RPVCCA_CC_SR_2015_05_05_I_CA_Franchise_Tax_Board_Exchange_Annual_Tax_DataCITYOF
MEMORANDUM
• s
PALOS VERDES
TO: HONORABLE MAYOR & CITY COUNCIL MEMBERS
FROM: KATHRYN DOWNS, ACTING DIRECTOR OF FINANCE
C
DATE: MAY 5, 2015
SUBJECT: RENEW AGREEMENT BETWEEN CITY AND THE
STATE OF CALIFORNIA FRANCHISE TAX BOARD TO
EXCHANGE ANNUAL TAX DATA
REVIEWED: DOUG WILLMORE, CITY MANAGERaAA J
RECOMMENDATION
Adopt Resolution No. 2015- ; AUTHORIZING THE CITY OF RANCHO PALOS VERDES
TO RENEW AN AGREEMENT WITH THE STATE OF CALIFORNIA FRANCHISE TAX
BOARD AUTHORIZING THE RECIPROCAL AND CONFIDENTIAL EXCHANGE OF
TAX DATA.
DISCUSSION
California Revenue and Taxation Section 19551.5 states that any city that assesses a
business tax or requires a business license needs to submit the collected tax
administration to the Franchise Tax Board at its request. This information includes
business name, address, Federal Employee Identification Number (FEIN) or Social
Security Number (SSN), ownership type and business start and end dates. Since January
2009, the FTB and participating California Cities have exchanged tax -related data through
the FTB's City Business Tax Program. Data provided by participating cities helps the FTB
identify self-employed individuals who have not filed required individual and business
entity tax returns. Data provided by the FTB can potentially aid cities in identifying
businesses that need to complete local business tax filing requirements (such as the
City's business license tax filing and payment). The intent of renewing this agreement is
for both the State and participating cities to continue benefiting by bringing in revenue
that might not be collected without the mutual exchange and analysis of data.
The proposed agreement between the FTB and the City has a term lasting from June 1,
2015 through December 31, 2017. The City agrees to provide the FTB with data annually
1
AGREEMENT RENEWAL BETWEEN CITY AND FRANCHISE TAX BOARD
May 5, 2015
Page 2 of 2
in June for 2015, 2016, and 2017. The FTB will provide the City with tax information in
December 2015 for tax year 2014, December 2016 for tax year 2015, and December
2017 for tax year 2016.
FISCAL IMPACT
There is no cost impact to the City. It is unknown how much additional business license
tax revenue would be generated as a result of this agreement.
Attachments:
Resolution No. 2015- (page 3)
Agreement between Franchise Tax Board and City - C1400220 (page 5)
2
RESOLUTION NO. 2015-
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF RANCHO PALOS
VERDES, AUTHORIZING THE CITY OF RANCHO PALOS VERDES TO
RENEW AN AGREEMENT WITH THE STATE OF CALIFORNIA
FRANCHISE TAX BOARD AUTHORIZING THE RECIPROCAL AND
CONFIDENTIAL EXCHANGE OF TAX DATA.
WHEREAS, businesses operating in the City of Rancho Palos Verdes are
required to pay all legally mandated local business forms and taxes; and,
WHEREAS, the City of Rancho Palos Verdes is required to report required tax
information to the State of California Franchise Tax Board annually; and,
WHEREAS, self-employed individuals in the State of California are required to
file appropriate individual and business entity income tax returns; and,
WHEREAS, entering into a reciprocal agreement with the State of California's
Franchise Tax Board's City Business Tax program will provide reciprocal tax information
that may identify businesses in the City of Rancho Palos Verdes that have local
business tax obligations; and,
WHEREAS, the term of the agreement between the City of Rancho Palos Verdes
and the State of California's Franchise Tax Board's City Business Tax Program will be
from June 1, 2015 to December 31, 2017;
NOW THEREFORE, THE CITY COUNCIL OF THE CITY OF RANCHO PALOS
VERDES DOES HEREBY FIND, DETERMINE AND RESOLVE AS FOLLOWS:
Section 1: The City Council of the City of Rancho Palos Verdes hereby
authorizes the City to enter into a reciprocal agreement with the State of California's
Franchise Tax Board and hereby approves said agreement, which is attached hereto as
Exhibit "A" and incorporated herein by this reference.
Section 2: The City Manager is hereby authorized to execute the agreement
on behalf of the City.
