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California Form 3574 Draft - Special Election For Business Trusts And Certain Foreign Single Member Llcs - 2016 Page 2

Special Election for Business Trusts and

CALIFORNIA FORM

TAXABLE YEAR

Certain Foreign Single Member LLCs

3574



Name of entity

California Secretary of State (SOS) file number

DBA

FEIN

Address (suite, room, PO box, or PMB no.)

City

State

ZIP code

If any of the entity’s information has changed, complete the section below.

Name of entity

California Secretary of State (SOS) file number

DBA

FEIN

Address (suite, room, PO box, or PMB no.)

City

State

ZIP code

1 Type of election: (See instructions, General Information A, Purpose).

a  Existing eligible business trust electing to be classified as a partnership (the same as federal).

b  Previously existing foreign single member limited liability company electing to be classified as a disregarded entity (the same as federal).

2 Effective date of election: month ______________ day ______________ year _____________ .

3 Person whom Franchise Tax Board may call for more information:

Name of contact person

Title

Telephone

(

)

Consent Statement and Signature(s)

Under penalties of perjury, I (we) declare all of the following:

• I (We) consent to the election of the above-named entity to be classified as indicated above.

• I am (We are) aware of the filing requirements under Revenue and Taxation Code Sections 18633 and 18633.5 relating to the return filing

requirements for a partnership or a disregarded entity.

• I am (We are) aware that this election is irrevocable.

• I (We) have examined the election and to the best of my (our) knowledge and belief, it is true, correct, and complete.

• If I am an officer, manager, or member signing for other members of the entity, I further declare that I am authorized to execute this consent on their

behalf.

Member’s name (print)

Signature

Title

Date

FTB 3574 2016

7411163

California Form 3574 Draft - Special Election For Business Trusts And Certain Foreign Single Member Llcs - 2016 Page 2

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