Form Ftb 4073 - Mandatory E-Pay Pay-By-Phone Authorization Agreement For Individuals
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2STATE OF CALIFORNIA
FRANCHISE TAX BOARD
PO BOX 942840
SACRAMENTO CA 94240-0040
Mandatory e-pay Pay-by-Phone Authorization Agreement for Individuals
If you use Web Pay to make your electronic payment, you do not need to complete this form. This form is only for
you to enroll in the pay-by-phone or Internet payment options provided by the Franchise Tax Board’s (FTB) Electronic
Funds Transfer (EFT) vendor.
Check appropriate box:
New Enrollment
Change Bank Account Information
Change Contact Information
Complete Sections I and II
Section I – Taxpayer Information
Name
Social Security Number
Address
City
State
ZIP Code
Telephone Number
Fax Number
Section II – Bank Account Information
Attach a voided check from the account to be debited. We will use your voided check to confirm the banking
information entered below. Do not attach a deposit slip or use the banking information from a deposit slip.
Bank Name and Address
Bank Account Number
Bank Transit and Routing Number
Checking
Savings
I certify that I have the authority to request electronic funds withdrawals from the bank account identified above. I
authorize FTB and its EFT vendor to make electronic funds withdrawals and payments to FTB from the above account as
directed by me through FTB’s EFT vendor. This authority remains in force until FTB receives written notice of cancellation.
Signature
Print Name
Date
Fax the completed form to:
OR
Mail the completed form to:
916.845.5340
STATE OF CALIFORNIA
E PROGRAMS CUSTOMER SERVICE UNIT MS F284
FRANCHISE TAX BOARD
PO BOX 1468
SACRAMENTO CA 95812-1468
Franchise Tax Board Privacy Notice
Get FTB 1131, Franchise Tax Board Privacy Notice, at ftb.ca.gov or call us at 800.338.0505. If outside the United
States, call 916.845.6600.
Please make a copy for your records.
FTB 4073 (REV 08-2013) SIDE 1
407300081371
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Parent category: Financial