HomeMy WebLinkAboutCC 4 COURT LIAISON 12-21-92CONSENT CALENDAR NO. 4
12-21-92-
;O
DATE: DECEMBER 101 1992
Inter -Com
TO: WILLIAM A. HUSTON, CITY MANAGER
FROM: POLICE DEPARTMENT
SUBJECT: AGREEMENT WITH C.H.P. -- COURT LIAISON SERVICES
Recommendations:
That City Council approve Resolution 92-152 which will authorize
the City of Tustin to continue to perform the court liaison duties
for the California Highway Patrol, Santa Ana Office.
Background:
Since 1989, the City of Tustin Police Department has been
performing the court liaison duties for the California Highway
Patrol, Santa Ana Office. The existing agreement is currently up
for renewal.
The new agreement provides for payment to the Tustin Police Depart-
ment from the California Highway Patrol in the amount of
approximately $15,444 per year. This is approximately one-half of
our court liaison officer's salary.
Sharing our court liaison officer with the California Highway
Patrol for this usage will not adversely effect this Department's
operation. The new contract has been reviewed by our City Attorney
and approved as to form and content.
W. DOUGLAS FRANKS
Chief of Police
WDF:dh
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RESOLUTION NO. 92=151
A RESOLUTION OF THE CITY COUNCIL OF THE
CITY OF TUSTIN, CALIFORNIA, APPROVING AN
AGREEMENT FOR COURT LIAISON CLERK WITH
THE CALIFORNIA HIGHWAY PATROL, SANTA ANA
OFFICE
The City Council of the City of Tustin does hereby
resolve. as follows:
WHEREAS, the Tustin Police Department and the
California Highway Patrol, Santa Ana Office, have found it
desirable to enter into an Agreement under which the Tustin
Court Liaison Clerk will deliver misdemeanor complaint
packages and subpoenas to and from the Central Orange County
Municipal Court and the Harbor Orange County Municipal Court
for the California Highway Patrol; and
WHEREAS, it appears to be in the best interests of the
City to enter into such an Agreement because of the
contribution by the California Highway Patrol to the cost of
providing a Court Liaison Clerk.
NOW, THEREFORE, BE IT RESOLVED that the attached
"Agreement For Court Liaison Clerk" is hereby approved;
BE IT
FURTHER RESOLVED
that the Mayor and
the City
Clerk are
hereby authorized
and directed to execute an
Agreement
in substantially
the form attached
to this
Resolution
as Exhibit "A" when
received from the California
Highway Patrol
for execution.
PASSED AND ADOPTED at a
regular meeting of
the City
Council of
the City of Tustin, held on the
day of
, 19
ATTEST:
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City Clerk
Mayor
STATE OF CALIFORNIA
T APPROVED BY THE CONTRACT NUMBER AM. N0.
STANDARD AGREEMEN
STD. 2 (REV. 4-90) ATTORNEY GENERAL 92—C6431
CONTRACTOR'S FEDERAL I.D. NUMBER
't'-12-1; AGREEMENT, made and entered into this 1St day of Apgust , 1992 ,
State of California, by and between State of California, through its duly elected or appointed, qualified and acting MSP
TITLE OF OFFICER ACTING FOR STATE AGENCY
Administrative Services Officer California Highway a 1
CONTRACTOR'S NAME
, hereafter called the State, and
CITY OF TUSTIN ( 714) 544-5424 , hereafter called the Contractor.
WITNESSETH: That the Contractor for and in consideration of the covenants, conditions, agreements, and stipulations of the State hereinafter expressed,
does hereby agree to furnish to the State services and materials as follows: (Set forth service to be rendered by Contractor, amount to be paid Contractor,
time for performance or completion, and attach plans and specifications, if any.)
1. Contractor agrees to provide the services of a Court Liaison
Clerk for the filing of California Highway Patrol misdemeanor cases
at Central Orange County Municipal Court District Attorney's Office,
and Harbor Orange County Municipal Court District Attorney's Office.
These services are to be provided for the Santa Ana Area California
Highway Patrol, 2031 East Santa Clara Avenue, Santa Ana, CA 92711.
2. Contractor agrees to provide service in accordance with the
attached Specifications marked EXHIBIT A, FORM 17A NONDISCRIMINATION
CLAUSE, STATE CONTRACT REQUIREMENTS and DISPUTE RESOLUTION PROVISION,
all of which are made by reference a part hereof.
