Form Ftb 4925 C2 - Application For Voluntary Disclosure (Page 5 of 5) in pdf

Form Ftb 4925 C2 - Application For Voluntary Disclosure Page 5

Provide the income and tax information requested above for each LLC applicant (primary and secondary, direct or indirect)

in the following format, and indicate if the entity is a primary or secondary applicant:

Tax Year, Starting From

R&TC 17942 Total

Withholding Amounts

Most Recent

Income from CA

LLC Fee

Under 18633.5

(MM/DD/YYYY – MM/DD/YYYY)

Sources

R&TC 17941 LLC Tax ($800)

(if applicable)

Part 8 – Signature

Failure to provide all requested information and to promptly respond to FTB inquiries concerning your

application will delay processing and may result in the application being denied.

I declare under penalty of perjury under the laws of the state of California that I am the applicant, or authorized

by the unnamed applicant(s) to act as its agent in applying for the Voluntary Disclosure Program, and that the

information given above and in the attached Exhibit A, Exhibit B, and any supplemental information is true and

correct to the best of my knowledge and belief.

Print Name

Signature

Date

FTB 4925 c2 (REV 12-2015) PAGE 5

Form Ftb 4925 C2 - Application For Voluntary Disclosure Page 5