Form Ftb 2049a - Fidm Election Form

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FIDM ELECTION FORM

STATE OF CALIFORNIA

FIDM MAIL STOP A181

FRANCHISE TAX BOARD

PO BOX 1468

SACRAMENTO CA 95812-9807

Use this form to elect the method for participating in the Financial Institution Data Match Program with the

Franchise Tax Board (FTB). Refer to the instructions for more information. When completed and signed by an

authorized representative of your organization, this form will be the official data processing agreement

with FTB.

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):

_________________________________

________________________________

_________________________________

________________________________

Action

Exchange Method

Effective Date of



Method 1

The All Accounts Method. During the first quarter of participation in a calendar year,

Change or Election

the financial institution submits a file to FTB of all open accounts. For subsequent

quarters, the file may contain all open or just updates of opened, closed, or

changed accounts.



Initial election

Method 2

FTB sends a list of child support debtors (the Inquiry File) to the financial institution.

The financial institution matches the Inquiry File against all open accounts and



Change election

returns a file (the Match File) of matched accounts. The Inquiry File is provided

electronically via the Internet.



Add or change

transmitter

Transmitter Information

If you plan to use a transmitter to exchange data with FTB, please provide the following transmitter

information:

Transmitter Name:________________________________________ FEIN:______________________________

Address:

ATTN

: ___________________________________________________________________

(optional)

___________________________________________________________________

Contact: ______________________________________ Phone: ______________________________________

Email:________________________________________ Fax: ________________________________________

Authorized Representative

Name

: ____________________________________Title:__________________________________

(please print)

Signature: ___________________________________________Date: _________________________________

42 USC Section 666 (a) (17) (C) establishes that a financial institution shall not be liable under any federal or state law to any person for any disclosure of information to FTB (acting on

behalf of the California Department of Social Services, the state’s IV-D agency) for providing the required information covered in 42 USC Section 666 (a) (17) (A) (i). In addition, a

financial institution will not be held liable for any other action taken in good faith to comply with the requirements of 42 USC Section 666 (a) (17) (C). Sections 19552 and 19271.6 of the

California Revenue and Taxation Code provide that unauthorized disclosure or use of confidential Franchise Tax Board information is a misdemeanor.

FTB 2049A (REV 08-2011) SIDE 1