Form Ftb 4092 C3 - Filing Application - California Franchise Tax Board - 2002

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STATE OF CALIFORNIA
Filing Application
FRANCHISE TAX BOARD
ATTN: DATA EXCHANGE SERVICES MS A-10
PO BOX 942840
SACRAMENTO CA 94240-6090
(916) 845-3778
Application is hereby made to transmit annual 1098/1099/5498/W-2G information returns to Franchise Tax Board.
Name of Firm (Transmitter):
Date:
Address:
Federal Employer Identification Number:
City, State and ZIP Code:
Reporting will begin with
Tax Year: _________
Contact for Technical Information (Name):
Title:
Telephone (Area Code & Ext.)
REPORTING INFORMATION
Please indicate the document type(s) you plan to file on cartridge, diskette, or CD.
1098
1099
5498
W-2G
Do you plan to act as a transmitter for other Payers?
Yes
No
MEDIA PREFERENCE
CARTRIDGE
CD
DISKETTE
NOTE: 4mm or 8mm cartridges, and 9-track tape reels are not acceptable.
AUTHORIZED REPRESENTATIVE OF ORGANIZATION REQUESTING APPROVAL
Name (Type or Print):
Title:
Signature:
Date:
FTB 4092 C3 (REV 10-2002)

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