INDIVIDUAL OR SOLE PROPRIETOR ENTER SOCIAL SECURITY — — NUMBER: (SSN required by authority of California Revenue and Tax Code Section 18646) 4 California resident—qualified to do business in California or maintains a permanent place of business in California. PAYEE RESIDENCY California nonresident (see reverse side)—Payments to nonresidents for services may be subject to State TYPE income tax withholding. No services performed in California. Copy of Franchise Tax Board waiver of State withholding attached. 5 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. AUTHORIZED PAYEE NAME (Type or Print) TITLE REPRESENTATIVE’S SIGNATURE DATE TELEPHONE ) ( 6 Please return completed form to: Housing and Community Development - Financial Assistance Department/Office: Division EMERGENCY SOLUTIONS GRANTS PROGRAM Unit/Section: 2020 West El Camino, MS 400 Mailing Address: Sacramento, CA 95833 City/State/ZIP: Telephone: FAX: (916) 263-3391
INDIVIDUAL OR SOLE PROPRIETOR ENTER SOCIAL SECURITY NUMBER: — — (SSN required by authority of California Revenue and Tax Code Section 18646) 4 PAYEE RESIDENCY TYPE California resident—qualified to do business in California or maintains a permanent place of business in California. California nonresident (see reverse side)—Payments to nonresidents for services may be subject to State income tax withholding. No services performed in California. Copy of Franchise Tax Board waiver of State withholding attached. 5 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. AUTHORIZED PAYEE REPRESENTATIVE’S NAME (Type or Print) TITLE SIGNATURE DATE TELEPHONE ( ) 6 Please return completed form to: Department/Office: Housing and Community Development - Financial Assistance Division Unit/Section: EMERGENCY SOLUTIONS GRANTS PROGRAM Mailing Address: 2020 West El Camino, MS 400 City/State/ZIP: Sacramento, CA 95833 Telephone: FAX: (916) 263-3391
esg-2016-application.docx