Form Ftb 3557 E - Application For Certificate Of Revivor
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STATE OF CALIFORNIA
EXEMPT ORGANIZATIONS UNIT MS F120
FRANCHISE TAX BOARD
PO BOX 1286
Date:
RANCHO CORDOVA CA 95741-1286
Application for Certificate of Revivor
For this tax-exempt entity, I request relief from suspension or forfeiture.
I previously submitted or I am enclosing all required payments, returns, or documents.
Entity Number: ___________________________________________________________________________
FEIN Number: ___________________________________________________________________________
Entity Name: ____________________________________________________________________________
Address:________________________________________________________________________________
Print Name:
_____________________________________
Title: ________________________________
Signature: ______________________________________
Date: ________________________________
Daytime Phone Number: ___________________________
Those who can sign this application on behalf of an entity (domestic or foreign) include:
• Any stockholder, creditor, member, general partner, or officer.
• Any person having an interest in relief from suspension or forfeiture.
Domestic entities can also have a majority of the surviving trustees or directors sign on their behalf.
Mail completed application to:
EXEMPT ORGANIZATIONS UNITS MS F120
FRANCHISE TAX BOARD
PO BOX 1286
RANCHO CORDOVA CA 95741-1286
FTB 3557 E (REV 11-2012)
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Parent category: Financial