Form Ftb 2280 Pc - Intent To Participate Page 2
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Agency Certification
(Complete in full and sign.)
This document notifies FTB that the _____________________________________ plans to participate in the Interagency
Agency/College
Intercept Collections Program for the 20
process year. In doing so, I certify that all debts submitted for offset comply
with the following Government Code Sections (please mark one):
State agencies and colleges — 12419.5, 12419.7, 12419.9, 12419.10, 12419.11, and 12419.12
County and city agencies — 12419.8 and 12419.10
Type of debt we intend to collect:
Dishonored
Parking
Check
Fees
Fines
Citations
Judgments
Unpaid
Taxes
Tuition
Insurance
Services
Overpayment
Other __________________________________
________________________________
__________________________________
________________________________
__________________________________
________________________________
I certify that the ____________________________________ agrees to pay administrative costs to the California
Agency/College
State Controller’s Office for processing these offset accounts, and that I am authorized to request services on behalf of
this agency/college.
I certify that all records, copies, files, and media submissions received by the
____________________________________ shall be destroyed in a manner acceptable to FTB. The approved
Agency/College
destruction methods that permanently render data unreadable and unusable include:
•
Degaussing and magnetizing disks.
•
Damage to disks that prevents their use in any disk drive.
•
Crisscross shredding if the shreds are 5/16 inch or smaller.
All unauthorized or suspected accessed, uses, and/or disclosures (incidents) of the information obtained under this
agreement shall be thoroughly reviewed by FTB. We comply with the incident reporting requirements, in accordance with
Civil Code Section 1798.29 and SAM Chapter 5300 (Information Security). The participant shall immediately notify FTB’s
Information Security Audit Unit. Their email is, SecurityAuditMail@ftb.ca.gov or call 916.845.5555. Notify the Information
Security Audit Unit of all incidents involving the information obtained under this agreement as applicable, and provide the
appropriate information to facilitate the required reporting to the taxpayers or state oversight agencies.
I agree that our agency’s/college’s fax signatures sent to FTB should be treated as original signatures.
Signature: _________________________________
Date: ________________________________
Title: ______________________________________
Telephone: ___________________________
FTB will not send or receive taxpayer social security numbers through regular email. Please do not use regular
email to request or send confidential taxpayer information. Call the IIC Program staff at 916.845.5344 to register for
our secure internet file transfer service.
FTB 2280 PC (REV 07-2013) SIDE 2
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