Form 4107 Mandatory E-Pay Election to Discontinue or Waiver Request - California

Form 4107 is a California Franchise Tax Board form also known as the "Mandatory E-pay Election To Discontinue Or Waiver Request". The latest edition of the form was released in December 1, 2013 and is available for digital filing.

Download an up-to-date fillable Form 4107 in PDF-format down below or look it up on the California Franchise Tax Board Forms website.

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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)
m
I 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.
m
I 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)
m
I 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).
m
Mandatory 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 Affidavit of Permanent Physical or Mental Impairment (line 3) is before the
penalty assessment.
• The statute of limitations for filing 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
410700121371
FTB 4107 (REV 12-2013) C2 PAGE 1
Print and Reset Form
Reset Form
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)
m
I 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.
m
I 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)
m
I 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).
m
Mandatory 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 Affidavit of Permanent Physical or Mental Impairment (line 3) is before the
penalty assessment.
• The statute of limitations for filing 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
410700121371
FTB 4107 (REV 12-2013) C2 PAGE 1
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
Medical License Number:
Physician’s Name:
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
m
m
a computer?
Yes
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
410700121373
FTB 4107 (REV 12-2013) C2 PAGE 3

Download Form 4107 Mandatory E-Pay Election to Discontinue or Waiver Request - California

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