well as to fulfill all requirements, guidelines, and conditions associated with a grant of Local Agency Technical Assistance funds as specified in D.22-02-026 including but not limited to execution and performance, payment, reporting and award acceptance requirements listed in Attachments 1 and 2 of this letter. Please sign and submit the following: 1. A Consent Form binding your organization to the terms of the grant and 2. A State of California payee data record for tax reporting purposes. You must submit these documents within 30 days of the date of this letter. If you do not, this award is void.

Thank you for your application and please direct any questions to Angela Beane ([email protected]) and/or refer to the Grantee Administrative Manual, available at https://bit.ly/CPUCLATA.

We appreciate your efforts to provide service to our fellow Californians.

Sincerely,

Robert Osborn
Director, Communications Division
California Public Utilities Commission

2 ATTACHMENT 1
Requirements
The grant award is predicated on the City of Sacramento’s agreement to provide technical assistance as detailed in its application. In its application, the City of Sacramento (“Grantee”) agreed and attested to comply with the specified Ministerial Review criteria as well as fulfilling all requirements guidelines, and conditions associated with a grant of Local Agency Technical Assistance funds as specified in D.22- 02-026, including but not limited to execution and performance, payment, reporting and award acceptance requirements. Key requirements of Local Agency Technical grant include, among others:
• All costs are related to the development of broadband network deployment projects to benefit unserved or underserved Californians. These projects may include, but are not limited to, the costs of joint powers authority formation, environmental studies, network design, and engineering study expenses.
• Grant may not exceed $500,000 per local agency, per fiscal year • A signed affidavit agreeing to comply with the terms, conditions and requirements of the grant and submits to the jurisdiction of the Commission with respect to the disbursement and administration of the grant as well as applicable state and federal rules concerning broadband services.
• Grantee must sign a Consent Form agreeing to the terms stated in the award letter as well as all Local Agency Technical Assistance Rules and Requirements, Guidelines and Application Materials in D.22-06-026. Link to form: lata-consent-form-9-27-22.pdf (ca.gov) • Grantee must complete the reimbursable work product within 24 months. • Grantee must provide Staff a copy of the final reimbursable work product.

Reporting
The grant award is contingent upon fulfilling the reporting requirements per D.22-06-026, Attachment

1. SB 156 requires grantees to fulfill the monthly reporting requirements set forth in Public Utilities Code section 281(l)(1) if they are using a licensed contractor or subcontractor* to undertake a contract or subcontract in excess of twenty-five thousand dollars ($25,000). The Commission is required to post that information on its website. Specifically, SB 156 requires the following to be reported to the Commission on a monthly basis:
• The name and contractor’s license number of each licensed contractor and subcontractor undertaking a contract or subcontract in excess of twenty-five thousand dollars ($25,000) to perform work on a project funded or financed pursuant to this section. • The location where a contractor or subcontractor described in subparagraph (A) will be performing that work.

3 • The anticipated dates when that work will be performed.

* Licensed contractor or subcontractor means any contractor that holds a California state license through the contractor’s state license board (https://www.cslb.ca.gov/).

Post-completion
Upon completion of the reimbursable work product and before final payment, Grantees must:
• Provide a signed completion form stating the technical assistance work has been completed suitable to be posted on the Commission’s webpage. The signed completion form must be provided prior to final payment and must include a short summary of the reimbursable work product(s) performed under the contract, including demonstration that the reimbursable work product(s) identify broadband infrastructure deployment projects that will help achieve the CASF deployment goal, and identification of the area(s) where the applicant intends to deploy broadband based on the reimbursable work product(s). • Provide a copy of each reimbursable work product’s final report(s), plans, studies, etc. produced under the contract.

Payment
Payment will be made directly to the local agency as the grant recipient. Local agency grantees may request partial reimbursement if they complete one or more of the approved reimbursable work products prior to completion of other reimbursable work products approved in the same grant authorization. Payment will be based upon receipt and approval of an invoice(s) submitted by the local agency showing the expenditures incurred for the reimbursable work product, along with the reimbursable work product final report/study/joint powers agreement, etc., and the completion reporting required above. The invoice(s) must be supported by documentation including but not limited to the actual cost of labor and any other expense that will be recovered by the grant.

