4107: Mandatory e-Pay Election to Discontinue or Waiver Request (Revision 2022-12)

California · FTB · Used for tax years 2024, 2025, 2026

California Form FTB 4107 PC requests a waiver of the mandatory electronic payment requirement and records your reason for the request. It includes a physician affidavit for permanent impairment waiver requests. It is not used to request relief from a mandatory e-pay penalty.

Who files this form

FTB 4107 PC is for taxpayers who must pay electronically and want to request a waiver. You may request a waiver if at least one of these exceptions applies:

  • For the previous taxable year, you made no estimated tax or extension payment over $20,000, and your tax liability did not exceed $80,000. The previous year is measured from the date you sign the form.
  • The tax liability or payments that triggered your mandatory e-pay requirement do not represent your future payments or tax liability.
  • You are requesting a permanent waiver because of a permanent physical or mental impairment that prevents you from using a computer. A completed and signed physician affidavit is required.

What you'll need

Have the following ready:

  • Your name, SSN or ITIN, and mailing address.
  • If you file jointly, your spouse’s or registered domestic partner’s (RDP’s) name and SSN or ITIN.
  • An explanation of your waiver reason, if applicable, with extra sheets if needed.
  • The required signatures and dates.

For a permanent impairment waiver, have your physician complete, sign, and date the Physician Affidavit of Permanent Physical or Mental Impairment. Send the original signed affidavit and keep a copy for your records. The affidavit asks for patient information, physician information and medical license number, a description of the impairment, and whether and when it prevented computer use.

If you file jointly, your spouse/RDP must submit their own FTB 4107 PC and their own physician affidavit to receive a permanent waiver.

How to file

  1. Complete your personal information. If you file jointly, include information for both you and your spouse/RDP.
  2. Select the waiver reason that best fits your situation and provide an explanation, if applicable.
  3. Sign and date the form. For joint filers, both spouses/RDPs must sign, or each taxpayer’s power of attorney on file with the Franchise Tax Board must sign for them.
  4. Attach any required documents. For a permanent waiver, include the original physician affidavit, completed, signed, and dated by your physician.
  5. Mail the request to:

STATE OF CALIFORNIA

FRANCHISE TAX BOARD

PO BOX 942840

SACRAMENTO CA 94240-0040

Continue paying electronically until the Franchise Tax Board notifies you in writing that your waiver is approved.

Common mistakes

  • Using this form to request penalty relief. FTB 4107 PC is only for a waiver of the mandatory e-pay requirement. To request abatement of a Mandatory e-Pay Penalty, use FTB 2917, Reasonable Cause; Individual and Fiduciary Claim for Refund.
  • Stopping electronic payments before approval. You must keep paying electronically until you receive written approval. Payments made by other means result in a penalty of 1% of the amount paid unless you show reasonable cause and not willful neglect.
  • Leaving out joint-filer information or signatures. Include your spouse’s/RDP’s information and SSN or ITIN. Both must sign, or each taxpayer’s power of attorney on file must sign for them.
  • Submitting an incomplete or missing physician affidavit. The Franchise Tax Board will not approve a permanent impairment waiver without a completed and signed affidavit. Send the original signed by your physician and keep a copy.
  • Assuming one permanent waiver request covers both joint filers. Each spouse/RDP needs their own FTB 4107 PC and physician affidavit to be permanently waived.

Questions people ask

Can I stop paying electronically once I mail my request?

No. Continue paying electronically until the Franchise Tax Board sends written approval of your waiver.

Do I need to meet both dollar limits for the previous-year exception?

Yes. You must have made no estimated tax or extension payment over $20,000, and your tax liability must not have exceeded $80,000 for the previous taxable year. The form measures the previous year from the date you sign.

What if my past payments do not reflect what I expect to pay in the future?

You may request a waiver if the tax liability or payments that caused you to meet the mandatory e-pay requirement are not representative of your future payments or tax liability.

What is required for a permanent impairment waiver?

Attach a completed, signed, and dated physician affidavit documenting the permanent physical or mental impairment and whether it prevents computer use. Send the original signed affidavit and keep a copy. A joint-filing spouse/RDP needs a separate form and affidavit to receive their own permanent waiver.

Can this form remove a Mandatory e-Pay Penalty?

No. To request penalty abatement, use FTB 2917, Reasonable Cause; Individual and Fiduciary Claim for Refund. Go to ftb.ca.gov/Forms and search for 2917.

Official sources

All versions of 4107