Form Ftb 4800 Meo - Federally Tax-Exempt Non-California Bond Interest And Interest-Dividend Payment Information Media Transmittal Page 2
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3DATA EXCHANGE TEBI MS L120
FRANCHISE TAX BOARD
Federally Tax-Exempt Non-California Bond Interest and
PO BOX 1468
Interest-Dividend Payment Information
SACRAMENTO CA 95812-1468
Media Transmittal
Tax Year
Date File Submitted
Complete the following information, attach additional sheets if needed, and include this form
with the file. See PAGE 4 for additional instructions.
1. Transmitter Information
FEIN:
Type of file submitted (circle one):
Original
Replacement
Correction
Name:
Address:
City:
Type of data submitted (circle one):
Bonds
Funds
Both
State:
ZIP Code:
2. Payer Information
List payers' names and respective payee totals for the records reported on this file.
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
Grand Total -
Grand Total -
Number of payee records reported by all payers:
Total of all payment amounts reported for all payers:
Under penalty of perjury, I declare that I have examined this return, including accompanying records, and to the best of my
knowledge and belief, it is true, correct, and complete. In the case of records without recipients' identifying numbers, I have
complied with the legal requirements by requesting such numbers from the recipients, but did not receive them.
Title
Date
Signature
3. Media Characteristics
CDs
File Name Used for Reporting:
4. Person to contact for media problems:
Name:
Telephone: (
)
-
Ext.
Email Address:
FTB 4800 MEO C1 (REV 10-2012) PAGE 3
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