Form Ftb 5841 C2 - Franchise Tax Board - State Of California Page 2
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3EXHIBIT A
To retain the participant’s anonymity only refer to the participant’s entity type when answering the following questions.
Attach additional sheets if necessary.
1.
In order to qualify for FCA consideration, the participant must be in a class of taxpayers as described in Revenue
and Taxation Code Section 19192, or a Limited Liability Partnership (LLP), Limited Partnership (LP), or General
Partnership (GP). List all participants requesting FCA consideration for which you are the authorized representative,
by entity type (i.e., Corporation X, Trust A, Beneficiary B, LLC X, etc.):
(1)
(4)
(7)
(2)
(5)
(8)
(3)
(6)
(9)
2.
Specify the tax years the participants are requesting FCA consideration:
___________________________________________________________________________________________
3.
Explain why there is an unfulfilled filing requirement and unpaid California tax liability for the tax years requested.
Provide facts as to why the participant’s situation qualifies for a waiver of penalties for reasonable cause:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
4.
Have any participants previously requested FCA or Voluntary Disclosure Program (VDP) consideration? If yes, list
participants and tax years:
___________________________________________________________________________________________
5.
Taxpayers who received a notice from FTB are not entitled to enter into an FCA. Has FTB notified the participants
about a filing obligation in this state? If so, specify which participants received a notice, the notice date, and the tax
years:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
6.
Participants in an FCA are required to file tax returns for all tax years they had a filing obligation in this state. If
participants state they only have records available for preparing accurate tax returns for a limited number of tax
years, FTB requires a statement under penalty of perjury attesting to that fact. If applicable, do the participants have
someone who is knowledgeable about their records and able to make such a statement under penalty of perjury
under the laws of the State of California?
___________________________________________________________________________________________
7.
If the participants have a California Secretary of State number, when was it registered and is it still active?
___________________________________________________________________________________________
FTB 5841 C2 (NEW 09-2010) PAGE 2
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