HEBBRON FAMILY CENTERREVITALIZATION PROJECT
Project Information Package
January 18, 2022
5 D. PROJECT INFORMATION PACKAGE CHECKLIST
Grantee sends the completed Project Information Package to Agency. Grantee should keep a complete copy of the Project Information Package for future use and reference.
Provide the package in order shown in the following checklist.
Required Documentation Page
☐ Project Information Package Checklist (this page) 4
☐ Project Information Form 6
☐ Project Summary 7
☐ Authorizing Resolution 8
☐ Cost Estimates (Development/Acquisition) 9, 10
☐ Project Timeline 13
☐ Property Data Sheet 14
☐ Land Tenure/Site Control Documents 6
☐ Photos of the Project Site 7
☐ Site Plan, if applicable 7
☐ Environmental Compliance Documents (if applicable) 15 ☐ Permit Approval Status, if applicable 16
☐ Payee Data Form (Std. 204) 18
Hebbron Family Center Revitalization Project
683 Fremont St. Salinas, CA 93905
APN: 004082038000, 004082036000, 004082016000, 004082017000, 004082023000, 004082024000 Project Description
The Hebbron Heights community of Salinas is one of the most densely populated and low-income communities in the entire city. Nestled in the middle of the neighborhood is the Hebbron Family Center (HFC), a community and recreation center serving residents of all ages six days a week. The existing HFC was constructed in the mid 60’s and is approximately 7,300 square feet in size.
The Recreation and Parks Master Plan adopted by council in 2019 represented a community engagement effort that connected with thousands of residents and community leaders over 18 months. The plan assessed the state of our current parks and community centers and engaged resident to prioritize need for maintenance and what the city needs to add to it. The plan includes a ranking of all potential improvement projects, and the Hebbron Family Center is ranked #1 due to current structural conditions as well as community feedback and priorities.
The current HFC would be demolished and a modern, 7,500 square -foot functionally-efficient HFC would be built. The immediate impact of a new building would be consistency – as well as expansion – in offerings. The design of the new HFC requires that at least 75 percent of the building’s square footage must be designed for recreation. The new HFC is described bel ow per the following six categories: main assembly room, smaller assembly room, meeting rooms, kitchen, Teen Lounge, and rooms not counted as recreational features or major support amenities.
Main assembly room. This space would occupy 4,640 square feet and accommodate at least 50 to 60 people for various community events and activities.
Smaller assembly room. This space would occupy 1,600 square feet and accommodate 25 to 30 people.
Meeting rooms. Two 180 square feet meeting rooms to accommodate 10 to 12 people.
Kitchen. A 400 square-foot commercial kitchen to accommodate preparation of food for special events and ongoing facility programming.
Teen Lounge. This space would occupy 500 square feet and accommodate 40 people.
Rooms not counted as recreational features or major support amenities include a lobby, 3 office spaces, restrooms, closets, storage rooms and hallways. These elements of the facility amount to 2500 square feet.
Outdoor improvements: Enhanced Tot Lot and playground with overhead fabric shade structure. Surrounding grass areas throughout the facility and a formal separate grass area – about half the size of the playground - would be situated immediately adjacent to the western side of the playground. Existing turf would be encircled with a concrete walkway and include a fabric shade structure . In the other grassy area, the following would be installed: An ADA-compliant, multi-level drinking, picnic tables, benches, trash receptacles, pathways, and area lighting. In addition, a security system with cameras and sensors would be installed.
Major Support Amenities. Major support amenities would include the following three features: an enhanced parking lot, enhanced landscaping throu ghout the HFC Complex, and enhanced lighting throughout the HFC Complex.
1 RESOLUTION NO. (N.C.S.)
RESOLUTION OF THE CITY OF THE SALINAS CITY COUNCIL
APPROVING THE ACCEPTANCE OF GENERAL FUND GRANT FUNDS FOR THE
HEBBROM FAMILY CENTER REVITALIZATION PROJECT
WHEREAS, the Legislature and Governor of the State of California have approved a grant for the project shown above; and
WHEREAS, the California Na tural Resources Agency has been delegated the responsibility for the administration of the grant project, setting up necessary procedures; and
WHEREAS, said procedures established by the California Natural Resources Agency require the Grantee to certify by resolution the approval of the Project Information Package before submission of said package to the State; and
WHEREAS, the Grantee will enter into an agreement with the State of California for subject project(s):
NOW, THEREFORE, BE IT RESOLVED that the Salinas City Council:
1. Approves the acceptance of general fund allocation for local assistance for the above project(s); and
2. Certifies that said agency understands the assurances and certification in the Project Information Form; and
3. Certifies that said agency will have sufficient funds to develop, operate and maintain the project(s) consistent with the land tenure requirements; or will secure the resources to do so; and
4. Certifies that said agency will comply with the provisions of Section 1771.5 of the California Labor Code.
5. If applicable, certifies that the project will comply with any laws and regulation including, but not limited to, the California Environmental Quality Act (CEQA), legal requirements for building codes, health and safety codes, disabled access laws, environmental laws and, that prior to commencement of construction, all applicable licenses and permits will have been obtained.
6. Certifies that said agency has reviewed and understands the General Provisions contained in the Project Agreement shown in the Procedural Guide; and
7. Appoints the Library and Community Services Director as agent to conduct all negotiations, execute and submit all documents including, but not limited to Project Information Form, agreements, pa yment requests and so on, which may be necessary for the completion of the aforementioned project(s).
