Form Ftb 2058 Pc - Temporary Exemption/suspension Request
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STATE OF CALIFORNIA
FIRM MS A243
FRANCHISE TAX BOARD
PO BOX 1468
SACRAMENTO CA 95812-1468
Temporary Exemption/Suspension Request
Use this form to request a Temporary Exemption or Temporary Suspension from the Financial Institution Record Match
(FIRM) program with the Franchise Tax Board (FTB). Refer to PAGE 2 of this form for additional information.
Financial Institution’s Name:
Federal Employer Identification Number (FEIN):
Street Address:
ATTN:
City:
State:
ZIP Code:
Mailing Address (if different from street address):
ATTN:
City:
State:
ZIP Code:
Telephone Number:
Fax Number:
Email Address:
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Type of Action Submitted:
1. Temporary Exemption (Less than 250 accounts). My institution requests a temporary exemption because it has
less than 250 open accounts: _______________
2. Temporary Exemption (Other). My institution requests a temporary exemption. Facts exist to grant a temporary
exemption under the requirements of R&TC Section 19266(a)(2)(C). Please provide sufficient detail.
3. Temporary Suspension. My institution qualifies for a temporary suspension because it has been classified as
undercapitalized, significantly undercapitalized, or critically undercapitalized its supervisory banking authority.
Please provide the notice from R&TC Section 19266(a)(2)(D).
Authorized Representative for Financial Institution
Officer’s Name (please print):
Title:
Signature:
Date:
FTB 2058 PC (REV 08-2013) PAGE 1
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