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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. ________
Transmitter Information
Only enter transmitter information if transmitter is different than the institution named 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 09-2007) SIDE 1