PASSED AND APPROVED this 18th day of January 2022, by the following vote:
AYES:
2 NOES:
ABSENT:
ABSTAIN:
APPROVED:
______________________________
Kimbley Craig, Mayor
ATTEST:
_________________________
Patricia M. Barajas, City Clerk
Project Elements Total Project Costs General Fund Grant Other Funding Other Funding
NON-CONSTRUCTION COSTS
Direct Project Management Administration 200,000.00$ 200,000.00$ Staff Time (direct costs only)
Incidental Charges Ineligible
Consultants 300,000.00$ 300,000.00$
Subtotal – Direct Management 500,000.00$ 500,000.00$ Planning, Design & Permitting
Staff Time (direct costs only)
Consultants - Design Fees 679,100.50$ 679,100.50$ Permit Costs 50,000.00$ 50,000.00$
Subtotal Planning, Design & Permitting 729,100.50$ 729,100.50$ CEQA Compliance (if applicable)
Staff Time (direct costs only)
Consultants
Subtotal – CEQA
SUB-TOTAL Non-Construction Costs 1,229,100.50$ 1,229,100.50$
CONSTRUCTION COSTS
Clear & grubbing 10,000.00$ 10,000.00$ Swppp/erosion controls 50,000.00$ 50,000.00$ Demo and dispose of concrete 22,500.00$ 22,500.00$ Demo and dispose of existing trees 7,500.00$ 7,500.00$ Demo and dispose of curbs 2,500.00$ 2,500.00$ Demo and dispose of existing asphalt 22,188.00$ 22,188.00$ Hebbron Family Center Revitalization Project Budget
683 Freemint St., Salinas, CA 93905
Misc. Demolition 25,000.00$ 25,000.00$ Demo and dispose of canopies 12,500.00$ 12,500.00$ Demo and dispose of existing buildings 65,250.00$ 65,250.00$ Subtotalfor demolition of current structure and site prep 217,438.00$ 217,438.00$ 20% Contingency 43,487.60$ 43,487.60$
Total 260,925.60$ 260,925.60$
Earthwork for building pad 43,050.00$ 43,050.00$ Building structure 3,780,000.00$ 3,780,000.00$ Outdoor plaza 225,000.00$ 225,000.00$
Sewer to building 75,000.00$ 75,000.00$ Water/fire lines to building 125,000.00$ 125,000.00$ Electrical to buildings 150,000.00$ 150,000.00$ Gas to buildings 45,000.00$ 45,000.00$ Subtotal for new building and outdoor site elements $4,443,050 $4,443,050 20% Contingency $888,610 $888,610
Total $5,331,660 $5,331,660
Grading and subgrades 33,600.00$ 33,600.00$ Curbs 18,000.00$ 18,000.00$
Storm drains 75,000.00$ 75,000.00$
Approaches 5,000.00$ 5,000.00$
Asphalt paving 32,000.00$ 32,000.00$
Pervious paving 144,000.00$ 144,000.00$
Striping/signage 3,500.00$ 3,500.00$
Subtotal for new parking lot 311,100.00$ 311,100.00$ 20% Contingency 62,220.00$ 62,220.00$
Total 373,320.00$ 373,320.00$
Rubberized play surface 39,000.00$ 39,000.00$ Gazebos 50,000.00$ 50,000.00$
Hardscapes 24,000.00$ 24,000.00$
Lighting 75,000.00$ 75,000.00$
Electrical 65,000.00$ 65,000.00$
Tables 6,000.00$ 6,000.00$
Misc. Amenities 25,000.00$ 25,000.00$
Playground allowance 100,000.00$ 100,000.00$ Fencing 30,000.00$ 30,000.00$
Storm drains 75,000.00$ 75,000.00$
Total for playground and amenities 489,000.00$ 489,000.00$ 20% Contingency 97,800.00$ 97,800.00$
Total 586,800.00$ 586,800.00$
2" water lines 25,000.00$ 25,000.00$
Connection to water meter 1,500.00$ 1,500.00$ Sprinklers 45,000.00$ 45,000.00$
Drip system 15,000.00$ 15,000.00$
Plants 40,000.00$ 40,000.00$
Trees 12,500.00$ 12,500.00$
Total for Trees, landscaping and irrigation system 139,000.00$ 139,000.00$ 20% Contingency 27,800.00$ 27,800.00$
Total 166,800.00$ 166,800.00$
Testing 6,500.00$ 6,500.00$
Disposal 65,000.00$ 65,000.00$
Subtotal for hazard waste disposal 71,500.00$ 71,500.00$ 20% Contingency 14,300.00$ 14,300.00$
Total 85,800.00$ 85,800.00$
TOTAL Construction Costs 6,805,305.60$ 6,805,305.60$ Contingency at 20%
PROJECT GRAND TOTAL 8,034,406.10$
PROJECT TIMELINE
Activity Description Timeline
Preliminary work on the project November 2021- August 2022 Submit CEQA documents February 2022 (exemption approved October 2019)
Submit final site design/plans/specifications July 2023 – December 2023 Submit evidence of bond acknowledgement sign N/A
Construction period June 2024- January 2026
Submit Project Closeout package with final Payment Request to State
February 2026
14 L. PROPERTY DATA SHEET
Complete the Property Data Sheet listing each parcel included in the proposed project, as well as the owner(s) of each parcel. Indicate and attach all required documents* including any clarifying comments below. Attach additional sheets if necessary.
