Form Ftb 4800 - Interest And Interest-Dividend Payment Reporting Requirement Letter Page 3
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1
2
3PROGRAM LIAISON TEAM MS F310
FEDERALLY TAX EXEMPT NON-CALIFORNIA
STATE OF CALIFORNIA
BOND INTEREST & INTEREST-DIVIDEND PAYMENTS
FRANCHISE TAX BOARD
PO BOX 1998
HARD COPY REPORTING FORM
RANCHO CORDOVA CA 95741-1998
PAYER INFORMATION
Name _________________________________________________ FEIN _____________________________________________
Street _________________________________________________
City ___________________________________________________
State __________________________________________________
ZIP Code _______________________________________________ Payment Year: _____________________
PAYEE INFORMATION
For more information on privacy and disclosure, get Franchise Tax Board Privacy Notice (FTB 1131) at
1. SSN
7. Amount Earned:
2. Name
8. Acct. No.:
3. Street
9. Fund Distribution Percentage:
4. City
10. CUSIP No.:
5. State
CUSIP Description:
6. ZIP Code
1. SSN
7. Amount Earned:
2. Name
8. Acct. No.:
3. Street
9. Fund Distribution Percentage:
4. City
10. CUSIP No.:
5. State
CUSIP Description:
6. ZIP Code
1. SSN
7. Amount Earned:
2. Name
8. Acct. No.:
3. Street
9. Fund Distribution Percentage:
4. City
10. CUSIP No.:
5. State
CUSIP Description:
6. ZIP Code
1. SSN
7. Amount Earned:
2. Name
8. Acct. No.:
3. Street
9. Fund Distribution Percentage:
4. City
10. CUSIP No.:
5. State
CUSIP Description:
6. ZIP Code
1. SSN
7. Amount Earned:
2. Name
8. Acct. No.:
3. Street
9. Fund Distribution Percentage:
4. City
10. CUSIP No.:
5. State
CUSIP Description:
6. ZIP Code
Mail to: PROGRAM LIAISON TEAM MS F310
Person to contact regarding this report:
FRANCHISE TAX BOARD
Name ______________________________________________
PO BOX 1998
( )
RANCHO CORDOVA CA 95741-1998
Telephone __________________________
Ext. __________
FTB 4800 (REV 12-2007) PAGE 5
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