3. Service coordinator for this contract shall be Lieutenant
D. Mc Kenna, California Highway Patrol Santa Ana Area, telephone
(714) 547-8311.
CONTINUED ON 1 SHEETS, EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
The provisions on the reverse side hereof constitute a part of this agreement.
IN WITNESS WHEREOF, this agreement has been executed by the parties hereto, upon the date first above written.
STATE OF CALIFORNIA
CONTRACTOR
AGENCY
CONTRACTOR (if other than an individual, state whether a corporation, partnership, etc.)
California Highway Patrol
Cit of Tustin
BY (AUTHORIZED SIGNATURE)
BY (AUTHORIZED SIGNATURE)
D
�
PRINTED NAME OF PERSON SIGNING
PRINTED NAME AND TITLE OF PERSON SIGNING
TITLE
ADDRESS
Administrative Services Officer
1300 Centennial Wav, stint CA 92680
AMOUNT ENCUMBERED BY THIS
PROGRAM/CATEGORY (CODE AND TITLE)
FUND TITLE MV Acct.
Department of General Services
DOCUMENT
Program 99
State Trans.
Use Only
$14,157.00 92/93
(OPTIONAL USE)
$15,444 = 93/94; $15,444
= 94/95; $1,287 = 95/96
PRIOR AMOUNT ENCUMBERED FOR
THIS CONTRACT
ITEM
CHAPTER
STATUTE
FISCAL YEAR
2720-001-044
587
1992
92/93
TOTAL AMOUNT ENCUMBERED TO
Cti2
OBJECT OF EXPENDITURE (CODE AND TITLE)
2675/418/10100
.. reby cerW upon my own personal knowledge that budgeted funds
T.B.A. NO.
B.R. NO.
are available for the period and purpose of the expenditure stated above.
SIGNATURE OF ACCOUNTING OFFICER
DATE
D
CONTRACTOR F� STATE AGENCY F� DEPT. OF GEN. SER. 1:1 CONTROLLER 1:1 90 56667
I . i1t �tDTzt.ralG'tC)I aivrf't's t: inClerrinif}, def c'crd and sal�'i' harttitt S5 tliE'+taitt', itS off ic'et'n. ail!t'IitS at Tl Cl E'iriltt(ri`!.'F'c
€ront ani aind ate claims and losses accruing or restihim-, to ain4 and all contractors, subcontractors,
riiai'4VV' 1ta`)tivli.. rt3►t) "E'.r"+< a ndl aIr"vi other Pa'r'son. fit'111 of (.or m)-atitor f or'nishill" or Sit(" PIN.Itlf'` �t"()rl 4;'!`v )4'f's,
rliater"tai: t stippltie:� i i connectionwith thu performance of this; contralct, an(I from ainy a nd all claims and
WSSe• X'c Flirt or ; E'staltilip If,) any Berson, Firm or corporation who nwN lac° Injured or- datniait�.red by tale
..'onf.. cit toll" in thw taerf o)rmance of this Co)ntI'dCt. '
'..f ti: Contractor, stile: ht-', awl I-wplo) -ees of Contractor, in thcs perfor-maiwe t)` tlw apre%'ment, siml'.
a ,,,t in an independent c'alpa Citi and Ii€ , a,� ofiicerk or- employees or- a(,ent.s of' Sta)tt. of ('ailitorniat.
. , T ne Stalte nn!N; Lermina`e be relieved ol'the payment o aIle' consideraitioll to C t)Iitiaii't"i`
should Contractor fail to perforin the co-venants herein contained at thc= time and in the manner lterei„
provided. In the event. of such termination the State may proceed with the work- in any manner deenieCR
proper by the State. T,c, cost to the Stade shall be deducted from any suni dut, the (Contractor under this
aFgreenient, and flit, iJaiiaricc' if'all�, shrill bc paid the Contractor upon demand.
4. Wilkho = b1c i'.`”"i a 'C. .'()m? enl of the State. this a�greetneitt is not a5`ttgna bic° by C:'ontrac.tor c it.her in «bole,
or in part..
5. Time is of the essence in this agreement.
6. No alteration or variation of the terms of this contract shall be valid unless made in writing and signed lir
the parties hereto, and no oral understanding or agreement not incorporated herein, shall be binding on
any of the parties hereto.
