Form Ftb 3520 - Franchise Tax Board Power Of Attorney Declaration - 2017
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1
2Franchise Tax Board
Power of Attorney Declaration
Part 1 – Taxpayer Information
Individual (Do not complete Fiduciary or Business Entity section in Part 1.)
Taxpayer Name
Initial Last Name
SSN or ITIN
Address (suite, room, PO Box, or PMB No.) Check box if new address .
Telephone No.
(
)
-
City
State
ZIP Code
Fiduciary (Complete for estates and trusts.)
Estate or Trust Name
SSN or ITIN
FEIN
Address (suite, room, PO Box, or PMB No.) Check box if new address .
Telephone No.
Fax No.
(
)
-
(
)
-
City
State
ZIP Code
Business Entity
Business Name
CA Corporation No.
Address (suite, room, PO Box, or PMB No.) Check box if new address .
FEIN
CA SOS No.
City
State
ZIP Code
Telephone No.
Fax No.
(
)
-
(
)
-
Exceptions for Paper Filing: Go to ftb.ca.gov to file this form through your MyFTB account. If you meet one of the exceptions listed below, you can submit this form by mail.
(Check all that apply.)
Located in a declared disaster area
Documented physical/mental impairment
Non-professional representative (for example, relative, friend, etc.)
First-time filer for the State of California
Do not have a PTIN, EFIN, California CPA, CTEC number, or California State Bar number
Estate or Trust
Other (explain):
Active duty military member in combat zone
Part 2 – Representative
The taxpayer in Part 1 appoints the following representative(s) as attorney(s)-in-fact:
Primary Representative
Check box if new Address Telephone No. Email
To appoint additional representatives, attach a list including all required information to this form.
Name
IRS CAF No.
PTIN
Address (suite, room, PO Box, or PMB No.)
Telephone No.
Fax No.
(
)
-
(
)
-
City
State
ZIP Code
Email Address (Include representative’s email address to ensure they receive email notifications.)
Additional Representative
Check box if new Address Telephone No. Email
Name
IRS CAF No.
PTIN
Address (suite, room, PO Box, or PMB No.)
Telephone No.
Fax No.
(
)
-
(
)
-
City
State
ZIP Code
Email Address (Include your representative’s email address to ensure they receive email notifications.)
Part 3 – Authorization for All Tax Years or Income Periods for a Limited Duration
I authorize the listed representative(s), in addition to anything otherwise authorized on this form, to represent me regarding any
matters with the Franchise Tax Board regardless of tax years or income periods. I understand that this authority will expire four
years from the date this Power of Attorney (POA) Declaration is signed or if a new POA is filed revoking this authorization.
352000091371
FTB 3520 (REV 02-2017) C1 PAGE 1
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