Form Ftb 4107 Pc - Mandatory E-Pay Election To Discontinue Or Waiver Request - General Instructions
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1General Instructions
If both spouses qualify as permanently physically or
mentally impaired, then each spouse must complete a
Beginning on or after January 1, 2009, California
separate form FTB 4107 PC, Mandatory e-Pay Election to
Revenue and Taxation Code (R&TC) Section 19011.5
Discontinue or Waiver Request.
requires taxpayers to remit all tax payments electronically,
Physician Affidavit Required
regardless of the taxable year for which the payment
applies, once any estimated tax or extension payment
On PAGE 3, you must provide a written statement from a
exceeds $20,000 or their tax liability exceeds $80,000
qualified physician that includes:
for any taxable year beginning on or after January 1,
1. The name and a description of your permanent physical
2009. Failure to comply with this requirement will result
or mental impairment.
in a penalty. For more information, go to ftb.ca.gov and
2. The physician’s medical opinion that the permanent
search for mandatory e-pay.
impairment prevents you from using a computer.
R&TC Section 19011.5 provides that any taxpayer who is
We will not approve your waiver request, if the Physician
required to pay electronically may request a waiver of that
Affidavit of Permanent Physical or Mental Impairment is
requirement (see below for waiver criteria). To request a
incomplete or not attached to FTB 4107 PC, Mandatory
waiver, mail or fax this completed form as indicated on this
e-Pay Election to Discontinue or Waiver Request.
page. You must pay electronically until we notify you we
approved your waiver request.
Mail Your Request to:
When to Use this Form
STATE OF CALIFORNIA
FRANCHISE TAX BOARD
Submit FTB 4107 PC, Mandatory e-Pay Election to
PO BOX 942840
Discontinue or Waiver Request, immediately after
SACRAMENTO CA 94240-0040
receiving FTB 4106 PC or FTB 4106 MEO, Mandatory
e-Pay Program Participation Notice.
Or fax to 916.843.0468
Internet and Telephone Assistance
Discontinue Mandatory e-Pay Election or
Website:
ftb.ca.gov
Temporary Waiver Request
Telephone: 800.852.5711 from within the United States
You can request a waiver from mandatory e-pay if one or
916.845.6500 from outside the United States
more of the following is true:
TTY/TDD:
800.822.6268 for persons with hearing or
speech impairments
• You have not made an estimated tax or extension
payment in excess of $20,000 during the previous
Get FTB 1131, Franchise Tax Board Privacy Notice,
taxable year or your tax liability reported for the
at ftb.ca.gov or call us at 800.338.0505. If outside the
previous taxable year did not exceed $80,000.
United States, call 916.845.6500.
• The amount you paid is not representative of your tax
liability.
Check the applicable box in Part 1 indicating your request.
We will review your waiver request and notify you in
writing of our decision.
If we grant a waiver and you subsequently meet the
mandatory e-pay requirements, you must resume making
electronic payments.
Permanent Physical or Mental Impairment –
Permanent Waiver Request
You may request a permanent waiver if you have a
permanent physical or mental impairment that prevents
you from using a computer.
Joint returns - If only one spouse qualifies as
permanently physically or mentally impaired, the
permanent waiver only applies for the permanently
physically or mentally impaired spouse.
If only one spouse obtains a permanent waiver, the other
spouse must pay any joint liability by mandatory e-pay.
FTB 4107 PC C2 (NEW 03-2012) PAGE 2
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