Form Ftb 622 - Voluntary Compliance Participation Agreement Form printable pdf download

Voluntary Compliance Participation Agreement Form

(Individual Income Taxpayers)

Please refer to the instructions for more information. When completed and signed by an authorized representative, this

form will serve as the official agreement with the Franchise Tax Board.

Attach to the Amended Individual Income Tax Return

For calendar year _____, or

Fiscal year beginning month _____ day _____ year_____, and ending month _____ day _____ year _____.

Your name as shown on return

Your Social Security Number:

Spouse's name as shown on return (if married filing jointly)

Spouse's Social Security Number:

Address

▲ Important ▲

You must enter

Your SSN(s) above

Select one:

Check one of the following Options and attach this form to each amended return. You must elect the same option for

each year of participation.

Option 1

□ I elect to participate in the VCI under Option 1. I understand that I waive my right to appeal or file a claim for refund

for any amounts paid under this VCI.

Option 2

□ I elect to participate in the VCI under Option 2. I understand this option will not affect my right to appeal or file a

claim for refund for any amounts paid under this VCI.

Please check if either of the following boxes applies.

□ A. I want to treat this election as a claim for refund. My basis for the claim is attached.

□ B. I do not want to treat this election as a claim for refund. I just want to maintain my appeal rights.

□ C. I have a pending federal action and want to treat this election as a claim for refund. My basis for the

claim is attached.

For more details, please see the instructions to this form under Option 2 Appeal Process.

PLEASE SIGN BELOW

Under penalty of perjury of the laws of the State of California, I declare that I examined this form, including any

accompanying statements, and to the best of my knowledge and belief it is true, correct, and complete. Declaration of

preparer (other than taxpayer) is based on all information of which preparer has any knowledge. I am properly

authorized to execute this form.

Your name (please print): __________________________ Spouse's name (please print): _______________________

Your signature: __________________________________ Spouse's signature _______________________________

Date: __________ Telephone number: _______________ Date: __________ Telephone number: _______________

Note: A Participation Agreement signed by a representative or an attorney-in-fact must be accompanied by a completed

power of attorney (Form FTB 3520) authorizing such signature.

For Privacy Act Notice, get form FTB 1131.

FTB 622 (REV 2-2004) Page 1

Form Ftb 622 - Voluntary Compliance Participation Agreement Form