Section 3: This resolution shall take effect immediately.
PASSED, APPROVED, AND ADOPTED THIS 5T" DAY OF MAY 2015.
MAYOR
3
ATTEST:
CITY CLERK
State of California )
County of Los Angeles )ss
City of Rancho Palos Verdes )
I, CARLA MORREALE, City Clerk of the City of Rancho Palos Verdes, hereby certify
that the above Resolution No. 2015- was duly and regularly passed and adopted by
the said City Council at a regular meeting held on May 5, 2015.
CITY CLERK
CITY OF RANCHO PALOS VERDES
E,
STATE OF CALIFORNIA
STANDARD AGREEMENT
STD 213 (Rev 06/03)
AGREEMENT NUMBER
C1400220
REGISTRATION NUMBER
1. This Agreement is entered into between the State Agency and the Contractor named below:
STATE AGENCY'S NAME
Franchise Tax Board
CONTRACTOR'S NAME
City of Rancho Palos Verdes
2, The term of this
Agreement is: June 1, 2015 through December 31, 2017
3. The maximum amount $ 0.00
of this Agreement is: NON-FINANCIAL AGREEMENT
4. The parties agree to comply with the terms and conditions of the following exhibits, which are by this reference made
a part of the Agreement.
Exhibit A — Scope of Work 3 pages
Exhibit C* — General Terms and Conditions GTC610
Exhibit D - Special Terms and Conditions 3 pages
Exhibit E - City Record Layout Specifications 2 pages
Exhibit F - FTB Record Layout Specifications 1 page
Exhibit G — Confidentiality Statement 1 page
Items shown with an Asterisk (*), are hereby incorporated by reference and made part of this agreement as if attached hereto.
These documents can be viewed at http://www.dgs.ca.gov/ols/Resources/StandardContractLanpuage.asax
IN WITNESS WHEREOF, this Agreement has been executed by the parties hereto.
CONTRACTOR California Department of General
Services Use Only
CONTRACTOR'S NAME (if other than an individual, state whether a corporation, partnership, etc.)
City of Rancho Palos Verdes
BY (Authorized Signature) DATE SIGNED(Do not type)
PRINTED NAME AND TITLE OF PERSON SIGNING
ADDRESS
30940 Hawthorne Blvd, Rancho Palos Verdes, CA 90275
STATE OF CALIFORNIA
AGENCY NAME
Franchise Tax Board
BY (Authorized Signature) DATE SIGNED(Do not type)
PRINTED NAME AND TITLE OF PERSON SIGNING ® Exempt per: SCM 1 - 4.04.A.2
Michael A. Banuelos, Procurement and Contracting Officer or Designee
ADDRESS
P.O. Box 2086, Rancho Cordova, CA 95741-2086
R
City of Rancho Palos Verdes
SCOPE OF WORK
Agreement # C1400220
This Agreement is entered into by and between the Franchise Tax Board, herein referred to as
(FTB) and the City of Rancho Palos Verdes, herein after referred to as the City.
Purpose:
This Agreement provides for FTB and the City to enter into a reciprocal agreement to exchange
tax data specific to city business license information for tax administration purposes. By entering
into a reciprocal agreement, each party agrees to bear its own costs of providing the data, and
the City is precluded from obtaining reimbursement.
Both parties will abide by the legal and confidential provisions of this Agreement. Exhibits A, C,
D, E, F, and G, attached hereto and incorporated by reference herein, set forth additional terms
to which the parties agree to be bound. No Federal Tax Information will be exchanged.
Legal Authority:
California Revenue and Taxation Code (R&TC) Section 19551.1 authorizes a reciprocal
agreement for the exchange of specified tax information between a city and FTB. RUC
Section 19551.5 mandates cities to provide city business licensing and tax information to FTB
upon request.
City Responsibilities:
1. The City agrees that the information provided by FTB will be used exclusively to administer
the City's business tax program.
2. The City agrees that information obtained under this Agreement will not be reproduced,
published, sold, or released in original or in any other form for any purpose; and will only be
accessed or used by City employees whose duties are to administer the City's business tax
program.
3. The City agrees to provide FTB with tax information pursuant to Exhibit E, Format
Specifications, which shall include but not be limited to the following:
• Business or owner's name.
• Business or residence address.
• Federal employer identification number or social security number.
• Ownership type.
