Form Ftb 2049b - Waiver Request Form
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1
2WAIVER REQUEST
WAIVER REQUEST
STATE OF CALIFORNIA
FIDM: MAIL STOP B-40
FRANCHISE TAX BOARD
PO BOX 460
FORM
FORM
RANCHO CORDOVA CA 95741-0460
FTB will consider waiver requests from the Financial Institution Data Match requirements under one of three
conditions: 1) the total number of open accounts held by the institution is less than 250; 2) the institution does
not maintain account information on a computerized record keeping system; or 3) the required system
modifications constitute an initial burden to institutions with complex system changes.
YOUR INSTITUTION
Name:
__________________________________
FEIN: ___________________________________
Contact:
__________________________________
Phone: _________________________________
Street address:
Mailing address
:
(if different from street address)
Attn
:__________________________________
Attn
: _____________________________
(optional)
(optional)
__________________________________
_____________________________
__________________________________
_____________________________
__________________________________
_____________________________
ACTION
QUESTIONNAIRE
1.
Do you have more than 250 open accounts?
Request waiver for the
entire calendar year of
Yes
No
_______.
Actual number: _________
Request waiver for part of
the calendar year of
_______.
2. Are your accounts available on a computerized record keeping
system?
Please specify the
quarters for which you
are requesting a waiver:
Yes
No
When do you plan to implement
computerized record keeping?
quarter 1
Date _______________
quarter 2
3. Please explain why you are unable to participate in the data
quarter 3
exchange at this time.
quarter 4
_____________________________________________________
_____________________________________________________
_____________________________________________________
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 03-2000) SIDE 1
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