Form Ftb 4925 C2 - Application For Voluntary Disclosure
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5State of California
Franchise Tax Board
Application for Voluntary Disclosure
Part 1 – Representative or Applicant Information
Representative’s or Applicant’s Name
Telephone Number
Representative’s or Applicant’s Street Address
FAX Number
City
State
ZIP Code
Part 2 – Information Required for Primary Applicant Entity
1. Is the applicant entity organized and existing under the laws of the state of California? . . . . . . . . . . .
Yes
No
2. Is the applicant entity qualified or registered with the California Secretary of State? . . . . . . . . . . . . . .
Yes
No
3. Does the applicant entity maintain and staff a permanent facility in California? . . . . . . . . . . . . . . . . . .
Yes
No
4. Has the applicant entity or a predecessor entity ever filed a tax return with FTB? . . . . . . . . . . . . . . . .
Yes
No
5. Has the applicant entity ever been the subject of an inquiry by FTB with respect to potential
liability for income/franchise taxes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
6. If the applicant entity is a trust, have trust administration activities ever been performed
in California? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
7. If the applicant entity is a trust, are there any California resident beneficiaries
(excluding contingent beneficiaries) of the trust? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If you answered Yes to any of the above questions, STOP . The applicant entity does not qualify for the VDP . If you
answered No to all seven questions, provide the following information:
1. Tax years to be covered by the agreement: ___________________________________________________________
2. Type of entity applying for the Voluntary Disclosure Program (VDP):
C corporation
S corporation
Limited liability company
Trust
3. State the basis you had for believing that you were immune from California tax: _______________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
4. Did you rely upon the advice of a person in a fiduciary position or other competent advisor that you were immune from
California tax? If so, describe the nature of the advice you received, status and competency of the person giving the
advice, and the approximate date that your received the advice: ___________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
5. Provide other information attesting to your good faith and lack of willful neglect in failing to file California tax returns
and pay California taxes: __________________________________________________________________________
______________________________________________________________________________________________
FTB 4925 c2 (REV 12-2015) PAGE 1
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Parent category: Financial