• North American Industry Classification Code or Standard Industry Classification Code.
• Business start and cessation dates.
• City Business Tax Number, to be assigned to the City by FTB.
4. The City agrees to extract and provide City data to FTB annually in June for each tax year
that the Agreement is in place: June 2015, 2016, and 2017. If the Agreement is executed
after June 30, 2015, the City will have 30 days after execution to provide FTB with the first
year's data.
1*1
City of Rancho Palos Verdes
F*cm.3kr_1
SCOPE OF WORK (continued)
Agreement # C1400220
5. The City agrees to submit the records to FTB electronically using FTB's Secure Web
Internet File Transfer (SWIFT) system.
6. The City agrees to submit the records to FTB in ASCII fixed -length format, .txt, per the
Format Specifications, Exhibit E.
7. The City agrees to resubmit data in the event data is initially submitted with errors. The
resubmission of data must be within 30 days of notification. If data is not submitted
accurately and timely, the City will forfeit its rights to FTB data for that year.
8. The City agrees that each City employee having access to FTB data shall sign a City
Business Tax Program Confidentiality Statement, FTB 712, (Exhibit G). The signed
statement is to be retained by the City and produced to FTB upon request.
9. The City agrees to submit to FTB a completed Safeguard Review Questionnaire prior to
receiving FTB data. The Safeguard Review Questionnaire is valid for the duration of the
Agreement.
10. The City agrees to provide a copy of the resolution, order, minutes reflecting passage of a
motion, or ordinance of the local governing body, authorizing the execution of the
Agreement.
FTB Responsibilities:
1. FTB agrees that information provided by the City will be used for tax administration and non -
tax programs that FTB administers and may be shared with other state or federal agencies
as authorized by law.
2. FTB agrees that information obtained under this Agreement will not be reproduced,
published, sold, or released in original or in any other form for any purpose, except as
provided in paragraph 1 or otherwise authorized by law.
3. FTB agrees to provide the City with data extracted from the Taxpayer Information (TI) and
Business Entities Tax System (BETS). FTB will provide the City with records for taxpayers
within the city's jurisdiction who indicate a business on their personal or business entity
income tax return. The Record Layout, Exhibit F (FTB 909A) shall include :
• Taxpayer name.
• Taxpayer address.
• Taxpayer social security number or federal employer identification number.
• Principal Business Activity code.
4. FTB agrees to match the data provided by the City using the social security number or
federal employer identification number against FTB's data with a "yes" or "no" indicator on
the Record Layout, Exhibit F (FTB 909A). The first year's data match is at the discretion of
FTB based on when the data is received from the City and processed.
7
City of Rancho Palos Verdes
[:7:1T3fIT_1
SCOPE OF WORK (continued)
Agreement # C1400220
5. FTB agrees to provide the City with an annual data extraction in December 2015 for tax year
2014, in December 2016 for tax year 2015, and in December 2017 for tax year 2016 via
SWIFT.
6. FTB agrees to register the City for a SWIFT account, allowing for the secure electronic
transmission of data.
7. FTB agrees to provide the City with a unique City Business Tax Number to be used for
reporting purposes only.
8. FTB agrees to allow the City to resubmit data within 30 days of notification, in the event data
is initially submitted with errors.
Project Coordinators:
The project coordinators during the term of this Agreement will be:
Franchise Tax Board
Felicia Hicks
City Business Tax Program Manager
Data Resources and Services Unit
P.O. Box 1468, Mailstop A181
Sacramento, CA 95812-1468
Phone: (916) 845-6304
Email: LocalGovtLiaisone-ftb.ca.gov
Return executed agreement to:
Franchise Tax Board
Ta Nita Martinez
Business Acquisitions Unit
P.O. Box 2086, Mailstop A-374
Rancho Cordova, CA 95741-2086
Phone: (916) 845-7199
Fax: (916) 843-1098
City of Rancho Palos Verdes
Kathryn Downs
Deputy Director of Finance
30940 Hawthorne Blvd.
Rancho Palos Verdes, CA 90275
Phone: (310) 544-5216
Email: kathryndCcD-rpv.com
No
City of Rancho Palos Verdes
SPECIAL TERMS AND CONDITIONS
Agreement # C1400220
1. DATA OWNERSHIP: The confidential tax information being provided to the City under this
Agreement remains the exclusive property of FTB. The City shall have the right to use and
process the disclosed information for the purposes stated in this Agreement, which right
shall be revoked and terminated immediately upon completion of this Agreement.
