Form Ftb 2049B – Fill Out and Use This PDF

Franchise Tax Board (FTB) will consider waiver requests from Financial Institution Data Match requirements under one of three conditions: 1) total number of open accounts held by the institution is less than 250; 2) institution does not maintain account information on a computerized record keeping system; or 3) required system modifications constitute an initial burden to institutions with complex system changes.

Your Organization

Name:__________________________________________________FEIN: ______________________________

Primary Contact: _________________________________________Email: _____________________________

Phone: __________________________Fax:___________________

Secondary Contact: _______________________________________Email: _____________________________

Phone: __________________________Fax:___________________

Street Address:	Mailing Address (if different from street address):
ATTN (optional): _________________________________	ATTN (optional): ________________________________
_________________________________	_________________________________
_________________________________	_________________________________

AUTHORIZED REPRESENTATIVE

Under penalty of perjury of the laws of the State of California, I declare that I have examined this form, including any accompanying statements, and to the best of my knowledge and belief it is true, correct and complete. Further, I declare that the financial institution I represent meets one of the three waiver qualifications listed on this form.

Name (please print): ______________________________________________Title: ______________________

Signature: ______________________________________________________Date: ______________________

FTB 2049B (REV 08­2011) SIDE 1

INSTRUCTIONS

FIDM Waiver Request Form

The intent of this form is to allow financial institutions time to prepare for participation or grow to a size of holding over 250 accounts. Once you meet these requirements, participation is mandatory, even though a waiver may have been previously granted. Complete this form to request a delay or waiver from 1 to 4 quarters of a calendar year. Include an authorized signature and fax it to 916.843.0890 or mail it to:

FIDM MAIL STOP A181

FRANCHISE TAX BOARD

PO BOX 1468

SACRAMENTO CA 95812­9807

Approval

Generally, a copy of the approved waiver is mailed or faxed to the financial institution within 45 days of the date of receipt. FTB considers waivers if you meet one of the following conditions:

1.Total number of open accounts held by your institution is less than 250.

2.Your institution does not maintain account information on a computerized system.

3.Time is needed to make system modifications.

Your Institution

Enter your institution's name exactly how it will be entered on FIDM Election Form (FTB 2049A) and your file when you begin participating.

Action

Use the chart below to determine if a full or partial calendar year waiver is needed. Specify which quarters you are requesting a waiver.

Quarter	Quarter Months	FTB Inquiry File	Methods 1 & 2
		Mail Date	Data Exchange
		(Method 2)	Due
1st Qtr	Jan, Feb, Mar	Apr 15	May 30
2nd Qtr	Apr, May, Jun	Jul 15	Aug 30
3rd Qtr	Jul, Aug, Sep	Oct 15	Nov 30
4th Qtr	Oct, Nov, Dec	Jan 15	Feb 28

Contact/Phone

Name and number of the person within your organization designated to answer questions regarding Financial Institution Data Match (FIDM).

FEIN

Federal Employer Identification Number.

Authorized Representative

Officer or executive of your organization.

Assistance

FTB operates a call site Monday through Friday to answer questions related to the Financial Institution Data Match process.

Telephone: 916.845.6304

Hours of Operation: 7 a.m. to 3:30 p.m.

Email Address: fidmhelp@ftb.ca.gov

FTB 2049B (REV 08­2011) SIDE 2