7. The consideration to be paid Contractor, as provided herein, shall be in compensation for all of
Contra3.t.olr's expense,,, incurred in the performance hereof, includine travel and per dicin, Hitless
Of rpt=r `.x �cC> +,. 'I"E's';i_' 4ii tk "O IUVC .
City of Tustin, 92-C6431
Page 2
August 1, 1992
4. The term of this contract shall be August 1, 1992 through
July 31, 1995.
5. This contract may be amended by written mutual consent of the
parties hereto.
6. This contract may be cancelled by either party upon thirty (30)
days prior written notice to the other party.
7. State agrees to pay Contractor monthly in arrears upon receipt of
an invoice One Thousand Two Hundred Eighty-seven Dollars ($1,287.00),
including all applicable taxes and expenses. Total contract amount
shall not exceed Forty-six Thousand Three Hundred Thirty-two Dollars
($46,332.00).
8. Payment shall be made from funds appropriated to the Department
of California Highway Patrol and subject to the fiscal procedures of
the State of California.
9. Contractor agrees to submit all invoice(s) in triplicate to the
service coordinator for approval clearly indicating this contract
number (92-C6431). Invoices not on pre-printed bill heads shall be
signed by the Contractor furnishing the service. Payment will be
made within fifty (50) calendar days from the postmarked date of a
properly submitted invoice.
10. This contract is valid and enforceable only if sufficient funds
are made available by the Budget Act of the appropriate fiscal year
for the purposes of this program. In addition, this contract is
subject to any additional restrictions, limitations or conditions
enacted by the Legislature which may affect the provisions, terms or
funding of this contract in any manner.
92-C6431
EXHIBIT A
COURT LIAISON CLERK
CITY OF TUSTIN
A. DUTIES AND RESPONSIBILITIES OF COURT LIAISON CLERK,
(CLERK, HEREINAFTER)
1. Pick up misdemeanor complaint packages at the California Highway
Patrol (CHP) Santa Ana Office by 0630 hours daily, Monday through
Friday, excluding holidays:
a. Deliver daily to the Central Orange County Municipal Court
(COCMC) District Attorney's Office.
b. Deliver Tuesdays and Thursdays to the Harbor Orange County
Municipal Court (HOCMC) District Attorney's Office.
2. Pick up all subpoenas at the COCMC daily; and HOCMC, Tuesdays and
Thursdays only, for CHP; and return those subpoenas to the
respective courts after service by the CHP.
3. The CLERK shall maintain a smooth and professional relationship
with the Court.
4. Submit to the CHP a report on the number of cases taken to
court. This report shall be completed daily.
B. DUTIES OF CALIFORNIA HIGHWAY PATROL, SANTA ANA OFFICE
1. The CHP will be responsible for the preparation of the
misdemeanor complaint packages to be filed at COCMC and HOCMC,
including transmittal sheets, and have them available for pick up
at the CHP Santa Ana Office.
2. Subpoenas will be made available at the pick up location of the
CHP Santa Ana Office, and a copy will be returned to the Court by
the Contractor's Court Liaison CLERK after service or rejection
in accordance with CHP policy.
3. The filing of felony cases will be the responsibility of the CHP
Santa Ana office.
4. Once notified by the COCMC Law Clerk that an officer is needed in
court, it will be the responsibility of the CHP to locate and
advise the officer. If unable to locate the officer, CHP shall
apprise the COCMC Law Clerk, who will advise the Court. All
payroll bookkeeping of CHP officer's court time will remain with
CHP.
5. For misdemeanor cases only, Officers will check in with CLERK on
subpoena date.
STATE OF CAUFORNW
STD. 17A (New 5/83)
NONDISCRIMINATION CLAUSE
(OCP - 1)
1. During the performance of this contract, contractor and its subcontractors shall not
unlawfully discriminate against any employee or applicantfor employment because
of race, religion, color, national origin, ancestry, physical handicap, medical
condition, marital status, age (over 40) or sex. Contractors and subcontractors shall
insure that the evaluation and treatment of their employees and applicants for
employment are free of such discrimination. Contractors and subcontractors shall
comply with the provisions of the Fair Employment and Housing Act (Government
Code, Section 12900 et seq.) and the applicable regulations promulgated
thereunder (California Administrative Code, Title 2, Section 7285.0 et seq.). The
applicable regulations of the Fair Employment and Housing Commission
implementing Government Code, Section 12990, setforth in Chapter 5 of Division 4
of Title 2 of the California Administrative Code are incorporated intothis contract by
reference and made a part hereof as if set forth in full, Contractor and its
subcontractors shall give written notice of their obligations under this clause to
labor organizations with which they have a collective bargaining or other
agreement.