2. STATEMENT OF CONFIDENTIALITY: The Franchise Tax Board has tax return
information and other data in its custody, which is confidential data. Unauthorized
inspection or disclosure of state tax return information or other confidential data is a
misdemeanor (Revenue and Taxation Code Section 19542, 19542.1 and 19552).
USE OF INFORMATION: The City agrees that the information furnished or secured
pursuant to this Agreement shall be used solely for the purposes described by this
Agreement. The information obtained by FTB shall be used for tax administration and
nontax programs that FTB administers and may be shared with other state or federal
agencies as authorized by law. The City and FTB further agree that information obtained
under this Agreement will not be reproduced, published, sold, or released in original or in
any other form for any purpose other than those identified in this Agreement or as
authorized by law.
4. EMPLOYEE ACCESS TO INFORMATION: Both FTB and the City agree that the
information obtained will be kept in the strictest confidence and shall make information
available to its own employees only on a "need to know" basis. The "need to know"
standard is met by authorized employees who need information to perform their official
duties in connection with the uses of the information authorized by this Agreement. Both
parties recognize their responsibilities to protect the confidentiality of this information as
provided by law and to ensure that such information is disclosed only to those individuals
and for such purposes authorized by the Revenue and Taxation Code.
5. DISCLOSURE OF CONFIDENTIAL INFORMATION: Any unwarranted disclosure or use of
state tax return information or any willful unauthorized inspection of the return information is
an act punishable as a misdemeanor. Inspection is defined to mean any examination of
confidential information. No one other than authorized employees may access, use, view,
or manipulate the data being transmitted to the City under this Agreement. The City, in
recognizing the confidentiality of state tax return information, agrees to take all appropriate
precautions to protect the confidential information obtained pursuant to this Agreement
from unauthorized disclosure. The City will conduct oversight of its users with access to the
confidential information provided under this Agreement, and will promptly notify FTB of any
suspected violations of security or confidentiality by its users.
Each City employee who may have access to the confidential data of FTB will be required
to sign a City Business Tax Program Confidentiality Statement, FTB 712 (Exhibit G),
attesting to the fact that he/she is aware of the confidentiality of the data and the penalties
for unauthorized disclosure thereof. The signed statement(s) shall be retained by the City
and furnished to FTB upon request.
A
City of Rancho Palos Verdes
EXHIBIT D
SPECIAL TERMS AND CONDITIONS (continued)
Agreement # C1400220
6. PROTECTING CONFIDENTIAL INFORMATION/ INCIDENT REPORTING: Both agencies,
in recognizing the confidentiality of information exchanged, agree to take all appropriate
precautions to protect the confidential information obtained pursuant to this Agreement
from unauthorized disclosure. Both agencies will conduct oversight of its users with access
to the confidential information provided under this Agreement and will immediately notify
the FTB's Information Security Audit Unit (SecurityAuditMaila-ftb.ca.aov) of any
unauthorized or suspected unauthorized accesses, uses and/or disclosures (incidents). For
purposes of this section, immediately is defined as within 24 hours of the discovery of the
breach. The notification must describe the incident in detail and identify responsible
personnel (name, title, and contact information). The agency with an incident will comply
with the incident reporting requirements in accordance with Civil Code Section 1798.29 and
SAM Chapter 5300 to facilitate the required reporting to the taxpayers or state oversight
agencies.
7. INFORMATION SECURITY: Information security is defined as the preservation of the
confidentiality, integrity, availability, authenticity, and utility of information. A secure
environment is required to protect the confidential information obtained from FTB pursuant
to this Agreement. The City will store information so that it is physically secure from
unauthorized access. The records received by the City will be securely maintained and
accessible only by employees of the city business license or tax programs who are
committed to protect the data from unauthorized access, use, and disclosure.
8. CLOUD COMPUTING ENVIRONMENT: A Cloud Computing Environment cannot be used
to receive, transmit, store or process FTB's confidential data without prior approval from
FTB's Chief Security Officer.
