Form Ftb 4800 - Interest And Interest-Dividend Payment Reporting Requirement Letter Page 2
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1
2
3DATA EXCHANGE TEB MS L120
Federally Tax Exempt Non-California Bond Interest and
STATE OF CALIFORNIA
Interest-Dividend Payment Information
FRANCHISE TAX BOARD
MEDIA TRANSMITTAL
PO BOX 1468
SACRAMENTO CA 95812-1468
Tax Year ____________ Date File Submitted_________________________
Please complete the following information, attach additional sheets if needed, and forward this
form with the file. See page 4 for additional instructions.
Transmitter Information
Type of file submitted (circle one):
FEIN:
Name
Original
Replacement
Correction
Address
City
Type of data submitted (circle one):
State
Bonds
Funds
Both
ZIP Code
Payer Information
List name of payers and respective payee totals for the records reported on this file.
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
GRAND TOTALS –
GRAND TOTALS –
Number of payee records reported by all payers:
Total of all payment amounts reported for all payers:
Under penalty of perjury, I declare that I have examined this return, including accompanying records, and to the best of
my knowledge and belief, it is true, correct and complete. In the case of records without recipients’ identifying numbers
I have complied with the requirements of the law by requesting such numbers from the recipients, but did not receive
them.
Signature _____________________________________
Title _________________________
Date __________________ ____
Media Characteristics
CARTRIDGES
Sequence
External Label #
DISKETTES/COMPACT DISKS
1 of
File name Used for Reporting:
Internal Header Labels (circle one):
2 of
Yes
No
3 of
Recording Mode (circle one)
Density (circle one):
Single
Double
4 of
EBCDIC
ASCII
Person to contact for media problems:
Record Length = 750, Blocksize = _____
Name ______________________________________________________________
Cartridge Compatibility (circle one):
3480
3490
Telephone __________________________________
Ext. __________________
FTB 4800 (REV 12-2007) PAGE 3
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