Form Ftb 2049b - Fidm Waiver Form
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FIDM Waiver Form
STATE OF CALIFORNIA
FIDM MAIL STOP A181
FRANCHISE TAX BOARD
PO BOX 1468
SACRAMENTO CA 95812-9807
Franchise Tax Board (FTB) will consider waiver requests from Financial Institution Data Match requirements under one of
three conditions: 1) total number of open accounts held by the institution is less than 250; 2) institution does not maintain
account information on a computerized record keeping system; or 3) required system modifications constitute an initial
burden to institutions with complex system changes.
Your Organization
Name:__________________________________________________FEIN: ______________________________
Primary Contact: _________________________________________Email: _____________________________
Phone: __________________________ Fax: ___________________
Secondary Contact: _______________________________________Email: _____________________________
Phone: __________________________ Fax: ___________________
Street Address:
Mailing Address
:
(if different from street address)
ATTN
_________________________________ ATTN
________________________________
(optional):
(optional):
_________________________________
_________________________________
_________________________________
_________________________________
ACTION
Questionnaire
Request a waiver for the entire
1. Do you have more than 250 open accounts?
calendar year of:
____________________
Yes
No
Request a waiver for part of the
Actual number: ___________________
calendar year of:
2. Are your accounts available on a computerized record
____________________
keeping system?
Specify the quarters for which you are
requesting a waiver.
Yes
No
When do you plan to implement
computerized record keeping?
Quarter 1
Quarter 2
Date ____________________
Quarter 3
Please explain why you are unable to participate in the data exchange
Quarter 4
at this time.
________________________________________________________
Note: Waivers will be valid for a
________________________________________________________
maximum of one calendar year.
________________________________________________________
________________________________________________________
AUTHORIZED REPRESENTATIVE
Under penalty of perjury of the laws of the State of California, I declare that I have examined this form, including any
accompanying statements, and to the best of my knowledge and belief it is true, correct and complete. Further, I declare that
the financial institution I represent meets one of the three waiver qualifications listed on this form.
Name
: ______________________________________________ Title: ______________________
(please print)
Signature: ______________________________________________________ Date: ______________________
FTB 2049B (REV 08-2011) SIDE 1
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