HomeMy WebLinkAboutState Water Resources Control Board 2016-08-08State Water Resources Control Board Division of Financial Assistance
Project Director Certification cou No. 1617-110
Grantee Name: City of Ukiah
Russian River Regional Storm Water Resource Management and
Project Name: Monitoring Plan
Project Director (PD): Tim Eriksen
Phone No.: (707) 463-6280 Email Address: teriksen�fukiah.com
Project Identification No.: 35374
Grant Agreement No.: D1612602
Program: Proposition 1 ® 13 ❑ 40 ❑ 50 ❑ 84 ❑
® As the assigned Project Director for this Project, I understand the Program requirements
and responsibilities of the Project Director, and
(Check one of the boxes below)
® I am a paid employee of the Grantee and not acting as a subcontractor on the Project,
-or-
F-1 The Grantee has no paid employees. I have been designated by the Grantee's Board or
governing body to be the Project Director, and am acting solely in that capacity. (A
Resolution for the designation must accompany this document).
Invoice Progress Report Signature Authorization (The designee(s) must be employed by the
Grantee.)
® I will review and sign invoices authorizing reimbursement for this Project and/or Grant
Progress Reports that accompany invoices.
® The following individual(s) are also authorized to sign invoices/Grant Progress Reports for
this Project:
Designee's Name: Richard J. Seanor ky
Print Name Si ture
Designee's Name: Jarod Thiele
Print Name VIRature
Secretary of State Verification (Excludes county, city, and state agencies.)
❑ I certify the Grantee has an active status with the California Secretary of State.
Entity Number
tj N/A.
Please sign, e, n ur o the Program Analyst.
l
Project Director Signature Date
Au orize epresentative Signature Date
07-25-2016
STATE OF CALIFORNIA -DEPARTMENT OF FINANCE
PAYEE DATA RECORD
(Required when receiving payment from the State of California in lieu of IRS W-9)
STD. 204 (Rev. 6-2003)
INSTRUCTIONS: Complete all information on this form. Sign, date, and return to the State agency (department/office) address shown at
FTI the bottom of this page. Prompt return of this fully completed form will prevent delays when processing payments. Information provided in
this form will be used by State agencies to prepare Information Returns (1099). See reverse side for more information and Privacy
Statement.
NOTE: Governmental entities, federal, State, and local (including school districts), are not required to submit this form.
PAYEE'S LEGAL BUSINESS NAME (Type or Print)
2
OF UKIAH
❑CITY
SOLE PROPRIETOR —ENTER NAME AS SHOWN ON SSN (Last, First, M.I.)
E-MAIL ADDRESS
I'5' .gAD"r G�y0-r.ki`&A'aigm
MAILING ADDRESS
BUSINESS ADDRESS
300 SEMINARY AVENUE
300 SEMINARY AVENUE
CITY, STATE, ZIP CODE
CITY, STATE, ZIP CODE
UKIAH, CA 95482-5400
UKIAH, CA 95482-5400
3
ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): 19 14 I — 16 I 0 I 0 I 0 (4 (4 (6 I
NOTE:
❑
Payment will not
0 PARTNERSHIP CORPORATION:
be processed
PAYEE
❑ MEDICAL (e.g., dentistry, psychotherapy, chiropractic, etc.)
without an
ENTITY
0 ESTATE OR TRUST ❑ LEGAL (e.g., attorney services)
accompanying
TYPE
❑ EXEMPT (nonprofit)
taxpayer I.D.
❑ ALL OTHERS
number.
CHECK
ONE BOX
0 INDIVIDUAL OR SOLE PROPRIETOR
ONLY
ENTER SOCIAL SECURITY NUMBER: l
SSN required by authority of California Revenue and Tax Code Section 18646
Fill California resident - Qualified to do business in California or maintains a permanent place of business in California.
0 California nonresident (see reverse side) - Payments to nonresidents for services may be subject to State income tax
PAYEE
withholding.
RESIDENCY
❑ No services performed in California.
STATUS
❑ Copy of Franchise Tax Board waiver of State withholding attached.
I hereby certify under penalty of perjury that the information provided on this document is true and correct.
a
Should my residency status change, I will promptly notify the State agency below.
AUTHORIZED PAYEE REP ESE ATI 'S NAME (Type or Print)
TITLE
Tim Eriksen
Director of Public Works / City Engr.
SIGN
DATE
TELEPHONE
08/02/2016
707 463-6280
Please return completed form to:
Department/Office: State Water Resources Control Board - Division of Financial Assistance
Grants Administration Unit
Unit/Section:
1001 I Street, 17th Floor
Mailing Address:
City/State/Zip: Sacramento, CA 95814
Telephone: ( 916) 341-5461 Fax: (916) 341-5296
E-mail Address: Kari.Holzgang@waterboards.ca.gov
STATE OF CALIFORNIA -DEPARTMENT OF FINANCE
PAYEE DATA RECORD
STD. 204 (Rev. 6-2003) (REVERSE)
Requirement to Complete Payee Data Record, STD. 204
1
A completed Payee Data Record, STD. 204, is required for payments to all non-governmental entities and will be kept on file at each
State agency. Since each State agency with which you do business must have a separate STD. 204 on file, it is possible for a payee
to receive this form from various State agencies.
Payees who do not wish to complete the STD. 204 may elect to not 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 backup withholding and
nonresident State income tax withholding. Amounts reported on Information Returns (1099) are in accordance with the Internal
Revenue Code and the California Revenue and Taxation Code.
2
Enter the payee's legal business name. Sole proprietorships must also include the owner's full name. An individual must list his/her
full name. The mailing address should be the address at which the payee chooses to receive correspondence. Do not enter
payment address or lock box information here.
3
Check the box that corresponds to the payee business type. Check only one box. Corporations must check the box that identifies
the type of corporation. The State of California requires that all parties entering into business transactions that may lead to
payment(s) from the State provide their Taxpayer Identification Number (TIN). The TIN is required by the California Revenue and
Taxation Code Section 18646 to facilitate tax compliance enforcement activities and the preparation of Form 1099 and other
information returns as required by the Internal Revenue Code Section 6109(a).
The TIN for individuals and sole proprietorships is the Social Security Number (SSN). Only partnerships, estates, trusts, and
corporations will enter their Federal Employer Identification Number (FEIN).
Are you a California resident or nonresident?
4
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.
Payments to all nonresidents may be subject to withholding. Nonresident payees performing services in California or receiving rent,
lease, or royalty payments from property (real or personal) located in California will have 7% of their total payments withheld for State
income taxes. However, no withholding is required if total payments to the payee are $1,500 or less for the calendar year.
For information on Nonresident Withholding, contact the Franchise Tax Board at the numbers listed below:
Withholding Services and Compliance Section: 1-888-792-4900 E-mail address: wscs.gen@ftb.ca.gov
For hearing impaired with TDD, call: 1-800-822-6268 Website: www.ftb.ca.gov
5
Provide the name, title, signature, and telephone number of the individual completing this form. Provide the date the form was
completed.
6
This section must be completed by the State agency 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.
Does the Budget Summary Total match the Budget Details Total? YES
Does the Budget Summary Total match the Budget Details Total? YES