Form Ftb 4595pit - Site And Training Class Information

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Site and Training Class Information
Date: ____/____/______
m
If you do not want this information released to the public, check here:
Location Name (Military Base Name/AARP Office/etc.):___________________________________________
Electronic Filing Identification Number (EFIN): __________________________________________________
Site Identification Number (Site ID): __________________________________________________________
Part 1 – Site Information
___________________________________________
_______________________________________
Public Contact Name
(Area Code) Telephone Number
Email Address (Required): ________________________________
Opening Date: ____/____/______
Closing Date: ____/____/______
Mailing Address Prior to Tax Season (Do Not Use a PO Box): ______________________________________
_______________________________________________________________________________________
___________________________________________
_______________________________________
Site Coordinator Name
(Area Code) Telephone Number
Schedule (Days and Hours Site is Open): ______________________________________________________
_______________________________________________________________________________________
Part 2 – Training Class Information
Class Coordinator Name: __________________________________________________________________
Class Location: __________________________________________________________________________
Street Address (Including Building and Room Number):___________________________________________
_______________________________________________________________________________________
City and ZIP Code: _______________________________________________________________________
How many volunteers will attend this State class? _____________
Will your agency provide an instructor for State training?
m
m
No
Yes, please print name:_________________________________________________________
First Choice
Second Choice
Date:________________
Date:________________
Time:________________
Time:________________
Email or fax your request to: Volunteercoordinator@ftb.ca.gov or 916.845.9004.
FTB 4595PIT (REV 06-2013)

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