Form Ftb 2059 Pc - Reimbursement Invoice For Fiscal Year
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1STATE OF CALIFORNIA
ACCOUNTING AND FINANCIAL RESOURCES SECTION
FRANCHISE TAX BOARD
PO BOX 2800
SACRAMENTO CA 95812-2800
Reimbursement Invoice for Fiscal Year Ending June 30, 20___
Financial institutions may be entitled to reimbursement from the Franchise Tax Board (FTB) for a Financial Institution Record
Match (FIRM) one-time start up cost not to exceed $2,500 and up to $250 per quarter for conducting the FIRM data match (Revenue
and Taxation Code Section 19266). Reimbursement is based on the FIRM data match services performed during the State’s fiscal year
ending June 30. For more information go to ftb.ca.gov and search for firm.
Participating FIRM financial institutions must complete and submit an STD 204, Payee Data Record Reimbursement Invoice no later
than 30 days following the end of the State’s fiscal year (by July 30). Any FIRM Reimbursement Invoice received after July 30 for the
prior fiscal year ending June 30 will not be honored.
Institution Name:
Federal Employer Identification Number (FEIN):
Mailing Address:
Telephone Number (including area code):
(
)
–
Institution Contact Name:
Telephone Number (including area code):
(
)
–
Contact Name’s Email Address:
A.
One-Time Start Up Cost and Reimbursement
The one time start up cost may only be claimed once by the participating FIRM financial institution.
Date(s) start up costs were incurred:
Actual cost (not to exceed $2,500.)
_________________
$ ___________________
B.
Quarterly Data Match and Reimbursement
Up to four quarters may be submitted at one time. Quarterly matched files are due May 30, August 30,
November 30, and February 28, unless the date is changed by the FTB.
Date (by quarter) the data match was submitted to FTB:
Actual cost (not to exceed $250 per quarter.)
_________________
$ ___________________
_________________
$ ___________________
_________________
$ ___________________
_________________
$ ___________________
Total Cost of Quarters:
$ __________________________
Total Amount of (A) and (B) requested:
$ __________________________
Financial Institutions are responsible for maintaining supporting documentation of these expenditures for 3 years.
The above financial institution has approved this cost for submission.
Officer’s Name (please print):
Title:
Signature:
Date:
Upon completion, please send this Reimbursement Invoice to:
For Internal Use:
ACCOUNTING AND FINANCIAL RESOURCES SECTION
FRANCHISE TAX BOARD
Invoice Number: _____________________
PO BOX 2800
SACRAMENTO CA 95812-2800
Approval Signature:___________________________
If you have any questions, please send an email to FTBFIRMhelp@ftb.ca.gov
FTB 2059 PC (REV 08-2013)
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