No Owner Name
Assessor Parcel
Number(s) Acreage
Indicate type of
ownership. For
acquisitions,
indicate type of
purchase.
For all parcels, indicate
*document used to
demonstrate ownership
and attach a copy of
each document -clearly
labeled with the APN -to
this document
If parcel(s) not owned by
Grantee(s) indicate *document
verifying long-term Permission
to Develop and maintain and
attach
Entity to perform O&M
# of years O&M to be performed
Fee Simple
Easement
Other
(describe)
Proof of Ownership (tax
bill, grant deed, etc.)
O&M
Agreement
Lease
JPA
Letter from
Owner
Other
(describe)
1 2
3 4
5 6
7 8
9 10
Comments:
Total Number of Parcels: ____________________Total Number of Acres: ______________________________________________ City of Salinas 004082038000 0.6707
City of Salinas 004082023000 0.1935
City of Salinas 004082024000 0.154
004082036000City of Salinas 0.1131
City of Salinas 004082017000 0.0872
004082016000City of Salinas 0.1028
City of Salinas 004082019000 0.2474
7 1.587
Tax bill
Tax bill
Tax bill
Tax bill
Tax bill
Tax bill
Tax bill
1.2.005
IMPORTANT MESSAGES PROPERTY INFORMATION
ASMT NUMBER:
ORIG ASMT:
FEE NUMBER:
TAX RATE AREA:
LOCATION:
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
2 ND
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
1 ST
VOTER APPROVED TAXES / TAXING AGENCY DIRECT CHARGES & SPECIAL ASSESSMENTS / FEES TOTAL TAXES 1st INSTALLMENT 2nd INSTALLMENT
PHONE # CODE DESCRIPTION ASSESSED VALUE X TAX RATE / 100 = TAX AMOUNT
COUNTY VALUES, EXEMPTIONS, AND TAXES
PHONE # DESCRIPTION PRIOR CURRENT BILLED
AGENCY TAXES + DIRECT CHARGES + FEES + PENALTY + COST + DELINQUENT PENALTIES GENERAL INQ (831) 755-5057
0 2021
2021
Cortac Number: B0099
CITY OF SALINAS
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
AGENCY TAXES
0 (800) 273-5167
004-082-023-000
004-082-023-000
004-082-023-000
005037
0 2021
2021
2021
$0.00
DELINQUENT AFTER 04/10/2022
$0.00
$0.00
PAYMENTS (831) 755-5057
$0.00
ADDR CHGS (831) 755-5035
VALUATIONS (831) 755-5035
12600
EXEMPTIONS (831) 755-5035
TAX RATES (831) 755-5040
$151.04
DELINQUENT AFTER 12/10/2021 (INCLUDES 10% PENALTY OF $7.49 AND $0.00 COST) $83.01 0 11/22/2021
MCWRA Zone 9
MONTEREY COUNTY SECURED PROPERTY TAXES - 2ND INSTALLMENT PAYMENT STUB FEES
NET TAXABLE VALUE
0 (831) 755-6700
$17.16
MCWRA Zone 2C Dvrsn
004-082-023-000
004-082-023-000
004-082-023-000
MCWRA Zone 2C Ops
CURRENT OWNER:
CURRENT OWNER:
11700
0 $31.58
$0.00
ACRES:
0 OWNER JAN. 1st:
004082023000720214000000075523100000008301420214
SECURED TAX ROLL FOR FISCAL YEAR JULY 1, 2021 - JUNE 30, 2022 2022
2022
2022
$75.52
$0.54
004082023000720214000000075523200000010301520214
MONTEREY COUNTY 2021 - 2022 PROPERTY TAX BILL
0 TO PAY TOTAL TAXES, RETURN BOTH STUBS BY 12/10/2021 $151.04 Salinas Union High 2014 AB 2017Ref
NoSalinasValleyMosquitoAbateme
0 0
0 0
MCWRA Zone 2C Admin
Salinas, CA 93902-0891
Salinas, CA 93902-0891
MONTEREY COUNTY SECURED PROPERTY TAXES - 1ST INSTALLMENT PAYMENT STUB
PENALTY & COST
$1.16
IF PAID BY 04/10/2022 $75.52
IF PAID BY 12/10/2021 $75.52
004-082-023-000
004-082-023-000
004-082-023-000
0 0.00
DELINQUENT AFTER 12/10/2021
(831) 755-4860
TBUN2WEB
Hartnell 14Ref A 15Ref AB 16 AB
MCWRA Zone 2Y
Original bill date 09/21/2021
Monterey County Tax Collector
Monterey County Tax Collector
(831) 755-4860
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CUT HERE - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 0 0
0 Salinas City SD 2008 Election Series BCD GO Ref A
$0.18
DIRECT CHARGES
11:48:03AM
0.032410
$0.00
MCWRA Zone 2C Splwy
12000
DELINQUENT AFTER 04/10/2022 (INCLUDES 10% PENALTY OF $7.49 AND $20.00 COST) $103.01 0 -
-
-
$75.52
0 0
(831) 753-5600
$95.76
0 CITY OF SALINAS
CITY OF SALINAS
CITY OF SALINAS
$151.04
0.044750
0 0
0 0
P.O. Box 891
P.O. Box 891
0 $151.04
0 (831) 796-7000
0.021686
