Form Ftb 4107 Pc C2 - Mandatory E-Pay Election To Discontinue Or Waiver Request Page 2
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3General Instructions
If both spouses/RDPs qualify as permanently physically or
mentally impaired, then each spouse/RDP must complete
Beginning on or after January 1, 2009, California
a separate form FTB 4107 PC, Mandatory e-Pay Election
Revenue and Taxation Code (R&TC) Section 19011.5
to 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 of the following conditions are met:
On PAGE 3, you must provide a written statement from a
• Your estimated tax or extension payment exceeds
qualified physician that includes:
$20,000
1. The name and a description of your permanent
• Your tax liability exceeds $80,000 for any taxable year
physical or mental impairment.
beginning on or after January 1, 2009.
2. The physician’s medical opinion that the permanent
impairment prevents you from using a computer.
Failure to comply with this requirement will result in a
3. The date the patient became permanently mentally or
penalty. For more information, go to ftb.ca.gov and
physically impaired.
search for mandatory e-pay.
We will not approve your waiver request, if the Physician
R&TC Section 19011.5 provides that any taxpayer who is
Affidavit of Permanent Physical or Mental Impairment is
required to pay electronically may request a waiver of that
incomplete or not attached to FTB 4107 PC, Mandatory
requirement (see below for waiver criteria). To request a
e-Pay Election to Discontinue or Waiver Request.
waiver, mail or fax this completed form as indicated on this
page. You must pay electronically until we notify you we
approved your waiver request.
Mail Your Request to:
STATE OF CALIFORNIA
When to Use this Form
FRANCHISE TAX BOARD
Submit FTB 4107 PC, Mandatory e-Pay Election to
PO BOX 942840
SACRAMENTO CA 94240-0040
Discontinue or Waiver Request, immediately after
receiving FTB 4106 PC or FTB 4106 MEO, Mandatory
Or fax to 916.843.0468
e-Pay Program Participation Notice.
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
916.845.6500 from outside the United States
You can request a waiver from mandatory e-pay if one or
TTY/TDD:
800.822.6268 for persons with hearing or
more of the following is true:
speech impairments
• You have not made an estimated tax or extension
Get FTB 1131, Franchise Tax Board Privacy Notice,
payment in excess of $20,000 during the previous
at ftb.ca.gov or call us at 800.338.0505. If outside the
taxable year or your tax liability reported for the
United States, call 916.845.6500.
previous taxable year did not exceed $80,000.
• 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/RDP qualifies
as permanently physically or mentally impaired, the
permanent waiver only applies for the permanently
physically or mentally impaired spouse/RDP.
If only one spouse/RDP obtains a permanent waiver, the
other spouse must pay any joint liability by mandatory
e-pay.
FTB 4107 PC C2 (REV 09-2012) PAGE 2
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