FTB Form 4107 PDF Details

The FTB 4107 form, provided by the State of California Franchise Tax Board, plays a crucial role for taxpayers who are mandated to make electronic payments but seek to discontinue or request a waiver from this requirement. This necessity arises under specific conditions outlined by the California Revenue and Taxation Code Section 19011.5, effective January 1, 2009, stipulating electronic remittance of tax payments for individuals whose estimated tax or extension payment exceeds $20,000 or if their tax liability surpasses $80,000 for any taxable year after 2009. Failure to comply attracts penalties, though the form allows for discontinuation or waiver requests under certain criteria, including not meeting the financial thresholds in the previous year or having payments that do not reflect the actual tax liability. Additionally, individuals with permanent physical or mental impairments can request a permanent waiver, contingent on an accompanying physician affidavit detailing the impairment and its impact on the ability to use a computer. This comprehensive document not only outlines the procedure for filing a request but also emphasizes the necessity of maintaining compliance with electronic payment mandates while providing avenues for exemptions based on individual circumstances.

QuestionAnswer
Form NameFTB Form 4107
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesRTC, PC, ftb form 4107, CALIFORNIA

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STATE OF CALIFORNIA

FRANCHISE TAX BOARD

PO BOX 942840

SACRAMENTO฀CA฀฀94240-0040

Mandatory e-Pay Election to Discontinue or Waiver Request

Name:

Social Security Number:

 

 

 

Spouse/Registered Domestic Partner (RDP) Name:

Social Security Number:

 

 

 

Address:

 

 

 

 

 

City:

State:

ZIP Code:

 

 

 

PART 1 – Discontinue Mandatory e-Pay Election or Temporary Waiver Request (check one box)

mI elect to discontinue making electronic payments because I have not made an estimated tax or extension payment in excess of $20,000 during the previous taxable year or my tax liability did not exceed $80,000 for the previous taxable year.

mI request a waiver from the mandatory e-pay requirement because the amounts paid were not representative of my tax liability, as explained below:

PART 2 – Permanent Physical or Mental Impairment – Permanent Waiver Request (refer to PAGE 2)

mI request a mandatory e-pay waiver because of a permanent physical or mental impairment. You must attach a completed and signed physician affidavit to this form (see PAGE 3).

mMandatory e-Pay Penalty Waiver. Check this box if you want us to review your account for possible waiver of a mandatory e-pay penalty we previously assessed. All the following must apply:

•฀ You฀received฀a฀mandatory฀e-pay฀penalty฀for฀payments฀you฀made฀before we approved your permanent physical or

mental impairment request.

•฀ The฀date฀on฀the฀Physician฀Afidavit฀of฀Permanent฀Physical฀or฀Mental฀Impairment฀(line฀3)฀is฀before the

penalty assessment.

•฀ The฀statute฀of฀limitations฀for฀iling฀a฀claim฀for฀refund฀of฀the฀penalty฀is฀still฀open.

PART 3 – Signature (if the waiver request is for a joint return, both spouses/RDPs must sign this form)

_____________________________________

____________________

_______________________________

Taxpayer Signature

Date

Telephone Number

_____________________________________

____________________

_______________________________

Spouse/RDP Signature

Date

Telephone Number

FTB 4107 PC C2 (REV 09-2012) PAGE 1

General Instructions

Beginning on or after January 1, 2009, California Revenue and Taxation Code (R&TC) Section 19011.5 requires taxpayers to remit all tax payments electronically, regardless of the taxable year for which the payment applies, once any of the following conditions are met:

•฀ Your฀estimated฀tax฀or฀extension฀payment฀exceeds฀

$20,000

•฀ Your฀tax฀liability฀exceeds฀$80,000฀for฀any฀taxable฀year฀

beginning on or after January 1, 2009.

Failure to comply with this requirement will result in a penalty. For more information, go to ftb.ca.gov and search for mandatory e-pay.

R&TC Section 19011.5 provides that any taxpayer who is required to pay electronically may request a waiver of that requirement (see below for waiver criteria). To request a waiver, mail or fax this completed form as indicated on this page. You must pay electronically until we notify you we approved your waiver request.