$4.36
0 PERS PROP (831) 755-5035
P.O. Box 891, Salinas, CA 93902-0891, (831) 755-5057, www.co.monterey.ca.us/taxcollector $0.30
MCWRA Zone 2Z
PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG 0 $0.00
MARY A. ZEEB Treasurer-Tax Collector
1.2.005
IMPORTANT MESSAGES PROPERTY INFORMATION
ASMT NUMBER:
ORIG ASMT:
FEE NUMBER:
TAX RATE AREA:
LOCATION:
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
2 ND
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
1 ST
VOTER APPROVED TAXES / TAXING AGENCY DIRECT CHARGES & SPECIAL ASSESSMENTS / FEES TOTAL TAXES 1st INSTALLMENT 2nd INSTALLMENT
PHONE # CODE DESCRIPTION ASSESSED VALUE X TAX RATE / 100 = TAX AMOUNT
COUNTY VALUES, EXEMPTIONS, AND TAXES
PHONE # DESCRIPTION PRIOR CURRENT BILLED
AGENCY TAXES + DIRECT CHARGES + FEES + PENALTY + COST + DELINQUENT PENALTIES GENERAL INQ (831) 755-5057
0 2021
2021
Cortac Number: B0099
CITY OF SALINAS
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
AGENCY TAXES
0 (800) 273-5167
004-082-024-000
004-082-024-000
004-082-024-000
005037
0 2021
2021
2021
$0.00
DELINQUENT AFTER 04/10/2022
$0.00
$0.00
PAYMENTS (831) 755-5057
$0.00
ADDR CHGS (831) 755-5035
VALUATIONS (831) 755-5035
12600
EXEMPTIONS (831) 755-5035
TAX RATES (831) 755-5040
$149.70
DELINQUENT AFTER 12/10/2021 (INCLUDES 10% PENALTY OF $7.44 AND $0.00 COST) $82.29 0 11/22/2021
MCWRA Zone 9
MONTEREY COUNTY SECURED PROPERTY TAXES - 2ND INSTALLMENT PAYMENT STUB FEES
NET TAXABLE VALUE
0 (831) 755-6700
$17.16
MCWRA Zone 2C Dvrsn
004-082-024-000
004-082-024-000
004-082-024-000
MCWRA Zone 2C Ops
CURRENT OWNER:
CURRENT OWNER:
11700
0 $31.58
$0.00
ACRES:
0 OWNER JAN. 1st:
004082024000620214000000074856100000008229720214
SECURED TAX ROLL FOR FISCAL YEAR JULY 1, 2021 - JUNE 30, 2022 2022
2022
2022
$74.85
$0.42
004082024000620214000000074856200000010229420214
MONTEREY COUNTY 2021 - 2022 PROPERTY TAX BILL
0 TO PAY TOTAL TAXES, RETURN BOTH STUBS BY 12/10/2021 $149.70 Salinas Union High 2014 AB 2017Ref
NoSalinasValleyMosquitoAbateme
0 0
0 0
MCWRA Zone 2C Admin
Salinas, CA 93902-0891
Salinas, CA 93902-0891
MONTEREY COUNTY SECURED PROPERTY TAXES - 1ST INSTALLMENT PAYMENT STUB
PENALTY & COST
$0.92
IF PAID BY 04/10/2022 $74.85
IF PAID BY 12/10/2021 $74.85
004-082-024-000
004-082-024-000
004-082-024-000
0 0.00
DELINQUENT AFTER 12/10/2021
(831) 755-4860
TBUN2WEB
Hartnell 14Ref A 15Ref AB 16 AB
MCWRA Zone 2Y
Original bill date 09/21/2021
Monterey County Tax Collector
Monterey County Tax Collector
(831) 755-4860
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CUT HERE - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 0 0
0 Salinas City SD 2008 Election Series BCD GO Ref A
$0.18
DIRECT CHARGES
11:50:28AM
0.032410
$0.00
MCWRA Zone 2C Splwy
12000
DELINQUENT AFTER 04/10/2022 (INCLUDES 10% PENALTY OF $7.44 AND $20.00 COST) $102.29 0 -
-
-
$74.85
0 0
(831) 753-5600
$95.76
0 CITY OF SALINAS
CITY OF SALINAS
CITY OF SALINAS
$149.70
0.044750
0 0
0 0
P.O. Box 891
P.O. Box 891
0 $149.70
0 (831) 796-7000
0.021686
$3.46
0 PERS PROP (831) 755-5035
P.O. Box 891, Salinas, CA 93902-0891, (831) 755-5057, www.co.monterey.ca.us/taxcollector $0.22
MCWRA Zone 2Z
PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG 0 $0.00
MARY A. ZEEB Treasurer-Tax Collector
1.2.005
IMPORTANT MESSAGES PROPERTY INFORMATION
ASMT NUMBER:
ORIG ASMT:
FEE NUMBER:
TAX RATE AREA:
LOCATION:
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
2 ND
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
1 ST
VOTER APPROVED TAXES / TAXING AGENCY DIRECT CHARGES & SPECIAL ASSESSMENTS / FEES TOTAL TAXES 1st INSTALLMENT 2nd INSTALLMENT
PHONE # CODE DESCRIPTION ASSESSED VALUE X TAX RATE / 100 = TAX AMOUNT
COUNTY VALUES, EXEMPTIONS, AND TAXES
PHONE # DESCRIPTION PRIOR CURRENT BILLED
AGENCY TAXES + DIRECT CHARGES + FEES + PENALTY + COST + DELINQUENT PENALTIES GENERAL INQ (831) 755-5057
