BOE-129-EFT (3-07)
STATE OF CALIFORNIA
EFT TRANSMISSION DECLARATION
BOARD OF EQUALIZATION
INSTRUCTIONS: Please complete the entire form and return it to the Board of Equalization (Board) office that provided this form to you. Otherwise, you may mail the completed form to your local Board office listed in the telephone directory under State Government, or as listed on our website at www.boe.ca.gov. Upon receipt of the completed form, the Board will review it and you will be notified by mail of the decision.
NAME OF TAXPAYER/FEEPAYER
ACCOUNT NUMBER
REPORTING PERIOD
I,
print name
, state that at approximately
time
circle one
a.m./p.m. on the
date
day of
month and year
I initiated an Electronic Funds Transfer to the State Board of Equalization as follows: Internet Method Touch Tone Telephone Voice Operator Payment amount : Debit date selected (if any): Reference Number Received:
Explanation:
CERTIFICATION
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
SIGNATURE TITLE DATE
PRINTED NAME
TELEPHONE NUMBER
(
)