Stanislaus — Download

Source: https://www.stanislaus.courts.ca.gov/system/files/trustpayeedatarecord-rev-82621.pdf

PAYEE DATA RECORD FOR INTEREST (in lieu of IRS W-9) Required in lieu of IRS W-9 form when receiving interest payments from the Judicial Council of California (JCC) on behalf of the Superior Courts of California

See page two for additional instructional information and Privacy Statement. Complete all
1 information on this form, sign, date, and return the form. Prompt return of this fully completed form

Instructions will prevent delays when processing payments. Information provided in this form will be used to prepare Information Returns (1099-INT).

SECTIONS 2 THRU 4 TO BE COMPLETED BY PAYEE OR AUTHORIZED REPRESENATIVE
PAYEE'S LEGAL NAME - AS SHOWN ON FEDERAL INCOME TAX RETURN

PAYEE’S BUSINESS NAME - IF DIFFERENT FROM ABOVE

2 PAYEE’S MAILING ADDRESS
Legal

Name CITY STATE ZIP CODE E-MAIL ADDRESS

TELEPHONE NUMBER FACSIMILE NUMBER

PARTNERSHIP CORPORATION EXEMPT (NON-PROFIT)
3 LIMITED LIABILITY COMPANY CORPORATION – LEGAL GOVERNMENT

Payee CORPORATION – MEDICAL OTHER – ESTATE OR TRUST Entity Type ENTER FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) - ________________________________________________________________________________________________________________________________________________________ NOTE A taxpayer INDIVIDUAL/SOLE PROPRIETOR identification number is required ENTER SOCIAL SECURITY NUMBER (SSN) - - If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN; however, the IRS prefers that you use your SSN. 4 Has Payee been the recipient of any prior interest payments from the Superior Courts of California within the last calendar year? Prior Payments to Yes No Payee

Under penalties of perjury, I certify that: 5 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be

Certification issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been NOTE notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to See instructions on report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and page 2 3. I am a U.S. citizen or other U.S. person, as defined by the IRS. I hereby certify under the penalty of perjury that the information provided on this document is true and correct. Should my information change, I will promptly notify the JCC at the address listed in Section 1.

PAYEE OR AUTHORIZED REPRESENTATIVE'S NAME (Type or Print) TITLE TELEPHONE

Contact Information and PAYEE OR AUTHORORIZED REPRESENTATIVE’S SIGNATURE DATE EMAIL ADDRESS signature

Requirement to Complete Payee Data Record A completed Payee Data Record (in lieu of the IRS W-9) is required for payments and will be kept on file at the Judicial Council of California, Trial Court Administrative Services Office. Since each state agency with which you do business must have a separate Payee Data Record on file, it is possible for a payee to receive a similar form from various state agencies. SECTIONS 2 THRU 4 TO BE FILLED OUT BY PAYEE OR AUTHORIZED REPRESENTATIVE Enter the payee’s legal name. Sole proprietorships must also include the owner’s full name. An individual must list his/her legal name as it appears on his/her Federal Income tax return. If a different name is used, that name should also be entered, beneath the legal name. 2 The mailing address should be the address at which the payee chooses to receive correspondence. The business address is the physical location of business, if different than mailing address. The phone number, e-mail address, and facsimile number should also be provided. 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 3 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 is their Social Security Number (SSN). A sole proprietor may have both a Federal Employer Identification Number (FEIN) and a SSN, the IRS prefers that sole proprietors user their SSN. Only partnerships, estates, trusts, and corporations will enter their FEIN. This form must be signed. Provide the name, title, e-mail, and telephone number of the individual completing this form. Also, provide the date the form was completed. Certification Instructions: You must cross out item 2 if you have been notified by the IRS that you are currently 5 subject to backup withholding because you have failed to report all interest and dividends on your tax return. If you are not a U.S. Citizen or U.S. person, as defined by the Internal Revenue Service, a different form may be required and tax withholdings may apply. See IRS website http://www.irs.gov/businesses/international/index.html for additional information.