0 2021
2021
Cortac Number: B0099
CITY OF SALINAS
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
AGENCY TAXES
0 004-082-036-000
004-082-036-000
004-082-036-000
005037
0 2021
2021
2021
$0.00
DELINQUENT AFTER 04/10/2022
$0.00
$0.00
PAYMENTS (831) 755-5057
$0.00
ADDR CHGS (831) 755-5035
VALUATIONS (831) 755-5035
12600
EXEMPTIONS (831) 755-5035
TAX RATES (831) 755-5040
$148.84
DELINQUENT AFTER 12/10/2021 (INCLUDES 10% PENALTY OF $7.40 AND $0.00 COST) $81.82 0 11/22/2021
MCWRA Zone 9
MONTEREY COUNTY SECURED PROPERTY TAXES - 2ND INSTALLMENT PAYMENT STUB FEES
NET TAXABLE VALUE
0 (831) 755-6700
$17.16
MCWRA Zone 2C Dvrsn
004-082-036-000
004-082-036-000
004-082-036-000
MCWRA Zone 2C Ops
CURRENT OWNER:
CURRENT OWNER:
11700
0 $31.58
$0.00
ACRES:
0 OWNER JAN. 1st:
004082036000220214000000074427100000008182820214
SECURED TAX ROLL FOR FISCAL YEAR JULY 1, 2021 - JUNE 30, 2022 2022
2022
2022
$74.42
$0.36
004082036000220214000000074427200000010182920214
MONTEREY COUNTY 2021 - 2022 PROPERTY TAX BILL
0 TO PAY TOTAL TAXES, RETURN BOTH STUBS BY 12/10/2021 $148.84 Salinas Union High 2014 AB 2017Ref
0 0
0 0
MCWRA Zone 2C Admin
Salinas, CA 93902-0891
Salinas, CA 93902-0891
MONTEREY COUNTY SECURED PROPERTY TAXES - 1ST INSTALLMENT PAYMENT STUB
PENALTY & COST
$0.80
IF PAID BY 04/10/2022 $74.42
IF PAID BY 12/10/2021 $74.42
004-082-036-000
004-082-036-000
004-082-036-000
0 0.00
DELINQUENT AFTER 12/10/2021
(831) 755-4860
TBUN2WEB
Hartnell 14Ref A 15Ref AB 16 AB
MCWRA Zone 2Y
Original bill date 09/21/2021
Monterey County Tax Collector
Monterey County Tax Collector
(831) 755-4860
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CUT HERE - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 0 0
0 Salinas City SD 2008 Election Series BCD GO Ref A
DIRECT CHARGES
11:51:07AM
0.032410
$0.00
MCWRA Zone 2C Splwy
12000
DELINQUENT AFTER 04/10/2022 (INCLUDES 10% PENALTY OF $7.40 AND $20.00 COST) $101.82 0 -
-
-
$74.42
0 0
(831) 753-5600
$95.76
0 CITY OF SALINAS
CITY OF SALINAS
CITY OF SALINAS
$148.84
0.044750
0 0
0 0
P.O. Box 891
P.O. Box 891
0 $148.84
0 (831) 796-7000
0.021686
$2.98
0 PERS PROP (831) 755-5035
P.O. Box 891, Salinas, CA 93902-0891, (831) 755-5057, www.co.monterey.ca.us/taxcollector $0.20
MCWRA Zone 2Z
PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG 0 $0.00
MARY A. ZEEB Treasurer-Tax Collector
1.2.005
IMPORTANT MESSAGES PROPERTY INFORMATION
ASMT NUMBER:
ORIG ASMT:
FEE NUMBER:
TAX RATE AREA:
LOCATION:
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
2 ND
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
1 ST
VOTER APPROVED TAXES / TAXING AGENCY DIRECT CHARGES & SPECIAL ASSESSMENTS / FEES TOTAL TAXES 1st INSTALLMENT 2nd INSTALLMENT
PHONE # CODE DESCRIPTION ASSESSED VALUE X TAX RATE / 100 = TAX AMOUNT
COUNTY VALUES, EXEMPTIONS, AND TAXES
PHONE # DESCRIPTION PRIOR CURRENT BILLED
AGENCY TAXES + DIRECT CHARGES + FEES + PENALTY + COST + DELINQUENT PENALTIES GENERAL INQ (831) 755-5057
0 2021
2021
Cortac Number: B0099
CITY OF SALINAS
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
AGENCY TAXES
0 (800) 273-5167
004-082-038-000
004-082-038-000
004-082-038-000
005037
0 2021
2021
2021
$0.00
DELINQUENT AFTER 04/10/2022
$0.00
$0.00
PAYMENTS (831) 755-5057
$0.00
ADDR CHGS (831) 755-5035
VALUATIONS (831) 755-5035
12600
EXEMPTIONS (831) 755-5035
TAX RATES (831) 755-5040
$197.30
DELINQUENT AFTER 12/10/2021 (INCLUDES 10% PENALTY OF $9.82 AND $0.00 COST) $108.47 0 11/22/2021
MCWRA Zone 9
MONTEREY COUNTY SECURED PROPERTY TAXES - 2ND INSTALLMENT PAYMENT STUB FEES
NET TAXABLE VALUE
0 (831) 755-6700
$34.52
MCWRA Zone 2C Dvrsn
004-082-038-000
004-082-038-000
004-082-038-000
MCWRA Zone 2C Ops
CURRENT OWNER:
CURRENT OWNER:
11700
0 $31.58
$0.00
ACRES:
0 OWNER JAN. 1st:
004082038000020214000000098657100000010847620214
