California Form 3555 – Fill Out and Use This PDF

Request for Tax Clearance							CALIFORNIA FORM
					3 5 5 5
Certificate — Corporations
Corporation name					California corporation number
Current address		Phone number			Federal employer identification number
		(	)
Date business commenced	Date business ceased or will			Latest income period for which a		Date filed:
in California:	cease in California:			California tax return has been filed:

We will issue a tax clearance certificate when all taxes have been paid or secured. All returns remain subject to audit until expiration of the normal statutes of limitation.

Please indicate the status of ANY IRS activity:

Has the IRS redetermined the corporation’s income tax	Is the IRS or the FTB currently examining the corporation
liability for any prior years that you have not previously	or has it notified the corporation of a pending examination?
reported to us? ❏ Yes ❏ No	❏ Yes ❏ No If yes, indicate the years involved:
If yes, send us a copy of the Revenue Agent’s Report.	Current examination:	__________________________
	Pending examination:	__________________________

Complete pages 2 and 3 of this form for an individual or other entity assumption of tax liability. Complete page 4 for a corporation, limited liability company, or limited liability partnership assumption of tax liability.

If we are to issue the tax clearance certificate on a taxes paid basis, please check this box and provide a copy of your final tax return. ❏

Supplemental Information. Please furnish the following information if another corporation will continue to conduct the business in California after the merger of the original corporation.

Federal employer identification number

If we are to mail the tax clearance certificate to somewhere other than the corporation listed above, please complete the following: (We will send a copy of the tax clearance certificate to the Secretary of State.)

Name

Address

Phone number (

)

Mail completed form to: DOCUMENT FILING SUPPORT UNIT

SECRETARY OF STATE – BUSINESS FILINGS 1500 11TH STREET

SACRAMENTO CA 95814

For more information concerning this form, telephone the Franchise Tax Board at (916) 845-4124.

Assistance for persons with disabilities: We comply with the Americans with Disabilities Act. Persons with hearing or

speech impairments, call: from voice phone (800) 735-2922, or from TTY/TDD (800) 822-6268.

FTB 3555 C1 (REV 09-2001) PAGE 1

Please complete Section A or B below.

A. INDIVIDUAL ASSUMPTION OF TAX LIABILITY

I unconditionally agree to file or cause to be filed with the Franchise Tax Board, under the provisions of the Bank and Corporation Tax Law, all tax returns and data required and to pay in full all accrued or accruing tax liabilities, penalties, interest, and fees due from the above named corporation at the effective date of dissolution or surrender.

My net worth (assets minus liabilities) is not less than: $ _____________________ .

(We require a detailed financial statement [PAGE 3].)

Name of individual assumer (print)		Social security number
Address
		Phone number (	)
Date	Signature

B. TRUST ASSUMPTION OF TAX LIABILITY

This trust unconditionally agrees to file or cause to be filed with the Franchise Tax Board, under the provisions of the Bank and Corporation Tax Law, all tax returns and data required and to pay in full all accrued or accruing tax liabilities, penalties, interest, and fees due from the above named corporation at the effective date of dissolution or surrender:

(We require a detailed financial statement [PAGE 3].)

Address

Phone number (

)

Trustee’s signature

FOR PRIVACY ACT NOTICE, SEE FORM FTB 1131.

FTB 3555 C1 (REV 09-2001) PAGE 2

FINANCIAL STATEMENT FOR INDIVIDUAL OR OTHER ENTITY

Corporation name	Corporation number

Statement of Assets and Liabilities

Item		Present	Liabilities	Equity in
		value (A)	balance due (B)	asset
Cash
Bank accounts
Stocks and bonds
Cash or loan value of insurance
Household furniture
Real property
Vehicles
Other assets (describe)
Federal taxes outstanding
Loans
Other (include judgements)
Net assets
(Total column A less total column B)				$
General Information (Please attach additional schedules if necessary.)
Net annual income	Source (name of business or employer)

Banks and savings and loan accounts (names and addresses)

Description and license number of each vehicle

Stocks and bonds (name of company, number of shares, etc.)

Real property (brief descriptions and locations)

I certify that the information above is correct to the best of my knowledge.

Assumer’s name (print) _____________________________________________________________________________________________________

Assumer’s address	____________________________________________________________ Phone number (	)	_______________________
Assumer’s signature	__________________________________________________________________________	Date	_______________________

FTB 3555 C1 (REV 09-2001) PAGE 3

CORPORATION, LIMITED LIABILITY COMPANY, OR LIMITED LIABILITY PARTNERSHIP ASSUMPTION OF TAX LIABILITY

The Assumption of Tax Liability

of (1) __________________________________________________________ )

	)
A corporation	) ________________________
	)	California Corporation number, Secretary of
		State file number, or federal employer
by (2) _________________________________________________________ )		identification number
	)
A corporation, limited liability company, or limited liability partnership	) ________________________
		California Corporation number, Secretary of
		State file number, or federal employer
		identification number

(Name of assumer) __________________________________________________ unconditionally

agrees to file with the Franchise Tax Board all tax returns and data required and pay in full all tax liabilities, penalties, interest and fees of (1) _________________________________________

_________________________________________________________________________________; at the

effective date of dissolution or surrender of the corporation.

	(2) _________________________________________
	Exact corporation, limited liability company, or limited liability partnership name
_______________________________________	_________________________________________
Printed name and title of officer/manager/partner/member	Signature and title of officer/manager/partner/member

State of _______________________________

County of _____________________________

On ________________________________________ before me, the undersigned, a notary public in and for

said state, personally appeared _______________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the entity upon behalf of which the person(s) acted, executed the instrument.

WITNESS my hand and official seal.

Signature ________________________________________________________

Name __________________________________________________________

(typed or printed)

Note: LLC, LLP, and corporation assumers must provide a financial statement.

FTB 3555 C1 (REV 09-2001) PAGE 4