To the extent that any portion of an award was used to reimburse a local agency for administrative costs associated with securing or completing a reimbursable work product, the local agency must submit an itemized accounting of such costs, demonstrating the total requested for reimbursement does not exceed 15 percent of the total authorized award. If any portion of reimbursement is found to be out of compliance, grantees will be responsible for refunding any disallowed amount along with appropriate interest rates determined in accordance with applicable Commission decisions. Grantees are required to maintain records such as files, invoices, and other related documentation for five years after final payment. Grantees shall make these records and invoices available to the Commission upon request and agree that these records are subject to a financial audit by the Commission at any time within five years after the final payment made to a grantee.

4 Execution and Performance
The City of Sacramento must complete the project within the 24-month timeframe in accordance with the terms of approval granted by the Commission. If the Grantee is unable to complete project within the 24-month timeframe, it must notify the Commission or Director of Communications Division as soon as it becomes aware of this prospect. The Commission may reduce or withhold payment for failure to satisfy this requirement. In the event that the Grantee or contractor fails to complete the work in accordance with the approval granted by the Commission, and as described in its application and contract, the Grantee must reimburse some or all of the funds it has received.

City of Sacramento must sign and submit the linked Consent Form agreeing to the terms of the award within 30 calendar days from the date of this letter. Failure to submit the Consent Form within the timeframe required, the CPUC will deem the grant or award null and void.

City of Sacramento must communicate in writing to the Communications Division’s Director regarding any changes to the substantive terms and conditions underlying the Commission’s approval of the grant (such as changes to a reimbursable work product contract, work plan or budget) at least 30 days before the anticipated. Substantive changes may require approval by either the Communications Division Director or by Commission Resolution before becoming effective.

The Commission has the right to conduct any necessary audit, verification, and discovery for work proposed or completed under the technical assistance to ensure that funds are spent in accordance with Commission rules and with the terms of approval by the Commission.

5 Attachment 2
Local Agency Broadband Technical Assistance
Reporting Requirements and Guidelines
Version October 2022

The Local Agency Technical Assistance program provides grants for eligible pre-construction work which facilitates the construction of broadband network projects. When the California Public Utilities Commission (CPUC) established the technical assistance grant program, the program was funded with American Rescue Plan Act monies administered by the U.S. Treasury. The source of technical assistance funding has changed. This guidance outlines grantee reporting.

The Commission issued Decision (D.) 22-02-026 establishing program requirements for the Local Agency Technical Assistance Grant Program.

Grantees must file quarterly progress reports to the Commission with the below information.

Narrative Project Information

1.1 The counties, cities and census designated places where households, businesses, and community anchor institutions are planned to be served by the broadband project.

1.2 Confirmation that the technical assistance is designed to support projects that, upon completion, reliably meet or exceed symmetrical 100 Mbps download and upload speeds.

1.3 Statement of intention about the pricing plans for projects that the technical assistance will support, such as offering of affordable plan or low-income plan subsidized with other funding (ACP).

1.4 Information on broadband need in the project area.

1.5 Statement describing the community benefits of broadband technical assistance.

Detailed Project Information

2.1 Individual work products granted by the program.
o Dollars/hours expended per task/work product.

2.2 Estimated construction start date (month/year).

2.3 Estimated construction completion date (month/year).

6 2.4 Estimated initiation of operations date (month/year).

2.5 Planned project technology type(s):
o Fiber
o Coaxial Cable
o Terrestrial Fixed Wireless
o Other (specify)

2.6 Estimated total miles of fiber to be deployed.

2.7 Planned number of locations to be served, broken out by type:
o Residential locations
o Business connections
o Community anchor institutions

2.8 Planned non-promotional prices including associated fees, speed tiers, and data allowance for each speed tier.

2.9 Other data on broadband need, by location.

Submission
To assist grantees with the filing of quarterly progress reports to the Commission, a sample of the reporting requirements is found in Attachment A of this document.

Planned project information listed in Attachment A should be submitted on a quarterly basis to the Commission’s email at [email protected]. Grantees need to include in the email subject line:

1. Application Name

2. Project Name

3. The Reporting Quarter/Month
Updated quarterly project submissions are required to be sent by the due dates shown below. Grantees are responsible for contacting the Commission at [email protected], if the information cannot be submitted on time.