SECURED TAX ROLL FOR FISCAL YEAR JULY 1, 2021 - JUNE 30, 2022 2022
2022
2022
$98.65
$1.90
004082038000020214000000098657200000012847220214
MONTEREY COUNTY 2021 - 2022 PROPERTY TAX BILL
0 TO PAY TOTAL TAXES, RETURN BOTH STUBS BY 12/10/2021 $197.30 Salinas Union High 2014 AB 2017Ref
NoSalinasValleyMosquitoAbateme
0 0
0 0
MCWRA Zone 2C Admin
Salinas, CA 93902-0891
Salinas, CA 93902-0891
MONTEREY COUNTY SECURED PROPERTY TAXES - 1ST INSTALLMENT PAYMENT STUB
PENALTY & COST
$4.14
IF PAID BY 04/10/2022 $98.65
IF PAID BY 12/10/2021 $98.65
004-082-038-000
004-082-038-000
004-082-038-000
0 0.00
DELINQUENT AFTER 12/10/2021
(831) 755-4860
TBUN2WEB
Hartnell 14Ref A 15Ref AB 16 AB
MCWRA Zone 2Y
Original bill date 09/21/2021
Monterey County Tax Collector
Monterey County Tax Collector
(831) 755-4860
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CUT HERE - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 0 0
0 Salinas City SD 2008 Election Series BCD GO Ref A
$13.02
DIRECT CHARGES
11:46:43AM
0.032410
$0.00
MCWRA Zone 2C Splwy
12000
DELINQUENT AFTER 04/10/2022 (INCLUDES 10% PENALTY OF $9.82 AND $20.00 COST) $128.47 0 -
-
-
$98.65
0 0
(831) 753-5600
$95.76
0 CITY OF SALINAS
CITY OF SALINAS
CITY OF SALINAS
$197.30
0.044750
0 0
0 0
P.O. Box 891
P.O. Box 891
0 $197.30
0 (831) 796-7000
0.021686
$15.34
0 PERS PROP (831) 755-5035
P.O. Box 891, Salinas, CA 93902-0891, (831) 755-5057, www.co.monterey.ca.us/taxcollector $1.04
MCWRA Zone 2Z
PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG 0 $0.00
MARY A. ZEEB Treasurer-Tax Collector
1.2.005
IMPORTANT MESSAGES PROPERTY INFORMATION
ASMT NUMBER:
ORIG ASMT:
FEE NUMBER:
TAX RATE AREA:
LOCATION:
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
2 ND
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
1 ST
VOTER APPROVED TAXES / TAXING AGENCY DIRECT CHARGES & SPECIAL ASSESSMENTS / FEES TOTAL TAXES 1st INSTALLMENT 2nd INSTALLMENT
PHONE # CODE DESCRIPTION ASSESSED VALUE X TAX RATE / 100 = TAX AMOUNT
COUNTY VALUES, EXEMPTIONS, AND TAXES
PHONE # DESCRIPTION PRIOR CURRENT BILLED
AGENCY TAXES + DIRECT CHARGES + FEES + PENALTY + COST + DELINQUENT PENALTIES GENERAL INQ (831) 755-5057
0 2021
2021
Cortac Number: B0099
CITY OF SALINAS
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
AGENCY TAXES
0 004-082-016-000
004-082-016-000
004-082-016-000
005037
0 2021
2021
2021
$0.00
DELINQUENT AFTER 04/10/2022
$0.00
$0.00
PAYMENTS (831) 755-5057
$0.00
ADDR CHGS (831) 755-5035
VALUATIONS (831) 755-5035
12600
EXEMPTIONS (831) 755-5035
TAX RATES (831) 755-5040
$36.10
DELINQUENT AFTER 12/10/2021 (INCLUDES 10% PENALTY OF $1.78 AND $0.00 COST) $19.83 0 11/22/2021
MCWRA Zone 9
MONTEREY COUNTY SECURED PROPERTY TAXES - 2ND INSTALLMENT PAYMENT STUB FEES
NET TAXABLE VALUE
0 (831) 755-6700
$17.16
MCWRA Zone 2C Dvrsn
004-082-016-000
004-082-016-000
004-082-016-000
MCWRA Zone 2C Ops
CURRENT OWNER:
CURRENT OWNER:
11700
0 $3.60
$0.00
ACRES:
0 OWNER JAN. 1st:
004082016000620214000000018051100000001983620214
SECURED TAX ROLL FOR FISCAL YEAR JULY 1, 2021 - JUNE 30, 2022 2022
2022
2022
$18.05
$0.36
004082016000620214000000018051200000003983420214
MONTEREY COUNTY 2021 - 2022 PROPERTY TAX BILL
0 TO PAY TOTAL TAXES, RETURN BOTH STUBS BY 12/10/2021 $36.10 Salinas Union High 2014 AB 2017Ref
0 0
0 0
MCWRA Zone 2C Admin
Salinas, CA 93902-0891
Salinas, CA 93902-0891
MONTEREY COUNTY SECURED PROPERTY TAXES - 1ST INSTALLMENT PAYMENT STUB
PENALTY & COST
$0.80
IF PAID BY 04/10/2022 $18.05
IF PAID BY 12/10/2021 $18.05
004-082-016-000
004-082-016-000
004-082-016-000
0 0.00
DELINQUENT AFTER 12/10/2021
(831) 755-4860
TBUN2WEB
Hartnell 14Ref A 15Ref AB 16 AB
MCWRA Zone 2Y
Original bill date 09/21/2021
Monterey County Tax Collector
Monterey County Tax Collector
(831) 755-4860
