FTB 8453 (PMT) 2021For Privacy Notice, get FTB 1131 EN-SP.
TAXABLE YEAR
2021
California Payment for Automatic Extension
and Estimate Payment Authorization for Individuals
FORM
8453 (PMT)
Part I Extension Payment Information for Taxable Year 2021 (Pay by 4/18/2022)
1 Electronic Funds Withdrawal (EFW) Amount
2 Withdrawal Date (mm/dd/yyyy)
Part II Scheduled Estimated Tax Payments for Taxable Year 2022 These are NOT installments of the current amount you owe.
First Payment 4/18/2022 Second Payment 6/15/2022 Third Payment 9/15/2022 Fourth Payment 1/17/2023
3 Amount
4 Withdrawal Date
Part III Banking Information for Electronic Funds Withdrawals from Parts I and II
5 Routing number
6 Account number
7 Type of account:
□
Checking
□
Savings
Payment Authorization
I authorize an EFW on the date indicated on line 2 for the amount stated on line 1, plus EFWs for the estimated payments to be made on
the dates indicated on line 4, for each amount stated on line 3, corresponding to the estimated payment date. The above EFWs are to be
made from the bank indicated on lines 5, 6, and 7. This authorization will remain in effect unless I contact the Franchise Tax Board (FTB)
to cancel the request. I request that the payment(s) above be deducted from the bank account on the date specified above. If this date
falls on a Saturday, Sunday, or holiday, the transfer is authorized for the next business day. If the FTB cannot deduct the payment from
the account because of insufficient funds or because the bank account is closed, the FTB may charge a dishonored payment penalty.
I will be responsible for any overdraft fees charged by the bank. Under penalties of perjury under the laws of the State of California, I
declare that I have completed this payment authorization to the best of my knowledge and belief; it is true, correct, and complete.
DO NOT MAIL THIS FORM TO THE FTB
Your name Your SSN or ITIN
Spouse’s/RDP’s name Spouse’s/RDP’s SSN or ITIN
Sign
Here
Sign
Here
Your signature ▶
Spouse’s/RDP’s
signature
▶
Date
Date
KEEP THIS FORM FOR YOUR RECORDS – DO NOT MAIL TO THE FTB
Date Accepted
Declaration of Electronic Return Originator (ERO) and Paid Preparer.
Under penalties of perjury, I declare that I have reviewed the entries on form FTB 8453 (PMT) and they are complete and correct to the
best of my knowledge. (If I am only an intermediate service provider, I declare that form FTB 8453 (PMT) accurately reflects the data
on the EFW request.) I have obtained the taxpayer's signature on form FTB 8453 (PMT) before transmitting the EFW to the FTB. I have
provided the taxpayer with a copy of all forms and information that I will file with the FTB and I have followed all other requirements
described in FTB Pub. 1345, 2021 Handbook for Authorized e-file Providers. I will keep form FTB 8453 (PMT) for the statute of limitations
period, and I will make a copy available to FTB upon request.
ERO’s
signature
Date Check if
also paid
preparer
◽
Check
if self-
employed
◽
ERO’s PTIN
Paid
preparer’s
signature
Date Check
if self-
employed
◽
Paid preparer’s PTIN
Firm’s name (or yours
if self-employed)
and address
▶
Firm's FEIN
ZIP code
