Form Ftb 2049b - Waiver Request Form
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1
2STATE OF CALIFORNIA
FRANCHISE TAX BOARD
FIDM : MAIL STOP B-40
PO BOX 460
RANCHO CORDOVA, CA 95741-0460
INFORMATION HOTLINE: (916) 845-6304
FTB will consider waiver requests from the Financial Institution Data Match requirements under one of three
conditions: 1) the total number of active accounts held by the institution is less than 250; 2) the institution does
not maintain account information on a computerized record keeping system; or 3) the required system
modifications constitute an initial burden to institutions with complex system changes (i.e. Year 2000).
YOUR INSTITUTION
Name:
__________________________________
FEIN: ___________________________________
Contact:
__________________________________
Phone: _________________________________
Street address:
Mailing address
:
(if different from street address)
____________________________________________
_________________________________________
____________________________________________
_________________________________________
____________________________________________
_________________________________________
____________________________________________
_________________________________________
ACTION
QUESTIONNAIRE
ο
1.
Do you have more than 250 active accounts?
Request waiver for the
entire calendar year
ο Yes
ο No
_______.
Actual number: _________
ο
Request waiver for part of
of calendar year
2. Are your accounts available on a computerized record keeping
_______.
system?
Please specify the
ο Yes
ο No ⇑
When do you plan to implement
quarters for which you
are requesting a waiver:
computerized record keeping?
ο quarter 1
Date _______________
ο quarter 2
ο quarter 3
ο quarter 4
3. If you are facing complex systems changes that will impair your
ability to meet the data match requirement, when do you plan to
Requests for waivers will be valid
implement the required changes?
for a maximum of one year only
and must be submitted by
Date _______________
th
October 15
for the succeeding
calendar year.
AUTHORIZED REPRESENTATIVE
Under penalty of perjury of the laws of the State of California, I declare that I have examined this form, including any
accompanying statements, and to the best of my knowledge and belief it is true, correct and complete. Further, I declare
that the financial institution I represent meets one of the three waiver qualifications listed on this form.
Name
: _____________________________________
Title: _____________________
(please print)
Signature:
_____________________________________
Date: _____________________
FTB 2049B (NEW 07-1998)
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