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CUT HERE - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 0 0
0 Salinas City SD 2008 Election Series BCD GO Ref A
DIRECT CHARGES
11:52:19AM
0.032410
$0.00
MCWRA Zone 2C Splwy
12000
DELINQUENT AFTER 04/10/2022 (INCLUDES 10% PENALTY OF $1.78 AND $20.00 COST) $39.83 0 -
-
-
$18.05
0 0
(831) 753-5600
$11.00
0 CITY OF SALINAS
CITY OF SALINAS
CITY OF SALINAS
$36.10
0.044750
0 0
0 0
P.O. Box 891
P.O. Box 891
0 $36.10
0 (831) 796-7000
0.021686
$2.98
0 PERS PROP (831) 755-5035
P.O. Box 891, Salinas, CA 93902-0891, (831) 755-5057, www.co.monterey.ca.us/taxcollector $0.20
MCWRA Zone 2Z
PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG 0 $0.00
MARY A. ZEEB Treasurer-Tax Collector
1.2.005
IMPORTANT MESSAGES PROPERTY INFORMATION
ASMT NUMBER:
ORIG ASMT:
FEE NUMBER:
TAX RATE AREA:
LOCATION:
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
2 ND
ASMT NUMBER: TAX YEAR: MAKE CHECK PAYABLE TO:
ORIG ASMT:
FEE NUMBER:
LOCATION:
1 ST
VOTER APPROVED TAXES / TAXING AGENCY DIRECT CHARGES & SPECIAL ASSESSMENTS / FEES TOTAL TAXES 1st INSTALLMENT 2nd INSTALLMENT
PHONE # CODE DESCRIPTION ASSESSED VALUE X TAX RATE / 100 = TAX AMOUNT
COUNTY VALUES, EXEMPTIONS, AND TAXES
PHONE # DESCRIPTION PRIOR CURRENT BILLED
AGENCY TAXES + DIRECT CHARGES + FEES + PENALTY + COST + DELINQUENT PENALTIES GENERAL INQ (831) 755-5057
0 2021
2021
Cortac Number: B0099
CITY OF SALINAS
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
(831) 755-4860
AGENCY TAXES
0 004-082-017-000
004-082-017-000
004-082-017-000
005037
0 2021
2021
2021
$0.00
DELINQUENT AFTER 04/10/2022
$0.00
$0.00
PAYMENTS (831) 755-5057
$0.00
ADDR CHGS (831) 755-5035
VALUATIONS (831) 755-5035
12600
EXEMPTIONS (831) 755-5035
TAX RATES (831) 755-5040
$148.84
DELINQUENT AFTER 12/10/2021 (INCLUDES 10% PENALTY OF $7.40 AND $0.00 COST) $81.82 0 11/22/2021
MCWRA Zone 9
MONTEREY COUNTY SECURED PROPERTY TAXES - 2ND INSTALLMENT PAYMENT STUB FEES
NET TAXABLE VALUE
0 (831) 755-6700
$17.16
MCWRA Zone 2C Dvrsn
004-082-017-000
004-082-017-000
004-082-017-000
MCWRA Zone 2C Ops
CURRENT OWNER:
CURRENT OWNER:
11700
0 $31.58
$0.00
ACRES:
0 OWNER JAN. 1st:
004082017000520214000000074427100000008182820214
SECURED TAX ROLL FOR FISCAL YEAR JULY 1, 2021 - JUNE 30, 2022 2022
2022
2022
$74.42
$0.36
004082017000520214000000074427200000010182920214
MONTEREY COUNTY 2021 - 2022 PROPERTY TAX BILL
0 TO PAY TOTAL TAXES, RETURN BOTH STUBS BY 12/10/2021 $148.84 Salinas Union High 2014 AB 2017Ref
0 0
0 0
MCWRA Zone 2C Admin
Salinas, CA 93902-0891
Salinas, CA 93902-0891
MONTEREY COUNTY SECURED PROPERTY TAXES - 1ST INSTALLMENT PAYMENT STUB
PENALTY & COST
$0.80
IF PAID BY 04/10/2022 $74.42
IF PAID BY 12/10/2021 $74.42
004-082-017-000
004-082-017-000
004-082-017-000
0 0.00
DELINQUENT AFTER 12/10/2021
(831) 755-4860
TBUN2WEB
Hartnell 14Ref A 15Ref AB 16 AB
MCWRA Zone 2Y
Original bill date 09/21/2021
Monterey County Tax Collector
Monterey County Tax Collector
(831) 755-4860
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CUT HERE - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 0 0
0 Salinas City SD 2008 Election Series BCD GO Ref A
DIRECT CHARGES
11:53:08AM
0.032410
$0.00
MCWRA Zone 2C Splwy
12000
DELINQUENT AFTER 04/10/2022 (INCLUDES 10% PENALTY OF $7.40 AND $20.00 COST) $101.82 0 -
-
-
$74.42
0 0
(831) 753-5600
$95.76
0 CITY OF SALINAS
CITY OF SALINAS
CITY OF SALINAS
$148.84
0.044750
0 0
0 0
P.O. Box 891
P.O. Box 891
0 $148.84
0 (831) 796-7000
0.021686
$2.98
0 PERS PROP (831) 755-5035
P.O. Box 891, Salinas, CA 93902-0891, (831) 755-5057, www.co.monterey.ca.us/taxcollector $0.20
MCWRA Zone 2Z
PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG PHONE # DESCRIPTION DIR CHRG 0 $0.00
MARY A. ZEEB Treasurer-Tax Collector
Hebbron Family Center Site Photos
Corner of N. Hebbron Ave. and Freemont St. – View of the multipurpose room.