2. This contractor shall include the nondiscrimination and compliance provisions of this
clause in all subcontracts to perform work under the contract.
STATE OF CALIFORNIA
CONTRACT REQUIREMENTS
STATEMENT OF COMPLIANCE
The prospective contractor's signature affixed hereon and dated shall
constitute a certification under the penalty of perjury under the
laws of the State of California that the bidder has, unless
complied with the nondiscrimination program requirements of
Government Code Section 12990 and Title 2, California Code
Regulations, Section 8103.
exempted,
of
NATIONAL LABOR RELATIONS BOARD
Contractor agrees that by signing the contract, does swear under
penalty of perjury that no more than one final unappealable finding
of contempt of court by a Federal court has been issued against the
contractor within the immediately preceding two-year period because
of the contractor's failure to comply with an order of a Federal
court which orders the contractor to comply with an order of the
National Labor Relations Board. (Public Contract Code Section 10296)
STATE AUDITOR GENERAL AUDIT PROVISION
The contracting parties hereto shall be subject to the examination -
and audit of the State Auditor General for a period of three (3)
years after final payment under the contract in accordance with the
Government Code Section 10532. In addition, the contractor may be
subject to examination and audit by representatives of the California
Highway Patrol. The examination and audit shall be confined to those
matters connected with the performance of the contract including, but
not limited to, the costs of administering the contract.
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
DISPUTE RESOLUTION PROVISION
By signing the contract, contractor agrees to abide by this
provision.
Any dispute concerning a question of fact arising under the
terms of this contract which is not disposed of within a
reasonable period of time by the Contractor and State
employees normally responsible for the administration of this
contract shall be brought to the attention of the
Administrative Services Officer (or designated
representative) of each organization for joint resolution.
At the request of either party, the State shall provide a
forum for discussion of the disputed item(s), at which time
the Administrative Services Officer, or his/her
representative, shall be available to assist in the
resolution by providing advice to both parties as to the
State of California, California Highway Patrol, policies and
procedures. If agreement cannot be reached through the
application of high level management attention, either party
may assert its other rights and remedies within this contract
or within a court of competent jurisdiction.
The rights and remedies of the State provided above shall not
be exclusive and are in addition to any other rights and
remedies provided by law or under the contract.
The mailing address for disputes shall be:
Department of California Highway Patrol
Business Services Section
Contract Management Unit
P. O. Box 942898
Sacramento, CA 94298-0001
STATE OF CALIFORNIA
STATEMENT OF COMPLIANCE
(Rev. 3-87)
COMPANY NAME
The company named above (hereinafter referred to as "prospective contractor") hereby certifies, unless
specifically exempted, compliance with Government Code Section 12990 and California Administrative Code,
Title 2, Division 4, Chapter 5 in matters relating to the development, implementation and maintenance of a
nondiscrimination program. Prospective contractor agrees not to unlawfully discriminate against any employee
or applicant for employment because of race, religion, color, national origin, ancestry, physical handicap,
medical condition (cancer related), marital status, sex or age (over forty).
CERTIFICATION
i. official named below, hereby swear that I am duly authorized to legally bind the prospective contractor to
the above described certification. I am fully aware that this certification, executed on the date and in the county
below, is made under penalty of perjury under the laws of the State of California.
NAME OF OFFICIAL
DATE EXECUTED
PROSPECTIVE CONTRACTOR SIGNATURE
PROSPECTIVE CONTRACTOR TITLE
PROSPECTIVE CONTRACTOR FEDERAL EMPLOYER I.D. NUMBER
EXECUTED IN THE COUNTY OF
87 43877
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
SHALL BUSINESS DATA SHEET
Reference No:
Please complete the questions below and return this form with your contract. This
information will be used for statistical purposes only.
1. Are you registered with the State of California Office of Small Minority
Business?
Yes No
If yes, please indicate vendor identification
number •
2. Indicate whether business is owned by male, female, or Disabled Veteran.
Male Female Disabled
(Must be at least Veteran (Must be at
51% owned) least 51% owned)
3. Check the one which best describes your ethnic background.
Black Filipino
Asian American Indians
Hispanic Caucasian/White or Other
The undersigned declares under penalty of perjury that the information set forth is
true and correct.