9. DESTRUCTION OF RECORDS: All records received by the City from FTB and any
database(s) created, copies made, or files attributed to the records received will be
destroyed within three years of receipt. The records shall be destructed in a manner to be
deemed unusable or unreadable and to the extent that an individual record can no longer
be reasonably ascertained. The City will notify FTB City Business Tax Program Manager
annually in writing at LocalGovtLiaison (d-)ftb.ca.gov that proper destruction methods have
been applied. FTB will destroy City data in accordance with the Department's data retention
policies.
10. SETTLEMENT OF DISPUTES: In the event of a dispute, the City shall file a "Notice of
Dispute" with the Chief Financial Officer of the Franchise Tax Board within ten (10) days of
discovery of the problem. Within ten (10) days, the Chief Financial Officer or his/her
designee shall meet with the City and the FTB contacts for purposes of resolving the
dispute. The decision of the Chief Financial Officer shall be final.
10
City of Rancho Palos Verdes
EXHIBIT D
SPECIAL TERMS AND CONDITIONS (continued)
Agreement # C1400220
11. SAFEGUARD REVIEW QUESTIONNAIRE AND REVIEW: Prior to sending data to the City,
FTB requires the City to submit a Safeguard Review Questionnaire certifying the protection
and confidentiality of FTB data. The FTB retains the right to conduct an on-site safeguard
review of the City. The City will be provided a minimum of seven (7) days' notice prior to an
on-site safeguard review being conducted by the FTB Disclosure Office. The on-site
safeguard review will examine the adequacy of information security controls established by
the City in compliance with the confidentiality requirements pursuant to this Agreement.
The City will take appropriate disciplinary actions against any user determined to have
violated security or confidentiality requirements.
12. LIMITED WARRANTY: Neither party warrants or represents the accuracy or content of the
material available through this Agreement, and each expressly disclaims any express or
implied warranty, including any implied warranty of fitness for a specific purpose.
13. CANCELLATION: Either party may terminate this Agreement, in writing for any reason,
upon thirty (30) days' prior written notice. This Agreement may be terminated by either
party in the event of any breach of the terms of this Agreement. Both parties agree that in
the event of a breach of the terms of this Agreement, it shall destroy all records and any
databases created, copies made, or files attributed to the records received. The records
shall be destructed in a manner to be deemed unusable or unreadable and to the extent
that an individual record can no longer be reasonably ascertained, upon destruction.
14. NO THIRD PARTY LIABILITY: Nothing contained in or related to this Agreement shall
create any contractual relationship between either of the Parties and any other party,
except between FTB and the City; and no other party shall relieve the City or FTB of its
responsibilities and obligations hereunder. Each of the parties agrees to be fully
responsible for the acts and omissions of its third party contractors and agents, and of
persons either directly or indirectly employed by the party. Neither of the parties shall have
any obligation to pay, or to see to the payment of, any monies to any party or persons
either directly or indirectly employed by the other.
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City of Rancho Palos Verdes
Agreement # C1400220
EXHIBIT E
CITY RECORD FORMAT SPECIFICATIONS (FTB 909)
Data Element Name Start End Field Usage Description
Pos. Pos. Size
SOCIAL SECURITY NUMBER
(SSN)
FEDERAL EMPLOYER
ID NUMBER (FEIN)
OWNERSHIP TYPE
1 9 9
10 18 9
19 19 1
OWNER'S LAST NAME
20
34
15
OWNER'S FIRST NAME
35
45
11
OWNER'S MIDDLE INITIAL
46
46
1
BUSINESS NAME
47
86
40
BUSINESS ADDRESS
87
126
40
NUMBER AND STREET
T = Trust
L = Limited Liability Company
CITY
127
166
40
STATE
167
168
2
ZIP CODE
169
177
9
BUSINESS START DATE
BUSINESS CEASE DATE
CITY BUSINESS TAX
NUMBER
178
185 8
186
193 8
194
196 3
AN
Must be present unless FEIN is
provided. Fill unused field with
zeros.
AN
Must be present unless SSN is
provided. Fill unused field with
zeros.
AN
Must be present:
S = Sole Proprietorship
P = Partnership
C = Corporation
T = Trust
L = Limited Liability Company
AN
Must be present if Ownership Type
in position 19 = S.
AN
Must be present if Ownership Type
in position 19 = S.
AN
May be left blank.
AN
Enter if business is operating under
a fictitious name (Doing Business
As (DBA)).
AN
Address of the business location or
the residence of the owner if sole
proprietorship.
A
Must be present.
A
Enter standard state abbreviation.