Facing the HFC from N. Hebbron Ave. – View of the Tiny Tot Classrooms.
Facing the HFC building from the parking lot on Fremont St.
Upstairs meeting space of the HFC.
Multipurpose room of the HFC. – View of room before and after closure.
LEGEND
NEW 15-GAL TREES
PLAYGROUND EXPANSION
NOT TO SCALE
PICNIC TABLE
SHADE STRUCTURE
RUBBERIZED PLAY
SURFACE
POROUS PAVER
PARKING STALLS
HEBBRON FAMILY CENTER
SITE PLAN
PARKING AREA
44 SPACES INCLUDING 2 ADA SPACES
NEW HEBBRON
FAMILY CENTER
OUTDOOR
PLAZA
ENTRANCE
DRIVEWAY
(EXISTING)
MULTIPURPOSE 1
4640 SF
MULTIPURPOSE 2
1600 SF
RESTROOMS
700 SF
KITCHEN
400 SF
TEEN
LOUNGE
500 SF
ENTRANCE
DRAFT
DRAFT
16 N. PROJECT PERMIT/APPROVAL STATUS
Indicate the status of all federal, state, and local permits required for the project. Describe any potential delays due to permitting (indicate specific permits). If acquiring a long-term encroachment permit, submit evidence the entity with jurisdiction is aware of the project and is willing to work with Grantee to issue the permit.
This list is not all inclusive. It is Grantee’s responsibility to identify and obtain applicable permits.
Permitting Agency Type of Requirement
Required
Applied
Acquired
Date
Expected
State Agencies:
California Department of Fish
and Wildlife Lake or Streambed Alteration Agreement (Section 1600) California Department of Fish
and Wildlife
Incidental Take Permit or Consistency Determination (CESA) (California Endangered Species Act)
Department of Transportation Encroachment Permit
Coastal Commission Coastal Development Permit
Coastal Commission Letter of Consistency
Regional Water Quality Control
Board 401 Water Quality Certification or Waste Discharge Requirement State Water Resources Control
Board Water Rights Permit
State Water Resources Control
Board General Industrial Storm Water Permit
State Lands Commission Permit (if using State owned property) State Office of Historic
Preservation
Section 106 Consultation with State Historic Preservation Officer (National Historic Preservation Act of 1986)
Federal Agencies
U.S. Fish and Wildlife Service
(USFWS)
Section 7 Consultation, Biological Opinion or Section 10 Permit (Endangered Species Act)
U.S. Army Corps of Engineers
(ACOE) Section 404 Permit (Clean Water Act)
U.S. Army Corps of Engineers Section 10 Permit (Rivers & Harbors Act of 1899) U.S. Coast Guard / U.S. Army
Corps of Engineers Section 9 Permit (Rivers & Harbors Act of 1899) U.S. National Resources
Conservation Service
Section 106 Consultation (National Historic Preservation Act of 1986)
National Marine Fisheries
Service (NMFS)
Section 7 consultation if federal nexus see ACOE, or Section 10 Permit
Local and Regional Planning Agencies
City/County Grading Permit
City/County Environmental Health Department
City/County Model Water Efficient Landscape Ordinance – Landscape Documentation Package
Central Valley Flood Protection
Board
Permission to Encroach on Waterways within Designated
Floodways
San Francisco Bay Conservation
and Development Commission Any relevant permit
Tahoe Regional Planning
Agency Any relevant permit
Local Resource Conservation
District Consultation
Flood Control Districts Floodway & Hydrological Analysis Others (e.g.,CalRecycle, State
Contractors Board, etc.):
N/A
N/A
N/A
N/A
N/A
x
x
x
x
x
x
N/A
N/A
pending
N/A
N/A
N/A
N/A
N/A
pending
pending
N/A
N/A
N/A
N/A
N/A
pending Site Plan Review and Building Permits
pending
pending
pending
pending
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
City of Salinas
350 Lincoln Avenue
Salinas, CA, 93901
[email protected]
9 4 6 0 0 0 4 1 2
Kristan Lundquist
Director
[email protected]
831-758-7222
Print Form
Reset Form
DocuSign Envelope ID: 26B9F43B-F8DA-4B71-9F0E-172D6DED5ECF 1/3/2022
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.
DocuSign Envelope ID: 26B9F43B-F8DA-4B71-9F0E-172D6DED5ECF