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State of California
Franchise Tax Board
Request for Filing Compliance Agreement
Representative’s Name:
Email Address:
Address:
Phone Number:
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Tax Years:
Fax Number:
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You must be authorized to represent participants in a Filing Compliance Agreement (FCA). If we approve the FCA request,
we will waive penalties if reasonable cause is a defense for the tax years provided in the FCA. We will not agree to any
additional conditions that are outside the scope of the FCA. The FCA only covers the approved parties and tax years
requested and subsequently listed in the FCA.
California filing obligations for additional parties or tax years for which no FCA consideration was requested and approved
may be subsequently identified upon review and processing of the submitted tax returns and will not be a part of the FCA
and may be subject to any applicable penalties, interest, and fees.
For more information go to ftb.ca.gov and search for FCA. For additional assistance, questions about the FCA can be
directed to Larry Womac, 916.845.6972.
Declaration
I declare under penalty of perjury, under the laws of the State of California, that I am the participant or our company is
authorized by the unnamed participants, to act as their agent in requesting an FCA. The information given above, in the
attached Exhibit A, and any supplemental information has been confirmed with all participants to be true and correct to
the best of my knowledge and belief.
______________________________________________________
Print Name
______________________________________________________
_____/_____/_______
Signature
Date
Mail your completed request to:
ATTN LARRY WOMAC
STATE OF CALIFORNIA
COMPLEX FILING ENFORCEMENT UNIT
FRANCHISE TAX BOARD
PO BOX 1779
RANCHO CORDOVA CA 95741-1779
FTB 5841 C2 (NEW 09-2010) PAGE 1