AN
Enter the five- or nine -digit ZIP
Code assigned by the U.S. Postal
Service. If only the first five -digits
are known, left -justify information
and fill the unused fields with zeros.
N
Enter the eight -digit date
(MMDDYYYY). Zero fill if not
known.
N
Enter the eight -digit date
(MMDDYYYY) if out of
business. Zero fill if unknown or still
in business.
N
Enter three -digit number assigned
by FTB.
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City of Rancho Palos Verdes
Agreement # C1400220
NORTH AMERICAN 197 202 6
N Enter the two- to six -digit NAICS
INDUSTRY CLASSIFICATION
code. Left justify. (example 99 will
SYSTEM (NAICS)
be 9900). Fill unused fields with
zeros.
STANDARD INDUSTRIAL 203 206 4
N Enter the 2-4 digit SIC code. Left
CLASSIFICATION (SIC)
justify (example 99 will be 9900).
Fill unused fields with zeros.
TOTAL RECORD LENGTH 206
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City of Rancho Palos Verdes
Agreement # C1400220
EXHIBIT F
FRANCHISE TAX BOARD RECORD LAYOUT SPECIFICATIONS (FTB 909A)
Field Name
Length
Start
Description
Pos.
ENTITY TYPE
1
1
"P" — personal income tax record;
"B" — business entity tax record.
SSN or FEIN
9
2
For "P" records, primary taxpayer's social
security number; For "B" records, federal
employer identification number.
LAST NAME
40
11
For "P" records, the primary taxpayer's last
name; For "B" records, business name.
FIRST NAME
11
51
For "P" records ONLY.
MIDDLE INITIAL
1
62
For "P" records ONLY.
SPOUSE SSN
9
63
For "P" records filed with a joint return.
SPOUSE LAST NAME
17
72
For "P" records filed with a joint return.
SPOUSE FIRST NAME
11
89
For "P" records filed with a joint return.
SPOUSE MIDDLE INITIAL
1
100
For "P" records filed with a joint return.
PBA CODE
6
101
Principal Business Activity code.
ADDRESS NUMBER
10
107
PRE -DIRECTIONAL DIRECTOR
2
117
Postal Service term (i.e., N, S, E, W, NE,
NW, SE, SW).
STREET NAME
28
119
STREET SUFFIX
4
147
e.g., ST, WAY, HWY, BLVD, etc.
POST -DIRECTIONAL INDICATOR
2
151
Postal Service term (i.e., N, S, E, W, NE,
NW, SE, SW).
STREET SUFFIX 2
4
153
APARTMENT/SUITE NUMBER
10
157
e.g., APT, UNIT, FL, etc.
CITY
13
167
STATE
2
180
Standard state abbreviation.
ZIP CODE
5
182
The five -digit ZIP Code assigned by the U.S.
Postal Service.
ZIP CODE SUFFIX
4
187
Provided if known.
CBT MATCH
1
191
"N" — No match per CBT data.
"Y" — Yes: CBT matched to state tax return
filed.
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City of Rancho Palos Verdes
EXHIBIT G
CONFIDENTIALITY STATEMENT (FTB 712)
Agreement # C1400220
State of California Franchise Tax Board
Confidential tax return information is protected from disclosure by law, regulation, and policy.
Information security is strictly enforced. Violators may be subject to disciplinary, civil, and/or
criminal action. Protecting confidential tax return information is in the best interest of the city and
state.
As a city employee, you are required to protect all information of or received from the Franchise
Tax Board (FTB). To protect confidential tax data, you must:
• Access or modify tax data solely to perform official duties.
• Never access or inspect tax data for curiosity or personal reasons.
• Never show or discuss confidential tax data with anyone who does not have a
need to know.
• Never remove confidential tax data from your worksite without authorization.
• Place confidential information in approved locations only.
Unauthorized inspection, access, use, or disclosure of confidential tax data is a crime under
state laws, including but not limited to, California Revenue and Taxation Code Sections 19542,
19542.1 and 19552 and Penal Code Section 502. Unauthorized access, inspection, use, or
disclosure may result in either or both of the following:
• State criminal action
• State and/or taxpayer civil action
I certify that I have read the confidentiality statement printed above. I further certify and
understand that unauthorized access, inspection, use, or disclosure of confidential
information may be punishable as a crime and may result in disciplinary and/or civil
action against me.
Name
Signature Date
15