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2017 Instructions for Form FTB 3504

Enrolled Tribal Member Certification

General Information

The instructions provided with California tax forms are a summary of California tax law and are only intended to aid taxpayers in preparing their state income tax returns. We include information that is most useful to the greatest number of taxpayers in the limited space available. It is not possible to include all requirements of the California Revenue and Taxation Code in the instructions. Taxpayers should not consider the instructions as authoritative law.

Generally, California taxes the entire income of California residents, and the California source income of nonresidents. However, if you meet certain requirements, your income is exempt from California tax.

For your income to be exempt from California tax, you must meet all of the following requirements:

  • You must be an enrolled member of a federally recognized California Indian tribe.
    • Go to and search for federally recognized tribes.
  • You must live in your tribe’s Indian country, which includes:
    • Reservations.
    • Dependent Indian communities.
    • Indian trust allotments.
  • You must earn or receive reservation source income from the same Indian country in which you live and are an enrolled tribal member.

For more information about Native American taxation, go to and search for Native American or call the Tribal Hotline at 916-845-2790.

A. Purpose

Use form FTB 3504, Enrolled Tribal Member Certification, to declare you reside within your tribe’s Indian country and you meet the tribal income exemption requirements. This form is optional.

B. Who Can File

Taxpayers, who are enrolled members of a federally recognized California Indian tribe earning or receiving reservation source income from the same Indian country in which they live, may file form FTB 3504.

File form FTB 3504 with your California Form 540, California Income Tax Return, or 540NR, California Nonresident or Part‑Year Resident Income Tax Return, if you meet the exemption requirements and also have income from other non-reservation sources. Follow the instructions for Schedule CA (540), California Adjustments – Residents, and Schedule CA (540NR) – California Adjustments – Nonresidents and Part-Year Residents, line 7 and line 21f to make income adjustments.

If you meet the exemption requirements and do not have any other income from non-reservation sources, you must complete the entire form FTB 3504, including the signature area at the bottom, and file form FTB 3504 as an information return at the address shown in General Information D, Where to File.

C. When to File

File form FTB 3504 for each tax year that you meet the exemption requirements. The 2017 form should be filed the following year between January 1, 2018 and October 15, 2018.

D. Where to File

If you are required to file Form 540 or Form 540NR, attach form FTB 3504 to the tax return and file using the address for that tax return.

If you have no other California filing requirement, sign and mail form FTB 3504 to:

PO BOX 1998

Specific Line Instructions

Using black or blue ink, print your name, your social security number, and street address in the spaces provided at the top of the form. Enter the complete physical address where you resided during the tax year in the spaces provided. A post office box is not acceptable. If you do not enter your full name, SSN, and signature, along with complete residency and enrollment verification in Part II, your certification will not be accepted.

Part I – Tribal Information

Line 1 – Enter the name of the Indian tribe you are an enrolled member of and your tribal enrollment number provided by your tribal government.

Line 2 – Enter the name(s) of the reservation(s) on which you resided during the tax year and dates of residency in the boxes provided.

Part II – Residency and Enrollment Verification

Line 3 – Enter the name and title of the tribal designee authorized by your tribal government. The designee must sign, print, and date form FTB 3504. If this information is not completed, your form FTB 3504 will not be accepted. Consult with your tribal government to identify the designee with signing authority.

Part III – Income Exemption Information

Line 4 – Exempt Income Sources

Column a - Enter the name of the exempt income source in this column.

Column b - Enter the physical address of where you worked, if applicable, in this column.

Column c - Enter the exempt income type (wages, per capita income, etc) in this column.

Column d - Enter the amount that qualifies as exempt income in this column.

Part IV – Residential Property Information

Line 5 – List the physical address for each residential property(ies) you own that is/are located outside the boundaries of your affiliated tribe. Include the property usage, who resided in the property, and dates you resided in the property.

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