Reporting Period Project Information Due to CPUC

7 October 1 – December 31, 2022 January 2, 2023
January 1 – March 31, 2023 April 1, 2023
April 1 – June 30, 2023 July 1, 2023
July 1 – September 30, 2023 October 1, 2023
October 1 – December 31, 2023 January 2, 2024
January 1 – March 31, 2024 April 1, 2024
April 1 – June 30, 2024 July 1, 2024
July 1 – September 30, 2024 October 1, 2024
October 1 – December 31, 2024 January 2, 2025
January 1 – March 31, 2025 April 1, 2025
April 1 – June 30, 2025 July 1, 2025
July 1 – September 30, 2025 October 1, 2025
October 1 – December 31, 2025 January 2, 2026
January 1 – March 31, 2026 April 1, 2026
April 1 – June 30, 2026 July 1, 2026
July 1 – September 30, 2026 October 1, 2026
October 1 – December 31, 2026 February 1, 2027

Additional Information
Reporting requirements and guidelines are subject to change, and CPUC or the Commission may define additional requirements on CPUC’s website.

These requirements, in spreadsheet format, are available at: https://www.cpuc.ca.gov/-/media/cpuc- website/divisions/communications-division/documents/broadband-implementation-for- california/technical-assistance-reporting-requirements-oct-2022.pdf

California Public Utilities Commission
Local Agency Technical Assistance Program

CONSENT FORM
Acknowledgement and Acceptance of Terms

Applicant Name: _________________________________________________________

Key Project Contact: ______________________________________________________

The Grantee identified above acknowledges receipt of the California Public Utilities Commission Resolution T-__________ or Award Letter Dated__________ and agrees to comply with all grant terms, conditions, and requirements set forth in the Resolution or Approval Letter including those in the Local Agency Technical Assistance Rules.

Undersigned representative of ____________________________________ [Name of Grantee] is duly authorized to execute this Consent Form on behalf of the Grantee and to bind the Grantee to the terms, conditions, and requirements set forth in California Public Utilities Commission Resolution T-_____________ or Award Letter.

Dated this ______ day of ______________, 20___.

Signature of Local Agency/Tribe:

_______________________________________________________________________

Title____________________________________________________________________

Printed Name____________________________________________________________

________________________________________________________________________

Organization or Name of Local Agency or Tribe:

________________________________________________________________________

Business Address (include street address, suite/apt. number, city, state, and ZIP Code):

_______________________________________________________________________

Telephone Number: ______________________________________________________

Email Address: ___________________________________________________________ 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) 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)

CITY, STATE, ZIP CODE E-MAIL ADDRE SS
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) CORPORATION (see instructions on page 2)☐ SOLE PROPRIETOR / INDIVIDUAL ☐ MEDICAL (e.g., dentistry, chiropractic, etc.)☐ SINGLE MEMBER LLC Disregarded Entity owned by an individual ☐ PARTNERSHIP
☐ ESTATE OR TRUST
☐ LEGAL (e.g., attorney services)
☐ 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.

The TIN is a 9-digit number. Note: Payment will not be processed without a TIN. •
•
•
•
•
•
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 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 sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).

For Single Member LLC (disregarded entity), in which the s ole 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.

Social Security Number (SSN) or
Individual Tax Identification Number (ITIN)
___ ___ ___ -___ ___ - ___ ___ __
_ ___
OR
Federal Employer Identification Number
(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 serv
ices performed in California
☐Copy of Fr
anchise Tax Board waiver of state withholding is attached.

Section 5 – Certification
I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Should my residency status change, I will promptly notify the state agency below.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITL E E-M AIL ADDRESS SI

GNATURE DATE TEL
EPHONE (include area code)
Section 6 – Paying State Agency
Please return completed form to:

STATE AGENCY/DEPARTMENT OFFICE U NIT/SECTION
M

AILING ADDRESS F
AX T
ELEPHONE (include area code)

CITY S TATE Z IP CODE E -MAIL ADDRESS
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)

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 subjec t to IRS TIN matching (when applicable).
• Sole Proprietor/Individual/Revocable Trusts – enter the name shown on your federal tax return. • Si
ngle 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 t
he 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 care, dentistry, etc. ● LLC that is to be taxed like a Corporation and is medical in nature Corporation-Medical
Corporation that is legal in nature (e.g. , services of attorneys, arbitrators, notary publics involving legal or law related matters, etc.) ● LLC that is to be taxed like a Corporation and is legal in nature Corporation-Legal
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 ● LLC that is to be taxed as a Corporation and does not meet any of the other corporation types listed above Corporation-All Other
Section 3 – Tax Identification Number
The State of California requires that all parties entering into business transactions that may lead to payment(s) from the st ate provide their Taxpayer Identification Number (TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax com pliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC 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. •
A
n 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. o
F
or 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.

F
or information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:

W
ithholding Services and Compliance Section: 1-888-792-4900 E-mail address: [email protected] F
or 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 signe e 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.

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