Name and Title (Type or Print)
Signature Date
Telephone Number
076-93 (11-91)
0355b
Firm
Street Address
City State
Zip
STATE OF CALIFORNIA
DRUG-FREE WORKPLACE CEI (CATION
STD. 21 (NEW 11-90)
COMPANY/ORGANIZATION. NAME
The contractor or grant recipient named above hereby certifies compliance with Government Code
Section 8355 in matters relating to providing a drug-free workplace. The above named contractor or
grant recipient will:
1. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation,
possession, or use of a controlled substance is prohibited and specifying actions to be taken against
employees for violations, as required by Government Code Section 8355(a).
2. Establish a Drug -Free Awareness Program as required by Government Code Section 8355(b), to
inform employees about all of the following:
(a) The dangers of drug abuse in the workplace,
(b) The person's or organization's policy of maintaining a drug-free workplace,
(c) Any available counseling, rehabilitation and employee assistance programs, and
(d) Penalties that may be imposed upon employees for drug abuse violations.
3. Provide as required by Government Code Section 8355(c), that every employee who works on the
proposed contract or grant:
(a) Will receive a copy of the company's drug-free policy statement, and
(b) Will agree to abide by the terms of the company's statement as a condition of employment on
the contract or grant.
CERTIFICATION
I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or
grant recipient to the above described certification. I am fully awarethat this certification, executed on
the date and in the county below, is made under penalty of perjury under the laws of the State of
California.
IN THE COUNTY
`:TOR or
TITLe
FEDERAL I.D. NUMBER
STATE OF CALIFORNIA
VENDOR DATA RECORD
(Required in lieu of IRS W-9 when dontg business with the State of California)
STD. 204 (TEMP -3-9Z
DEPARTMENT/OFFICE California Highway Patrol PURPOSE: Information contained in this form
Contract Management Unit will be used by State agencies to prepare Infor-
ASE STREET ADDRESS mation Returns (Form 1099) and forwithholding
RETURN P. 0. Box 942898 on payments to nonresident vendors.
To: (See Privacy Statement on reverse.)
CITY, STATE, ZIP CODE Sacramento, CA 94298-0001
VENDOR'S BUSINESS NAME OWNERS FULL NAME (Last, Fent M.l.)
STREET ADDRESS
CITY, STATE, AND ZIP CODE
INSTRUCTIONS:
ARE YOU SUBJECT TO FEDERAL UALKUr
WITHHOLDING?
(See instructions for IRS Form W9)
❑ YES ❑ NO
(1). Check box indicating type of business entity and provide taxpayer identification number.
(2). Check box indicating resident or nonresident. (See reverse for additional information).
(3). Check one or more VENDOR ACTIVITY boxes specifying vendor activity type.
❑CORPORATION
(Enter Federal Employer Identification Number)
I I .I I I
Resident - Qualified to do business in CA /
❑ Permanent place of business in CA
❑MEDICAL SERVICES(Including dentistry,
Podiatry, psychotherapy, optometry,
d"ropracdc, eta)
❑
SERVICES (NON MEDICAL)
/SUPPLIES
❑EQUIPMENT
(Exempt from State withholding)
❑
RENT
❑OTHER
(sbaCHO
Lj Non Resident (See Reverse)
(� INDIVIDUAL(SOLE PROPRIETOR
❑
NON EMPLOYEE COMPENSATION (Including
repair maintenance,and maint�nan, construction, eta)
ElEQUIPMENT/SUPPLIES
(Exempt from State wifhholdi►p)
Enter Social Security Account Number only, NOT FEIN)
sy,0ng t►s�
❑CAL
podiatry, PdWitWOPYo0MO&Y
d iroprack, eta)
❑ Resident ❑ Non Resident (See Reverse)
❑
INTEREST (Exempt from State withholding)
❑PARTNERSHIP
❑
RENT
(Enter Federal Employer Identification Number)
I I I
I I I I I I I I
❑
ROYALTIES
❑ Resident ❑ Non Resident (See Reverse)
❑
PRIZES AND AWARDS
❑ESTATE OR TRUST
❑
OTHER (specify)
(Enter Federal Employer Identification Number)
I I I I I I I
I I I
❑ Resident (Estate) - Decedent was a CA resident at
the time of death
❑ Resident (Trust) - At least one trustee is a CA
resident
❑ Non Resident (See Reverse)
• '- -' -- .ter_ �__..�....s tom.
e...e �nrJ i•nrra�i
I hereby certify under penalty of perjury mar the inrormauvn prurrtwww wit alt• -7 •-- -• -- ---
If my residency status should change, I will promptly Inform you.
