Form Ftb 4800 - Federally Tax Exempt Non-California Bond Interest And Interest-Dividend Payment Information Magnetic Media Transmittal
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1
2Federally Tax Exempt Non-California Bond Interest and
STATE OF CALIFORNIA
Interest-Dividend Payment Information
FRANCHISE TAX BOARD
PO BOX 942840
MAGNETIC MEDIA TRANSMITTAL
SACRAMENTO CA 94240-6090
Tax Year ____________Date File Submitted_________________
Please complete the following information, attach additional sheets if needed, and forward this
form(s) with the file. See reverse side for additional instructions.
Transmitter Information
FEIN:
Type of file submitted (circle one):
Name, Address, City, State, ZIP Code
Original
Replacement
Correction
Test
Payer Information
List name of payers and respective payee totals for the records reported on this file.
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
Name:
Name:
FEIN:
FEIN:
No. of Payees:
No. of Payees:
$
$
GRAND TOTALS-
:
Number of payee records reported by all payers:
Total of all payment amounts reported for all payers
Under penalties of perjury, I declare that I have examined this return, including accompanying records on magnetic media,
and to the best of my knowledge and belief, it is true, correct and complete. In the case of records without recipients’
identifying numbers I have complied with the requirements of the law by requesting such numbers from the recipients, but
did not receive them.
Signature ______________________________________
Title ________________________
Date ______________________
Media Characteristics
TAPES/CARTRIDGES
Sequence
External Label #
DISKETTES
Internal Header Labels (circle one):
1 of
Filename Used for Reporting:
2 of
BONDINT
Yes
No
3 of
Recording Mode (circle one)
Density (circle one):
Single
Double
4 of
EBCDIC
ASCII
Person to contact for media problems:
Record Length = 750, Blocksize = _____
Name _____________________________________________________________
Cartridge Compatibility (Circle one):
Telephone __________________________________
Ext. __________________
3480
3490
FTB 4800 (REV 12-2000) PAGE 3
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