Form Ftb 2280 Pc - Intent To Participate
Download a blank fillable Form Ftb 2280 Pc - Intent To Participate 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 2280 Pc - Intent To Participate 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
1
2Print and Reset Form
Reset Form
STATE OF CALIFORNIA
INTERAGENCY INTERCEPT COLLECTION PROGRAM MS A140
Check this box if you are making revisions.
FRANCHISE TAX BOARD
PO BOX 2966
RANCHO CORDOVA CA 95741-2966
Email: iicgroup@ftb.ca.gov
Telephone: 916.845.5344
Fax: 916.843.2460
Intent to Participate
(Complete both sides of this form, sign, and either fax or mail it to us.)
Age
ncy ty
pe:
b) Name: __________________________________
State
College
City
County
Court
Position: _________________________________
1. Agency name: ______________________________
Telephone: (____)________________ Ext. ______
Division/branch: _____________________________
Email address: ____________________________
2. Agency code: ________
(Enter the two-digit code the Franchise Tax Board
c) Name: __________________________________
(FTB) assigned your agency.)
Position: _________________________________
3. Process year 20
Telephone: (____) _______________ Ext. ______
Email address: ____________________________
4. Public contact unit:
Provide an address and telephone number for your
6. Agency mailing address to send warrants, fund
debtors to contact you directly.
transfers, and billings:
For agencies that do not have a public contact window,
Do not provide third party information.
prov ide a post office box.
Agency name: ______________________________
Unit name: _________________________________
Agency name: ______________________________
Address: ___________________________________
Unit name: _________________________________
Room/suite/floor: ____________________________
Address: ___________________________________
City: ______________________________________
Room/suite/floor: ____________________________
State: ____________________ ZIP Code: ________
City: ______________________________________
Contact name: ______________________________
State: ____________________ ZIP Code: ________
Telephone: ( ____) _________________ Ext. ______
Telephone: (____) ________________ Ext. _______
Email address: ______________________________
Check this box if the public contact unit is a
Fax number: (____) ___________________________
collection agency/service provider.
Provide name: _____________________________
7. SWIFT agency contact information:
5. FTB Intercept Program liaisons:
Name: _____________________________________
Provide the names and direct telephone numbers of
Telephone: (____) _________________ Ext. ______
up to three individuals we may contact to resolve
SWIFT email address: ________________________
issues or obtain account information. These individuals
8. Select your agency type (one only):
should be authorized to request intercept services.
State agency or college
a) Name: __________________________________
Complete either A, B, or C. The State Controller
Position: _________________________________
will credit the intercepts accordingly.
Telephone: (____) ______________ Ext. _______
A. General checking account number:
Email address: ____________________________
_________ (Three-digit number)
(We may provide email addresses to the State
B. Special fund: _____________________
Controller's Office for billing purposes.)
(Fund #)
(Org. Code)
State Controller’s account number:_____________
(Contact your accounting office for this number.)
C. Warrant
City or county agency:
Special Districts – bridge tolls and high occupancy toll
lane fees. (Government Code Section 12419.12)
A warrant will be issued to your agency listing the
intercept funds sent to you.
FTB 2280 PC (REV 07-2013) SIDE 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Instructions For Form Ftb 8633 - California Application To Participate In The E-file Program - 2000
Financial
Instructions For Form Ftb 8633 - California Application To Participate In The E-file Program - 2001
Financial
Form Ftb 4107 Pc - Mandatory E-pay Election To Discontinue Or Waiver Request - General Instructions
Financial
Related Categories
Parent category: Financial