When to Use this Form

Submit FTB 4107 PC, Mandatory e-Pay Election to

Discontinue or Waiver Request, immediately after receiving฀FTB฀4106฀PC฀or฀FTB฀4106฀MEO,฀Mandatory

e-Pay Program Participation Notice.

Discontinue Mandatory e-Pay Election or Temporary Waiver Request

You can request a waiver from mandatory e-pay if one or more of the following is true:

•฀ You฀have฀not฀made฀an฀estimated฀tax฀or฀extension฀ payment in excess of $20,000 during the previous taxable year or your tax liability reported for the previous taxable year did not exceed $80,000.

•฀ The฀amount฀you฀paid฀is฀not฀representative฀of฀your฀tax฀

liability.

Check the applicable box in Part 1 indicating your request. We will review your waiver request and notify you in writing of our decision.

If we grant a waiver and you subsequently meet the mandatory e-pay requirements, you must resume making electronic payments.

Permanent Physical or Mental Impairment – Permanent Waiver Request

You may request a permanent waiver if you have a permanent physical or mental impairment that prevents you from using a computer.

Joint returns - If only one spouse/RDP qualifies as permanently physically or mentally impaired, the permanent waiver only applies for the permanently physically or mentally impaired spouse/RDP.

If only one spouse/RDP obtains a permanent waiver, the other spouse must pay any joint liability by mandatory e-pay.

If both spouses/RDPs qualify as permanently physically or mentally impaired, then each spouse/RDP must complete a separate form FTB 4107 PC, Mandatory e-Pay Election to Discontinue or Waiver Request.

Physician Affidavit Required

On PAGE 3, you must provide a written statement from a qualified physician that includes:

1.The name and a description of your permanent physical or mental impairment.

2.The physician’s medical opinion that the permanent impairment prevents you from using a computer.

3.The date the patient became permanently mentally or physically impaired.

We will not approve your waiver request, if the Physician Afidavit฀of฀Permanent฀Physical฀or฀Mental฀Impairment฀is฀

incomplete or not attached to FTB 4107 PC, Mandatory e-Pay Election to Discontinue or Waiver Request.

Mail Your Request to:

STATE OF CALIFORNIA

FRANCHISE TAX BOARD

PO BOX 942840

SACRAMENTO฀CA฀94240-0040

Or fax to 916.843.0468

Internet and Telephone Assistance

Website:

ftb.ca.gov

Telephone:

800.852.5711 from within the United States

 

916.845.6500 from outside the United States

TTY/TDD:

800.822.6268 for persons with hearing or

 

speech impairments

Get FTB 1131, Franchise Tax Board Privacy Notice,

at ftb.ca.gov or call us at 800.338.0505. If outside the United States, call 916.845.6500.

FTB 4107 PC C2 (REV 09-2012) PAGE 2

Physician Affidavit of Permanent Physical or Mental Impairment

Patient/Taxpayer – Your physician must complete this affidavit of your permanent physical or mental impairment. Send in the original affidavit signed by your physician. Keep a copy for your records.

Physician – Complete and sign the following:

Patient Information

Name:

Social Security Number:

 

 

 

Address (number, street, room, or suite number):

 

 

 

 

 

City:

State:

ZIP Code:

 

 

 

Physician Affidavit of Permanent Physical or Mental Impairment

Physician’s Name:

Medical฀License฀Number:

 

 

 

Physician’s Business Address (number, street, room, or suite number):

 

 

 

 

 

City:

State:

ZIP Code:

 

 

 

1.Please provide a description of the patient’s permanent physical or mental impairment. (If you need additional space, attach a separate piece of paper.)

2.In your medical opinion, does the permanent impairment prevent the patient from using

a computer?

m Yes

m No

 

 

 

3. To the best of your knowledge, when did the patient become permanently mentally or physically

 

 

impaired and become unable to use a computer?

____ /____ /_____

Signature

The patient named above is/was under my care. I completed the above information and declare this statement to be true and correct to the best of my knowledge and belief under penalty of perjury.

_____________________________________________________________

______________________________

Physician’s Signature

Date

FTB 4107 PC C2 (REV 09-2012) PAGE 3

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