AUTHORIZED VENDOR REPRESENTATNE'S NAME (Type or Print) TITLE
__—URE
DATE
r:
.1. .f:. x{•i
CONTRACT/LEASE NUMBER NONEMPLOYEEMEDICAL
11COMPENSATION ❑ SERVICES ❑ RENT ❑ OTHER
REPORTABLE INCOME CODE PER STATE ADMINISTRATIVE MANUAL SECTION 8422.19 (Chea On.) INITIALS
❑� ❑2 ❑3 ❑4 ❑5 ❑6 ❑7
Mpecif'1
DATE INITIALED
TELEPHONE NUMBER
NONRESIDENT WITHHOLDING
❑ STANDARD RATE
❑ WAIVED
❑ REDUCED RATE %
STATE OF CALIFORNIA
VENDOR DATA RECORD
STD. 204 (TEMP. 1-92) (REVERSE)
ARE YOU A RESIDENT OR A NONRESIDENT?
Each corporation, individual/sole proprietor, partnership, es-
tate or trust doing business with the State of California must
indicate their residency status along with their vendor identi-
fication number.
A corporation will be considered a "resident" if it has a
permanent place of business in California. A permanent place
of business has been established if the corporation is organized
and existing under the laws of this state or, if a foreign
corporation, it has qualified to transact intrastate business. A
corporation which has not qualified to transact business (e.g.,
a corporation engaged exclusively in interestate commerce)
will be considered as having a permanent place of business in
this state only if it maintains a permanent office in this state
which is permanently staffed by its employees.
For individuals/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 fora temporary or transitory purpose.
Generally an individual who comes to California for a purpose
which 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 consid-
ered a nonresident.
For withholding purposes, a partnership is considered a resi-
dent partnership if it has a permanent place of business in
California. An estate is considered a California estate if the
decedent was a California resident at the time of death and a
trust is considered a California trust if at least one trustee is a
California resident.
More information on residency status can be obtained by
calling the numbers listed below:
From within the United States, call .......1-800-852-5711
From outside the United States, call ......1-800-854-6500
For hearing impared with TDD, call ...... 1-800-822-6268
ARE YOU SUBJECT TO NONRESIDENT
WITHHOLDING?
Payments made to nonresident vendors, including corpus
tions, individuals, partnerships, estates and trusts, are subject
to withholding. Nonresident vendors 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. How-
ever, no withholding is required if total payments to the vendor
for the calendar year are $1500 or less.
A nonresident vendor can request that income taxes be with-
held at a lower rate or waived. A waiver will generally be
granted when a vendor has a history of filing California returns
and making timely estimated payments. If the vendor activity
is carried on outside of California or partially outside of
California, a waiver or reduced withholding rate may be
granted. For more information, contact:
Franchise Tax Board
Withhold at Source Unit
Attention: State Agency Withholding Coordinator
P.O. Box 651
Sacramento, CA 95812-0651
(916) 3694900 FAX (916) 369-4831
If a reduced rate of withholding or waiver has W
authorized by the Franchise Tax Board, attach a ck
to this form.
PRIVACY STATEMENT
Section 7(b) of the Privacy Act of 1974 (Public Law 93-5791) requires that any federal, state, or local governmental agency which requests
an individual to disclose his 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.
The State of California requires that all parties entering into business transactions that may lead to payment(s) from the State should
provide their Taxpayer Identification Number (TIN) in order to facilitate the preparation of Form 1099 and other information returns
as required by the Internal Revenue Code, Section 6109 and the State Revenue and Taxation Code, Section 18934. The TIN for individual
and sole proprietorships is the Social Security Number (SSN).
It is mandatory to furnish the information requested. Federal law requires that payments for which the requested information is ._.
provided be subject to a 20% 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 business.
If you have any questions regarding this notice, please call the Department of Finance, Fiscal Systems and Consulting Unit, at (916) 445-0385.