Form Ftb 4107 Pc C2 - Mandatory E-Pay Election To Discontinue Or Waiver Request

Download a blank fillable Form Ftb 4107 Pc C2 - Mandatory E-Pay Election To Discontinue Or Waiver Request in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Ftb 4107 Pc C2 - Mandatory E-Pay Election To Discontinue Or Waiver Request with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Print and Reset Form
Reset Form
STATE OF CALIFORNIA
FRANCHISE TAX BOARD
PO BOX 942840
SACRAMENTO CA 94240-0040
Mandatory e-Pay Election to Discontinue or Waiver Request
Name:
Social Security Number:
Spouse/Registered Domestic Partner (RDP) Name:
Social Security Number:
Address:
City:
State:
ZIP Code:
Part 1 – Discontinue Mandatory e-Pay Election or Temporary Waiver Request (check one box)
m
I elect to discontinue making electronic payments because I have not made an estimated tax or extension payment in
excess of $20,000 during the previous taxable year or my tax liability did not exceed $80,000 for the previous
taxable year.
m
I request a waiver from the mandatory e-pay requirement because the amounts paid were not representative of my
tax liability, as explained below:
Part 2 – Permanent Physical or Mental Impairment – Permanent Waiver Request (refer to PAGE 2)
m
I request a mandatory e-pay waiver because of a permanent physical or mental impairment. You must attach a
completed and signed physician affidavit to this form (see PAGE 3).
m
Mandatory e-Pay Penalty Waiver. Check this box if you want us to review your account for possible waiver of a
mandatory e-pay penalty we previously assessed. All the following must apply:
• You received a mandatory e-pay penalty for payments you made before we approved your permanent physical or
mental impairment request.
• The date on the Physician Affidavit of Permanent Physical or Mental Impairment (line 3) is before the
penalty assessment.
• The statute of limitations for filing a claim for refund of the penalty is still open.
Part 3 – Signature (if the waiver request is for a joint return, both spouses/RDPs must sign this form)
_____________________________________
____________________
_______________________________
Taxpayer Signature
Date
Telephone Number
_____________________________________
____________________
_______________________________
Spouse/RDP Signature
Date
Telephone Number
FTB 4107 PC C2 (REV 09-2012) PAGE 1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 3