Fillable Form Firm Ms A243 - Election printable pdf download

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STATE OF CALIFORNIA

FIRM MS A243

FRANCHISE TAX BOARD

PO BOX 1468

SACRAMENTO CA 95812-1468

Election

Financial institutions use this election form to participate in the Financial Institution Record Match (FIRM) program with the Franchise

Tax Board (FTB). Refer to the reverse side of this form for additional information. When completed and signed by an authorized

representative of your institution, this form serves as the official data processing document with FTB.

Institution Information

Financial Institution Routing Number:

Institution’s Name:

Federal Employer Identification Number (FEIN):

Institution’s Address:

City:

State:

ZIP Code:

Mailing Address: (if different from street address)

City:

State:

ZIP Code:

Primary Contact Name:

Telephone Number:

Fax Number:

Email:

(

)

–

(

)

–

Secondary Contact Name:

Telephone Number:

Fax Number:

Email:

(

)

–

(

)

–

Action

Exchange Method (Choose One)



Effective Date of

Method 1

All Accounts Method. The first quarter of participation, you submit a file to us of all

Election or Change

open accounts through a secured transfer application. For subsequent quarters, the

file may contain all open accounts or just updates of opened, closed, or changed

accounts. By selecting this method you are stating your financial institution does not

have the technical ability to process the data exchange, or to employ a third party data



processor to process the data exchange.

Initial election



Method 2

Matched Accounts Method. You or your authorized third party designee must retrieve a

Change election

downloadable file of a list of debtors (the Inquiry File) through a secured web internet



Add or change

file transfer (SWIFT) application. You match the Inquiry File against all open accounts

transmitter

and return a file (the Match File) of the matched accounts. The matched file is returned

through a SWIFT application.

Transmitter Information

If you use a transmitter or third party (transmitter) to exchange FIRM data with FTB, please provide the following transmitter’s contact

information. By designating a transmitter, the financial institution grants FTB permission to exchange FIRM data and communicate with

the transmitter on behalf of the financial institution.

Transmitter Name:

FEIN:

Address: ATTN: (optional)

City:

State:

ZIP Code:

Contact:

Telephone Number:

Fax Number:

Email:

(

)

–

(

)

–

Authorized Representative for Financial Institution

Name (please print):

Title:

Signature:

Date:

You and your designated associates will protect the confidentiality of any data or information supplied to the financial institution by FTB or FTB’s designated data matching

agent. Subdivision (e) of R&TC Section 19266 provides: e) A financial institution shall incur no obligation or liability to any person arising from any of the following:

(1) Furnishing information to FTB as required by this section. (2) Failing to disclose to a depositor or accountholder that the name, address, social security number or other

taxpayer identification number, or other identifying information of that delinquent tax debtor was included in the data exchange with FTB required by this section. (3) Any other

action taken in good faith to comply with the requirements of this section.

FTB 2060 PC (REV 08-2013) PAGE 1

Form Firm Ms A243 - Election

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