Print and Reset Form
Reset Form
STATE OF CALIFORNIA
SERVICE AND SUPPLY
DATA EXCHANGE FIDM
FRANCHISE TAX BOARD
9646 BUTTERFIELD WAY
SACRAMENTO CA 95827
Data Exchange Transmittal Form
Financial Institution Data Match
File Creation Date _______________
Type of Reporting:
Method 1
Method 2
Data Exchange Quarter ____
Year______
(1-4)
Financial Institution Information
Institution FEIN ________________________________
Number of Records Reported _____________
Institution Name ___________________________________________________________________________
Address __________________________________________________________________________________
City __________________________________________________ State _________ Zip _________________
Contact Person ________________________________________ Phone ________________
Ext. ________
Email _____________________________________________________________________________________
Transmitter Information (Complete only if different from above.)
Transmitter Name ___________________________________________ FEIN _________________________
Address __________________________________________________________________________________
City __________________________________________________ State _______
Zip __________________
Contact Person _________________________________________ Phone _________________ Ext. ________
Media Characteristics:
3 ½” Diskette ____ or CD ____
File name used on Diskette or CD ______________________________
Tape cartridges:
____ EBCDIC
____ ASCII
SERIAL NUMBER ________________
____ STD LBL
____ NO LBL
BLOCK SIZE _____________________
Send this form with your media file to:
Shipping
:
U.S. Postal Service:
(preferred method)
SERVICE AND SUPPLY
DATA EXCHANGE FIDM MS L120
DATA EXCHANGE FIDM
FRANCHISE TAX BOARD
FRANCHISE TAX BOARD
PO BOX 1468
9646 BUTTERFIELD WAY
SACRAMENTO CA 95812-1468
SACRAMENTO CA 95827
(Must use PO Box for U.S. Postal Service Delivery)
FTB 2049C (REV 01-2009) SIDE 1